We Hardly Knew Ye

fifty years ago today

Frequency and the Frame

Stern considers the argument over frequency when analysts try to define what psychoanalysis is. He advocates that intrinsic criteria (not extrinsic criteria such as frequency) ought to define what analysis is, and does not think interpretation of transference is such an intrinsic, defining criterion. What is intrinsic to the process emerges from the dyad within the ‘analytic third’ and requires “freedom to find their way into” the process. Frequency does not distinguish psychoanalytic psychotherapy from psychoanalysis, but rather it is the training of the clinician, and her willingness to engage in such a process with each particular patient, which delineates therapy from analysis. This willingness includes an openness to negotiation.

Because some things the analyst imposes “unilaterally,”Goldberg also does not think that everything in the clinical situation is co-created or negotiable. [Here I think he may have a too narrow definition of negotiation. Negotiation requires that we put our desires on the table, but does not guarantee that we get to have what we want. Negotiation means it can be talked about in a welcoming way, and is not the same as compromise or submission.]  Goldberg agrees that analysis cannot be defined simply by external criteria such as frequency, but notes that certain external criteria – a place of meeting, an agreed upon meeting time, for example—and an understanding not to physically harm each other, are required for the process and for a sense of safety. He asks us to consider the purpose of the frame and what is its mechanism of action. It is not enough that frequency be negotiable, rather we must investigate what effect increased or decreased frequency has on psychic reality and self regulation.  But what is intrinsic to analysis? Goldberg cautions against but notes that what we believe intrinsic often cannot be separated from our theoretical point of view.

Goldberg, P. (2009). With Respect to the Analytic Frame: Commentary on Paper by Steven Stern. Psa. Dial., 19:669-674.

Stern, S. (2009). Session Frequency and the Definition of Psychoanalysis. Psychoanal. Dial., 19:639-655

Responding to Patients

There is no formula for what to say or when to say it. Rather, in a moment to moment appreciation of the effect our words have had on a patient, we will perpetually fumble and tweak our utterances. Attention to detail in communication will guide us as we attempt to proceed in a meaningful way. After we speak, patients may say nothing; they may quietly consider our words; they may sigh in relief or exasperation; they may weep silently; they may appear as if slapped in the face. We strive to be attuned to minute changes— in face, posture, breath, tone, prosody, and so on, as well as in narrative—for the effect we may have had. We do well to be able to admit when we have made a mistake. Often, a response from the patient with confirmatory material, or new material, means we have said something of meaning to the patient.

We ask ourselves: When do I feel compelled to speak up? Am I aware of at least some of my motivations to speak? Do they include the wish to know more, or only to correct or inform the patient? Can I apply an experience-near, emotional, and cognitive context to my remarks? Am I more or less attuned or empathically immersed in this moment? Am I involved or distracted? Is something in my own physical state or personal life having an effect on my level of attunement? Is something in my visceral or fantasy experience in the moment intimating unspoken information about the patient’s experience? What might it being trying to tell us?Does something about the patient’s demeanor, affect, voice, or the content of the material lead me to dissociate from it? What do I find so disturbing, and why? Do I want to invite the patient to help me in exploring answers to these questions?

Buirski and Haglund, from a Self psychology perspective, move us into the area of how we respond to or what we say to patients. They note interpretations that provide new cognitive knowledge when made with empathic attunement –resonating both cognitively and affectively—serve the selfobject function of promoting self cohesion through self understanding.  They go so far as to say that “for  verbal interpretations to generate meaningful cognitive and emotional understanding, they must be given within the context of a primary selfobject relationship” [italics mine]. An interpretation, constructed from the experience of both patient and analyst, is meant to help organize the patient’s experience. While their paper is about how verbal interpretation can serve as a selfobject function, they nevertheless recognize the function of procedural and perceptual communication in making meaning. Haim, while from a more traditional perspective, nonetheless asks, “When the analyst talks, is he working to regulate the patient’s tension level, or her or his own?” Haim is forthright about her uncertainties of when to respond and what to say.  She decides that “the best time to make an intervention is when the patients asks for one” [Spotnitz’s ‘contact functioning’]. Both authors seem aware of the relational and intersubjective component of experience between patient and analyst.

Buirski, P., Haglund, P. (1999). Chapter 3 The Selfobject Function of Interpretation. Progress in Self Psychology, 15:31-49.

Haim, R.J. (1990). The Timing of Interventions: A Countertransference Dilemma, when to Talk and When Not to Talk. Mod. Psychoanal., 15:79-87.

Benjamin elaborates the Third

The Tampa Bay psychoanalytic community will be enriched on December 7, 2013 by “A Day with Jessica Benjamin” hosted by the Tampa Bay Psychoanalytic Society. Psychoanalyst, philosopher, feminist, and a remarkable theoretician and author, Benjamin has reminded developmental psychoanalysts that mother is not simply an object to baby but a subject in her own right who—along with soothing, mutual regulation, reverie, and developmental impetus—also brings language, law, and thirdness to the dyad. When the mother identifies with her baby (because she was once a baby) and she experiences herself as the adult mother holding her baby, thirdness (of baby, mother once baby, and present mother) ensues, that is, mother’s ability to hold two positions simultaneously adds to the dyad the third vertex of a triangle, creating potential space for new things between both members of the dyad.  Thirdness, says Benjamin, orients the intersubjective analytic work, both as communion experience (one in the third) and symbolic experience toward differentiation (third in the one dyad). When thirdness breaks down in the therapeutic situation, complementarity leads to impasses and enactments.

Benjamin defines intersubjectivity as a developmental achievement of mutual recognition, as when the baby—much like the effect, described by Winnicott, of the mother’s survival creating for the infant externality—sees the mother as a separate other no longer under his omnipotent control. While there is some sadness with the loss of fantasized omnipotent control over the other, there is joy that the other as a subject is now worthy to recognize in turn, and greater joy still that this separate other sometimes shares like-mindedness, choosing communion and not simply united by subjugation of will. Now each subject in the dyad can recognize the other as a subject, not merely an object to serve the needs of the self.  This subject to subject interacting is highly precarious, for each subject keeps falling to the side of treating the other as if an object. “Holding the tension” then becomes the Herculean task of the analyst as she tries to refrain from oppressing the analysand with her expectations, her theories, and her will and strives instead to keep thirdness viable.

Benjamin, J. (2004). Beyond Doer and Done to: An Intersubjective View of Thirdness. Psychoanal Q., 73:5-46.

Negotiating a deepening of the treatment

The negotiation between analyst and potential analysand, says Wilson, includes facilitating an unending process of “mutual adaptation” toward “a ‘thought community.’”  He writes, “A thought community works to bring into existence new objects, or so modifies old objects that they appear in a new way…”  I surmise that, here, there may be an interpenetration of subjectivities, a ‘hive mind’ where, as Freud noted, one’s unconscious speaks to the unconscious of another. Both patient and analyst participate in many thought communities at a given time, and the analyst facilitates the awareness of the tensions that exist between them as they approximate a closer and closer shared reality and come to terms with differences. One such difference might include the fury at the not good-enough mother clashing with the new found and mitigating recognition that mother had also been deprived as a child. It is the perturbations that make for fruitful moments of negotiation.

Tensions as well exist between differing theories held by the analyst. While theories may serve to ‘hold’ the analyst in times of inevitable uncertainty, adherence to theory may also generate tensions. To which theories we adhere is multifactorially, and unconsciously, determined. Wilson notes the pressure “to adhere and yet not to adhere...” to our theories. Both patient and analyst must adapt not only to each other but to their shared or disparate theories. Wilson expects that analysis will take on a stability “constituted by more than the individual inputs of analysis and patient” [the analytic third], and that the analyst will move “from the realm of precepts to the realm of understanding” and both participants will move toward “understanding how to understand” as they develop together an analytic space where the work of analysis can be fruitfully done.

Wilson, A. (2004). Analytic preparation: The creation of an analytic climate with patients not yet in analysis …

         J. Amer. Psychoanal. Assn., 52:1041-1073.

Listening

Bohm reminds us that we are, as we listen to patients,  influenced by our theories and training; and while theories may help us organize and make sense of what we hear, we must be careful not to fit the patient into the Procrustean bed of our theories, but instead be open to surprise and  learning anew. We must tolerate uncertainty and accept that we cannot always know what is going on in every moment of the therapeutic encounter. I am reminded of a visit to Tampa in Sept 2010  from Sandor Shapiro  [see post 9-12-10] when he noted that theory helps mitigate the analyst’s anxiety and not to underestimate the value of lessening the analyst’s anxiety!  Bohm suggests we “work with mixtures of exploring and applying attitudes” and he favors “more pluralistic thought systems.”

Meissner, while accepting as fact objectivity and neutrality, nonetheless reminds us to listen at “multiple levels of discourse simultaneously.” He writes, “The analyst listens not merely to the words…but also to the tone, pace, affective coloring, nuances of expression, and …  other behavioral factors…” and he believes (re: reading the patient) that “there is no reading at all without a previously accepted framework.”

Ideas about listening analytically are on my mind not just because they are being discussed by candidates and students in the introductory series, but also because attorneys, among others, have recently inquired about how psychoanalytic listening differs from that done by a psychiatrist. I can’t help but think that my psychiatry training taught me to listen from a statistical point of view with the aim of fitting what I heard into columns A and B of a Chinese menu of diagnoses, whereas my psychoanalytic training thought me to listen from the unique and singular POV of one patient’s experience, to listen for not just what the patient says, but for what s/he intends, and even to read between the lines for intentions that the patient may not yet be aware that s/he has.  All the while we cannot be completely sure of the other's subjectivity, except, as candidate Dimitris Tsiakos, points out, we are the while participating (co-creating) our subjectivities. If you don't mind the mixed metaphor, it is a tough nut to juggle so many balls in the air simultaneously .