Tuesday, December 10, 2013

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.

Sunday, December 8, 2013

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.”]

Friday, December 6, 2013

Nelson Mandela has died

              Nelson Mandela     July 18, 1918-December 5, 2013

Peace and reconciliation, not revenge.
He defeated the enemy with forgiveness, 

Monday, December 2, 2013

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