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 .

Yes to aggression

For Winnicott, aggression is the infant’s natural exuberance and assertion, its motor activity, a ruthlessness without the intention of destruction, and it fuels creativity and the self’s coming into being (becoming alive, having a sense of self).  Aggressiveness, as such, is part of who the infant is, a necessary part—and by implication, should be a welcomed part if the infant is to come into being without dissociating or distorting part of himself as a Not-me [Bromberg’s dissociated not-me]. Freud and Klein saw aggression as innate, as part and parcel of the death instinct. Winnicott sees destruction, infant ruthlessness, not as essentially hostile, but rather as a necessary part of the developmental struggle, much like Phyllis Greenacre’s analogy of a chick ‘hatching’ -breaking out of its shell. Winnicott disagreed with Klein (and Freud) about the innateness of aggression (the kind with hostility) , seeing hostile aggression instead as a natural consequence of frustration, and, as such, its intensity and fate dependent on the environment’s ability to adapt to the infant’s needs without creating undue frustration. With this understanding of the consequence and interplay of the infant’s aggression with the environment of objects, Winnicott provides us with the relational aspect. He recognizes that an infant’s development is always in relation to its mother (there is no such thing as a baby)  and that a reliable relationship is essential to healthy development. Afterall, it was the mother’s reliable response to the needs of the infant which allowed him in the first place the illusion of a sense of omnipotence.

The sense of self coming into being is central to Winnicott. Because the infant’s sense of self comes into being in relation to its mother, and because her attitude –including the contents of her mind—toward her infant and his aggression greatly impact his sense of self, it is imperative that the mother [and the analyst] accept and allow for expression of his aggression, and survive it, so that aggression can be integrated into his whole self, the Me, so he can become, so he can become whole. The mental health and contents of the mother’s mind are as important, maybe more so, to the infant’s development as is the intrapsychic life of the baby that Klein and Freud so privileged. 

The analyst’s attitude, likewise, becomes important in her interactions with her patient and his aggression.  Aggression, for Winnicott, is what facilitates a creative life, a life lived by a spontaneous and authentic self. If the mother grossly impinges on the baby’s sense of self and his becoming, she disrupts his continuity of being, his going on being. If the analyst derails the patient, she too impinges. Because I include Winnicott’s theory of aggression as aiding the creative potential in becoming the self, as well as in separating the self (Me) from the other (Not-me), I do not theoretically want to dispense with the patient's aggression, even though in reality at times it is very difficult to both bear and survive.

Beginning a treatment and use, or not, of the couch

Beginning an analytic treatment can be stressful for the candidate -analyst, too. How does one understand what has brought the patient to treatment and what does one do with what is learned? How does one negotiate with the analysand an environment which facilitates the analytic process? Does one use the couch or not?

Meadow reminds us that the initial phase of treatment focuses on “avoid[ing] injury to the ego” …and to help them to talk.” She and patients decide together whether they are a fit and, if she thinks so, she conveys her “willingness to work with him.” She uses three guides: diagnosis, “contact function” and “ego insulation” or protection to help her discern “what attitudes the patient can comfortably have me take” and “[w]hat quantity of stimulation will help the patient to be in the room with me and to talk.” Meadow states that “change takes place within the doctor-patient relationship” and so for “patients who have given up hope of getting what they need from others” we must figure out “how to bring them into a relationship with the analyst.” In the initial phase, she keeps a reign on her subjectivity, stating “The projector does not need a contradictory perception…”

Geist, too, reminds us to hold our subjectivity in check when doing so benefits the patient. He cautions against trying to fit the patient into the Procrustean bed of our theories and recommends co-creating experiences “that facilitate mutual growth and healing.” This is most easily achieved by empathic immersion which also allows “the analyst to use his or her subjectivity and authenticity in the service of the patient’s growth.” Geist delineates three modes of empathy:

1.      Vicarious introspection, where “we sense in ourselves the feeling states of the analysand”

2.      Empathic resonance, where “[w]e react unselfconsciously to the patient’s associations…with qualities of spontaneity, humor, metaphor, creativity…playfulness and meditation…in a mutual act of giving and receiving”.

3.      Somatic empathy, where we use our “physical feelings  that reflect a visceral communication” such as “a sinking feeling in the pit of my stomach”.

The empathic stance, says Geist, keeps us experience near, “ facilitates the patient feeling deeply understood…[which]creates a …powerful bond between patient and therapist”. It also “enables the analyst to become acutely attuned to the multiplicity of his own internal states”.

Working as such requires a frame. Is the couch a necessary component of that frame? Aruffo, despite his traditional roots, acknowledges that sometimes the analytic process is better facilitated by the patient’s sitting up. Lying on the couch is not the goal, whereas exploration of the patient’s refusal to do so is as worthy of exploration as any other. He also recognizes that interpretation of intrapsychic processes is sometimes superseded by the need for the “interactive” touch. He writes that “at times, spontaneity increases the effectiveness of an intervention” and that “mutative moments…always involve a personal interaction”. While his clinical examples show no danger of ‘wearing the attributions’ or of query of ‘the patient’s experience of the analyst’s subjectivity’, we can be heartened by Aruffo’s advocacy for maintaining “rapport” even if I was hard pressed to discern in his clinical examples how exactly that was maintained. Forrest is much more unequivocal. After a brief history of the ideas about use of the couch, he states its many pros and cons.  The cons include “errors of affect appraisal”; the absence of the analyst’s facial expressions to communicate care, empathy, sadness, etc; the ability of the reclining analysand to hide one’s shame; a loss of a sense of the egalitarian; regression beyond what is therapeutic; infantilization; and possibly a sense of torment akin to torture with its restricted vision, unanticipated startle, and sense of submission.

Re: Aruffo, candidate Stavros Charalambides noted:

the couch has become rather an inheritance of the orthodox movement and is faced with serious skepticism under contemporary thought… I consider the face to face treatment essential for those clients with serious developmental traumas(personality disordered) as the interplay with significant others has created the basis for their trauma …[which can be] repaired via …an analytic third …co-created in the space between them, something I think the couch seriously eliminates. ..[E]specially with borderline clients facial expressions of the analytic dyad is essential for linking internal self states with facial gestures. In my recent training with Beatrice Beebe she explained that having done her research with mother-infant attunement led her to deny the couch as a mean to offer curative care to patients that have experienced their mother as sadistic or depressive.

The candidate disagreed with Afuffo’s:

If the rules tell us an intervention is wrong but it produces a desirable effect, then the rules must change.

I am not sure this is always  the case .Sometimes being attuned to the rules and deciding not to follow them enlight[en]s the therapist with the freedom to create something new, sometimes with the analysand's help in this. This does not mean necessarily that we have to change the rules (framework) but rather [we have] to be aware when not to follow them. Techniques that are products of spontaneity or/and authenticity within [one] analytic dyad [do not] necessarily constitute a new framework for another analytic dyad.

Aruffo, R.N. (1995). The Couch: Reflections from an Interactional View of Analysis. Psa. Inq., 15:369-385.

Forrest, D.V. (2004). Elements of Dynamics III: The Face and the Couch. J. Amer. Acad. Psychoanal., 32:551-564.

Geist, R. (2007). Who are You, Who am I, and Where are We Going: Sustained Empathic Immersion in the Opening Phase of Psychoanalytic Treatment. Int. J. Psa. Self Psychol., 2:1-26.

Meadow, P.W. (1990). Treatment Beginnings*. Mod. Psa., 15:3-10. 

Expanding the Frame

The Introduction to Psychoanalytic Concepts I and the Practical Analytic Subjectivity I courses dovetail nicely this week for both address the fee aspect of the analytic frame. Bass advocates for flexibility

Because analysts work within different frames over the course of a day's work…a notion of the analytic frame is misleading… Rather, analytic frames come in many different shapes … constructed out of a variety of materials, varying in intent …understanding and articulating the particular ways in which the frame doesn't fit inevitably becomes an integral aspect of an evolving therapeutic process.

flexibility in negotiation of each dyad’s unique frame, paying “attention to the vicissitudes of the ongoing negotiation”, a negotiation that is ongoing as both patient and therapist  change over the course of treatment.  [Levine, too notes that  “[t]he frame is established and re-established daily From his relational perspective, Bass recognizes that the analytic frame is co-created and contextual. He may actively enjoin the participation of the patient, even inquiring about her experience of him in negotiating the fee so as to invite in possibly disavowed aspects of his subjectivity. He writes “My unconscious life with any given patient is implicated”.  Furthermore, 

the establishment of the frame serves both as a relatively fixed, clearly defined container for the therapeutic work and as a point of departure for the negotiation of transference-countertransference elements, and enactments, and the working through of such enactments in an intersubjective field.

Bass reminds us (from Mitchell, 1993)

what is most important is not what the analyst does, as long as he struggles to do what seems, at the moment, to be the right thing; what is most important is the way in which analyst and analysand come to understand what has happened.

In class, we discuss again the fee, including an easy to read, brief paper by Allen which, despite it’s use of the meta-psychological language such as strengthening of the ego and superego, and more importantly, the not yet considered (in 1971) importance of including the patient in the negotiation of the analyst’s dilemma (such as: ‘I charge for missed appointments and need to make a living but worry I will be re-enacting your “rigid overly demanding mother who never gave an inch” ‘-case 4; or conversely, ‘I am of two minds about charging for missed appointments when you were so ill, but worry I will be failing to expect you to be the responsible adult that you are just as your laissez faire parents failed to see you as capable‘ –case 5), it makes several helpful points:  

when a therapist ignores or fails to properly deal with the whole area of payment or nonpayment of his patient's bills, he too is violating an explicit and agreed upon responsibility—namely, that of effectively functioning as his patient's therapist

Gedo states: 'When a patient in psychotherapy fails to pay his bill he has violated an explicit and agreed upon responsibility'. I would like to add that, conversely, …as I understand it, is that the withholding of payment for psychotherapy is best explained in the conceptual framework of the transitional phenomenon of Winnicott (6): when the withholding of payment is an attempt by the patient to deny his separateness from the therapist, the retained money represents a transitional object.

And the long arc of the analytic attitude where the patient is

being recognized by the analyst as something more than he is at present

Expanding [see post March 10, 2011] the idea of the frame is my favourite of the class papers this week, by Miller and Twomey, not because of its ideas about salary and fee for service, but because it brings in the idea of the Third as an essential component of the frame.

In the analytic situation, this third element is supplied by the analytic setting…[and]“triangular space” in analytic work is the therapist's symbolic thinking… both influenced by and independent of the patient's mind. … [T]he Third keeps the analytic situation from degenerating into nothing but a personal encounter… Without the Third to structure the relationship between patient and therapist the dyad falls prey to the danger of merger and incoherence in which everything outside its relationship is excluded and denied.

Allen, A. (1971). The Fee as a Therapeutic Tool. Psychoanal Q., 40:132-140.

Bass, A. (2007). When the Frame Doesn't Fit the Picture. Psychoanal. Dial., 17:1-27.

Levine, A.R. (2009). Bending the Frame and Judgment Calls in Everyday Practice. JAPsA., 57:1209-1215.

Miller, L., Twomey, J.E. (2000). Incoherence Incognito: The Collapse Of The Third In A Fee... Contemp. Psa., 36:427-456.

Multiplicity of Selves

The TBIPS Relational Study Group meets by conference call at 2:00pm on the second and fourth Friday of the month and welcomes all clinicians to discuss interesting papers on relational subjects. Yesterday was a particularly lively discussion of Donnell Stern’s 2004 paper which asked ‘how is it possible for the analyst to see her unconscious involvement with her patient?’ In this dauntingly lengthy paper the answer was not so clear, but perhaps the answer is found in the concept of the multiplicity of selves where one self state sees another. [One ego psychologist asked, ‘How is this different from the observing ego?’ but Stern did not bridge or contrast the two concepts, perhaps because the structural theory is too differently meta-psychological these days.]

While it seems the paper was to expand and illustrate Bromberg’s ideas on dissociation and how disparate parts must be brought in relation to, in awareness of, each other before conflict can exist, Bromberg’s ideas were somewhat obfuscated by so many other ideas (such as the author’s need to debunk the idea of a core or true self, inviolate and incommunicable, in favour of self as social construction, necessary perhaps as we consider the multiplicity of selves; Stern does make a nice case for countertransference reinforcing  transference). Clinically, the patient and analyst become aware of dissociated self states through enactments understood only in hindsight. Furthermore, “It is only when we can tolerate conflicts between multiple states that we can negotiate [Pizer] the disagreement between them.” (p 210). “Negotiation is an ongoing never-finished weighing of the alternatives…[W]e cannot negotiate until conflict comes about.” (p.211) and “[T]he self is healed by the creation of conflict.” (p.217)

The group argued a bit about whether everything is an enactment (the trope used to be: everything is transference). I leaned toward favoring Stern’s description of enactments as “rigid and unyielding” which leaves open the possibility that there is much unconscious involvement— such as, as Stern noted, mutual regulation— which are yielding and fluid and promote growth in both analyst and patient. Two of my favorite points of the paper had to do with love and with an analytic attitude. Referring to Wolstein, Stern said that a perquisite of love is “the capacity and willingness to know and accept one’s deepest view or sense of the other.” (p. 203) [I was reminded of Natterson’s 2003 paper; see Oct. 1, 2013 post.] Regarding the analytic attitude, Stern noted that for “reparative and facilitative unconscious involvement –accepting, loving, humorous, or playful” the analyst has to ‘mean it’…”it has to be more deeply felt than mere conscious decision…” (p. 205)

My favorite point, perhaps because I am of late preoccupied with Winnicott’s ideas on survival, was on the analytic attitude as it deals with aggression: “The analyst’s role is not defined by invulnerability…but by a special (though inconsistent) willingness, and a practiced (though imperfect) capacity, to accept and deal forthrightly with her vulnerability.” And “If the analyst characteristically denies his own aggressiveness…he is unlikely to feel empathic when the patient is feeling aggressive. Instead, the analyst is likely to identify  with…the patient’s internal objects  that scold or reject the patient  [Racker’s complementary countertransference] for having angry feelings or behaving aggressively.” (p.216)

This dense and rich paper left more to be discussed than one one-hour meeting allowed. I look forward to revisiting it with my generous colleagues.

Stern, D.B. (2004). The Eye Sees Itself: Dissociation, Enactment, and the Achievement of C... Contemp. Psychoanal., 40:197-237.