Revisiting the Classics of Countertransference and Free Association

As far as I know Heimann was the first to expand countertransference from “transference on the part of the analyst” to include “all the feelings which the analyst experiences towards his patient.” She noted that feelings for another can be both transference feelings and “refer to another person in his own right and not as a parent substitute,” that is, “not everything a patient feels about his analyst is due to transference.” Moreover, Heimann noted, this countertransference was not to be eschewed, but to be used as an important tool to understanding the patient’s unconscious, stating that the analyst’s feelings in response to the patient are “the most dynamic way in which the patient’s voice reaches” the analyst. She evoked Freud and contemporary analyst when she wrote “the analyst’s unconscious understands that of his patient.” Heimann also stressed that the analytic situation is “a relationship between two persons.” [her italics]

Even if contemporary analysts then part ways with Heimann— who interpreted the psychological world through drive and defense and the structural theory, did not see enactments as inevitable, and may have over interpreted the transference and underemphasized attachment needs— we laud her relational use of countertransference and her intimation of its co-creation –here I give the benefit of the doubt that she could not help but see what came from the patient and was received by the analyst was a co-creation though she does not insert the ‘co’: “the analyst's counter-transference is not only part and parcel of the analytic relationship, but it is the patient's creation.”

Forty years later, Aron notes how psychoanalysis, as contemporarily practiced, often neglects the free association method. The classical technique of free association, unlinked from drive and defense and  updated  by a two-person psychology, remains useful, he writes, to avoid the pitfalls of the analyst’s being overly self referential as to transference and projective identification. While Heimann noted that the patient contributes to the analyst’s countertransference, likewise, in its converse, Aron notes, the analyst contributes to the free association of the patient. Aron does not, however, advocate an a priori bias toward interpreting implicit transference resistance nor toward interpreting the interactional impact of the analyst, but says that the analyst must follow the patient’s lead (associations) in deciding when and how to intervene. He concludes with : “The[free association] method presupposes that all that the patient says can be meaningfully tied together and shown to belong to a continuum of psychic life…”

Aron, .L. (1990). Free Association and Changing Models of Mind. J. Amer. Acad. Psychoanal., 18:439-459.

Heimann, P. (1950). On Counter-Transference. Int. J. Psycho-Anal., 31:81-84

Benjamin on Recognition and Regulation

In bringing front and center to psychoanalytic discourse the subjectivity of the mother (not just the mother as object to the infant), Jessica Benjamin, adding to Daniel Stern’s paradigm of play, elaborates the importance, the imperativeness, of mutual recognition in the clinical encounter. What an honor (made possible by a contribution from the Florida Organization for Relational Studies) to have such a gifted and renowned thinker at the December 7, 2013 local Tampa Bay Psychoanalytic Society program meeting.

Attachment and infant-caregiver research have shown that sharing of affective states, where one experiences and understands that another ‘feels the same as I do,’ co-creates a rhythm of interaction—what Benjamin calls the rhythmic third (formerly called the one in the third)—which diminishes existential fear and isolation. The rhythmic third, the up and down orientation of affect in the same direction— which is soothing in its recognition, lets the analyst, as well, know that s/he is not alone in the universe.

It is through recognition, of shared affective states, that affect regulation occurs. Intersubjectivity is the sharing of affective states. It transforms complementarity such that one can feel empowered  with a sense of agency because, not only is one recognized but, one can recognize the other’s feeling in a way that can be shared and creates joy. Mutual recognition can be effected and empowers the self by seeing the self as recognizer, more powerful than simply being mirrored (recognized). Benjamin says recognition and regulation are “twins,” that is, are interdependent. As such, mutuality needs to be in the foreground. Affect regulation is necessary but not sufficient, for we do not want only to keep affects within a tolerable, manageable range. We want additionally to create meaning, acquired within the communion of mutual recognition.

A cornerstone of mutuality is the recognition of impact.  It is the realization by the mother that the child actually needs to discover something about her responses, what it is like for her to be a real human being in a real world. Recognition adds to regulation when the analyst can manifest the impact of the analysand such that the analysand experiences both the analyst and her/himself as a subject with feelings and agency. Sometimes recognition of affects at all from the analyst is a new experience for the patient.

Incumbent on the analyst is survival (Winnicott) so that the analysand does not have confirmation of the fear that her/his feelings can destroy the other. Yet, as Benjamin notes, it is not always easy for the clinician to tolerate and bear the affective state of another, particularly the pull to despair. To help mark (Gergely ) –similar enough to help the patient know you are on the same page, but dissimilar enough so patient does not fear you yourself will be dysregulated and overwhelmed; the mother marks her response to the infant’s distress by showing that she is not distressed in the same way but also that she knows the infant is distressed— affect, Benjamin looks to the third.  By acknowledging what is happening [e.g. ‘Your expectation that I not disappoint you is not unreasonable, you deserve understanding; and yet I am not perfect and so cannot always live up to your expectation.’] creates  a sense of the moral third, a sense of a lawful world where meaning exists and, though expectations can be violated, attachment can be recreated.

Breakdowns in mutuality occur when complementarity prevails. It is as if only one can survive. It is the belief that only one subjectivity is in the room, as if the other is not allowed to have thoughts, or as if one is making the other feel something. This is a breakdown of the moral third where it seems the other can only submit or resist. Benjamin advocates the need for parents to implicitly communicate to their children (or analysts to their analysands) that there is a lawful world in which other subjectivities can exist, a world of mutual understanding where everyone has a right to live, called a moral third. Sharing of affect allows us a way out of an impasse.

[The third, an unfelicitous term which has not ‘jumped’ to common psychoanalytic  parlance, seeks, noted Benjamin, another word to capture that area where negotiation can occur, where two are united to transcend destruction, where the analyst is not under the sway of projective identification and can retain the capacity to think, and where the analyst can tolerate greater degrees of vulnerability. At dinner last night, Paulina Robalina suggested “intermedium.”]

Nelson Mandela has died

              Nelson Mandela     July 18, 1918-December 5, 2013

Peace and reconciliation, not revenge.

He defeated the enemy with forgiveness, 

A Differing Perspective on the Irma Dream

The hall—numerous guests, whom we were receiving

He becomes aware of himself as a multiple self .Different parts of himself are gathering together unconsciously to negotiate their existence .He is dissociated though therefore he cannot experience this multiple existence of his parts as owned by himself therefore he alleviates himself from accompanied anxiety by projecting the ownership to familiar persons with whom there are ‘unfinished businesses’.

I reproached Irma for not having accepted my solution; I said: ‘If you still get pains, it's your own fault,

He approaches first the internal saboteur self-state. The pains are substitutes of cocaine. He is aware of taking cocaine as a self -attacking procedure and is afraid of recognizing the devastating power of such a self state .He comes aware of the Winnicotian anxiety of self-fragmentation and tries to renegotiate this relationship in himself.

Irma's complaint: pains in her throat and abdomen and stomach; it was choking her

The survivor self state is taking the lead now. It complaints to himself that he was not listening to it so far. This part of himself was warning him by physical symptoms (the pain in his nose) that something was going on, it was calling for his attention and action.Throat ,abdomen and stomach are somatic areas that are used for digestion. His survivor self state warns him of not being able to digest his theory thoroughly; his theory is incomplete, in pain. He starts to feel guilty of having constituted a theory that is inadequate (this is a disguised occurrence of a narcissistic injury).

She looked pale and puffy

By visual representations he becomes aware of his vulnerable (narcissistically wounded) self. He still cannot own this part as his and he needs to project it on a wounded woman (Irma) as way to feel superior to his injury.

I was alarmed at the idea that I had missed an organic illness

He is becoming alerted on his inability to reflect properly on himself. He is becoming gradually aware that his grandiosity made him blind to experience his vulnerability. He is unconsciously aware that his internal saboteur would be able to create a physical illness that he could not cope with or/and eliminate its origins.He starts to understand that his physical problem with his nose and his solution to it(taking cocaine)could bring him into psychological death ,implying he was aware of his ‘deadly’ addiction to cocaine.

I took her to the window to look down her throat. She showed some recalcitrance, like women with false teeth. I thought to myself that really there was no need for her to do that

His addicted part of himself receives finally more attention and consequently there is a more careful glance to it. The internal saboteur initially resists such a closer relationship. The false teeth are representing the oral aggression of the internal saboteur ,the false self that is disguised under the narcissistic cocoon. He understands the vanity of his narcissistic defences though he is not ready to explore them deeper.

What I saw in her throat: a white patch and turbinal bones with scabs on them

He moves more deeply to understand his wounded self. He can now contain some pain of his traumatized self and the wounded self’s image becomes clearer.

I at once called in Dr. M., and he repeated the examination

He doubts his self image is accurate and calls for an external representation of himself . Dr.M is his disguised Mother .His mother is being put in authoritarian position, although he is in need of his mother’s representation he becomes aware of his rage against her of putting him in an inferior position. On another level Dr M is really his superior colleague and he painfully questions him of the way he represents Froyd as a medical professional.Froyd becomes aware of his dependent positioning around authoritative figures. The cocaine dependency is a self-attacking manifestation of his grandiose self-rage attacking the self of himself that is need of external mirroring.

Dr. M. was pale, had a clean-shaven chin and walked with a limp

He is fighting against the external object .His maternal representation of him cannot be internalized without pain. He is becoming furious of such a procedure and he unconsciously realizes the nature of his narcissistic injury. On another level he is aware that the closer his relationships get the more his narcissistic vulnerability (his fear of how other people perceive him) is expressed.

My friend Otto was now standing beside the patient and my friend Leopold was examining her and indicated that there was a dull area low down on the left

.

He is still questioning his representation in other significant authoritarian people of his circle. Leopold is one of his self-states that can see clearly his narcissistic wound. The underlying friendship with Otto and leopeold (his self-states) indicates his self becomes more cohesive.

A portion of the skin on the left shoulder was infiltrated

He understands his death anxiety issue as another narcissistic wound. He understands he is not immortal and he is connected more with the physical pain that is his disguised  pain of realizing he is getting older .

In spite of her dress

The dress is the narcissistic defenses that although there are still there they cannot longer hide the narcissistic wound. However he is afraid of a possible collapse without his defences therefore the dress cannot be taken away.

Dr. M. said: ‘It's an infection, but no matter. Dysentery will supervene and the toxin will be eliminated

Dr.M becomes familiar with his injury but cannot offer more empathy. Froyd becomes aware that his theory although significant in understanding the symptom lacks proper interpersonalization and here there is another narcissistic injury  .On another route his mother was able to understand his vulnerabilities though her understanding was not expressed properly for him.

We were directly aware of the origin of the infection.

The self states party reveal a coherent self. He understands now the psychodynamics of his injury and has a clearer opinion of what went wrong.

When she was feeling unwell, my friend Otto had given her an injection

He understands he needs his friends to overcome his injury; he can now let them become closer to him.  On another level he understands there are parts of himself that are healthy and can really help him if he sustain  a better internal relationship with them.

A preparation of propyl… propyls … propionic acid

He needs to smell the perfume of closer relationships but still he gets in the paranoid position .The perfume is perceived as contaminating acid, that is closeness is still threatening. He is shimmering between close and distant. 

Injections of that sort ought not to be made so thoughtlessly

He understands the paradox of taking care of himself with cocaine a way that is revealing his self-attacking mechanisms. On another level the injection could be an interpersonal injection that is necessary to be done thought anxiety provoking if not regulated in proper dose of proximity.

And probably the syringe had not been clean

Here there is indication of phantasies of being contaminated by close relationships (indication that his mother was scary for him).

by Stavros Charalambides

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 .