Response to Commentaries

In replying to the commentaries, I continue to explore differences between a complexity model of the mind and an intrapsychic one, and elaborate aspects of the complex negotiation process that occurred between my patient, Kerri, and me. Taking up Chefetz's notion that a “change in self-state predicts observed fluctuations in the capacity to mentalize,” I consider ways that self-states in both the patient and analyst fluctuate, influence, and reorganize the unfolding process, including the systemic capacity to mentalize.     

Psychoanalytic Companioning

In this paper I offer an integration of object relations and relational conceptions of clinical interaction and suggest a register of psychoanalytic companioning. I suggest that when working with patients and states where there is no self-other definition and therefore no mutuality, the path to healing and growth is via companioning the patient into the darker, more regressed and unformed states of illusion and merger rather than via the promotion of separateness and relatedness, which, I propose, will accrue from within the companioning register. The analyst works from within an unobtrusive relational position. I offer a case example of my work in this register and suggest that this offers a different register of the use of the analyst’s subjectivity: one that is receptive, “cooperative” (Trevarthen) and responsive to the patient’s internal world and objects, rather than analytic and knowing. I consider the dimensions of intersubjectivity that cohere with the dimensions and levels of the patient’s mentalization as outlined by Leciurs and Bouchard (1997).     

A Response to the Contributors

Abstract

In my “response to the contributors” I emphasize that I was moved to write my book in response to the question “Why are so many well-trained colleagues, young and old, having so much difficulty developing satisfying analytic practices?” To answer that question I proposed to explore my experience successfully developing and maintaining an analytic practice.

In attempting to answer the question I inadvertently stumbled upon a revolutionary (with a “small r”) answer to the problem. I discovered, in my attitudes and in my way of working in a consultation and the early phase of an analytic collaboration, a new “concrete puzzle solution” to the problem of how to help a prospective, often reluctant collaborator give analysis a “try.”

My book emphasizes my view that courses on “analyzability” and differential diagnosis are based on psychiatric rather than psychoanalytic diagnostic schema and may interfere with candidates' ability to learn how to create analytic patients.

Since I was a candidate, courses on analyzability have always seemed to me to resemble an exclusive club, deciding whom to exclude and whom to admit, rather than a procedure based on sound clinical experience. Analytic experience has demonstrated that it is not possible in a consultation to predict accurately the outcome of an analysis. To make matters worse, it is probable that an analyst whose mind is focused on the task of evaluating a prospective analysand contributes to creating an environment in which certain patients are experienced as sicker than they might otherwise be.

In spite of the fact that it is not possible in a consultation to predict accurately the outcome of an analysis, many experienced “senior” analysts believe an analyst can and should be evaluative and selective. In their discussions of the subject, they focus primarily on characteristics of the patient rather than the match.

In my book I emphasize that in a consultation there are advantages in focusing on the patient's responses to the idea of engaging in a trial of analysis. The issue of the match and the particular time in their lives are significant from my perspective. The analyst's gender, age, personality, and related state of mind may be as important in effecting the outcome of a trial as any feature of the patient's mind.

My book shifts the emphasis of the focus of inquiry in a consultation from the patient to the analytic couple. It offers a different way of teaching candidates to work with prospective collaborators.     

Did You Say He Has a Hitler Mustache?: Analytic Vulnerability and Destabilization in the Face of Trauma

This paper looks at analytic vulnerability and destabilization through a detailed clinical example. There are different ways in which we may be vulnerable with our patients. In this paper I describe the raw and sudden vulnerability of allowing ourselves to be in a place of not knowing when both patient and analyst are unable “to see.” I describe an experience in which I lose my ability “to see,” both literally and metaphorically, while in session with a patient who is unable “to see” because she has dissociated her experience of loss and her experience of a sense of danger when in the presence of her stepfather. I link this clinical experience to the patient’s dissociated feelings and to my history of intergenerational trauma as well to current cultural violence and hate.     

Psychoanalytic Opus Nigrum

This paper presents my developmental experience in becoming an analyst as the daughter of one of the first psychoanalysts in a growing city in northern Mexico. Using historical and social context, I will explain my training conditions. In medieval times, maltreatment was impossible to avoid, and competence was a personal quest. My psychoanalytic education has been widened in scope by research that afforded me the opportunity to free my “psychoanalytic spirit.” Acceptance of reality and openness to new experiences are crucial for transformation. Answers can be found by considering new, unprecedented possibilities and striving for excellence through curiosity-driven research.     

The Analyst as Catalyst: Cultivating Mind in the Shadow of Neglect

I describe an effort to cultivate mind and deepen relatedness in patients who exhibit rudimentary thought and constricted forms of object contact, due to the effects of certain neglect or serious disturbance. Some of these patients require the analyst to serve as a catalyst, who takes proactive steps to summon a psychic realm to the patient’s experience and to forge components of the dyadic bonds that promote such function. The insights of the object relations tradition into foreclosed development are noted. I argue that such insights can be optimally applied with the benefit of the relational school’s emphasis on forms of dyadic engagement and use of the analyst’s subjectivity. In some cases of neglect, and others in which serious developmental challenge is the result of disturbance, priority is placed on the patient’s growth. Similarly, in my case illustration, my goal in using my subjectivity, as a catalyst, is for my patient to take his own emerging mind and psychic self with interest.     

Strangers in Paradise: Trevor,Marley, and Me: Reggae Music and the Foreigner Other

The “immigrant” position calls forth a sense of “strangeness” as a constructed Other. What happens when the self is experienced as a limited, hybridized version of the self one might otherwise be, with opportunity to shape one’s identity? Intersubjectivity is conceptualized as a generative, developmental space in which the “I-ness of me” locates fertile ground for such a project. How do analyst and patient negotiate mutual experiences of alienation in a shared culture of origin, as they encounter experiences of foreignness in a foreign land? As with relational spaces, the construct, “immigrant” is positioned as a thing in itself—a transitional space—in which Otherness might be interrogated. The work of crossing boundaries at the meeting points of race and class is discussed, as two Jamaicans, embedded in the power of Reggae music, engage in psychoanalytic, and socio-political “talk.” Or, is it that we dance?     

No Turning Back

ABSTRACT

It has been 16 years since the publication of my article, “Infertility in the age of technology: From frozen sperm to egg donation.” Today I would title it simply “Fertility in the age of technology.” In that article, I presented Diana, an analytic patient in her middle forties, who became a mother through implantation of a donor egg. Her journey to parenthood was fraught with physical and emotional trauma partly as a result of ever more high-tech and invasive treatments. The purpose of my 2000 article was to discuss the anxieties that the then new biotech treatments caused for both patient and analyst. I stated, “What makes this unique for the analytic process is that we analysts must confront our own anxieties and the underlying fantasies stimulated by the new procedures at the same time as we are helping our patients analyze theirs. Patient and analyst alike become inextricably linked in an exploration that will ultimately have a profound impact on both participants. Regardless of theoretical position, we become a part of the process, willingly or not” (Blum, 2000, p. 1543). Now, in this article, I look beyond the consulting room. I reflect upon the relationship between societal influences and technological advances and their integration into psychoanalytic theory.     

The Write of Passage From Candidate to Analyst: The Experience of Writing Analytic Process

This article describes my experience of learning to write analytic process. It illustrates how the depth of understanding I achieved from learning to write transparently about analytic work was instrumental in the consolidation of my analytic training and my development of an analytic identity. Practicing analysis requires letting our minds function at multiple levels—integrating, synthesizing, free-associating, attending, and maintaining our own reverie—simultaneously. This is a large task for any analyst, much less a beginning analyst. Writing about this process necessitates not only understanding what has transpired in our offices with our patients but also developing the ability to explain that intimate and unique interpersonal dyad to our peers. Learning to do analytic work is not the same as learning to write about it; and writing about psychoanalytic process is very different from participating in it (Reiser, 2000). The goal of writing analytic process is not primarily to tell the story of the patient but to demonstrate our thinking, experience, and understanding as analysts. To do this requires both a depth of understanding of what we do and a mastery of analytic process.

While there may be different ways to synthesize and integrate our analytic training and to accomplish the significant task of progressing from candidate to analyst, learning to write analytic process was pivotal for me. It was a “rite of passage,” culminating in the development of an increased sense of identity, maturity, and confidence as an analyst.     

Breakdown in communication: On finding the child in the analysis of an adult

SUMMARY

In this paper a patient is described in whom communication with parts of herself and with her objects, internal and external, had broken down. I suggest that her way of communicating was achieved by projective identification, as described by Klein (1946) and Bion (1962). The only way she could deal with and communicate her own very “bothered” feelings was to “put them” into the analyst. In this way she “bothered” the maternal or analytic mind in such a way as to make the analyst experience feeling like a “bothered” child.

I have tried to show how the analyst holds or contains these feelings, and to show the gradual establishment in the patient of a different way of communicating with the analyst and with the more primitive parts of herself.     

Incognito or not? the patient's subjective experience of the analyst's private life

This paper examines the meaning for the patient of the analyst's personal life and personality which are ostensibly banished from the consulting room. The therapist has a not‐always‐so‐secret “secret life”; that the patient is supposed to “not know”; about. Yet, more or less unconscious perceptions, impressions, and fantasies about extratherapeutic aspects of the analyst are omnipresent and significantly color the psychoanalytic enterprise.

Moreover the analyst as a person generally plays a critical and underacknowledged role in the patient's experience of the endeavor. Constructing multiple overlapping images of the analyst and of the analytic relationship, the patient discovers himself or herself in the matrix of these relationships with various images of the analytic other. The analysand is motivated to make sense of the analyst as wholly as possible, the better to place into context the analyst's interventions. The patient's resulting view of the analyst's subjective experience acts as a lens that filters and subtly alters the meaning of the analyst's communications.

I illustrate these points by relating my work with a patient whose dreams uncannily picked up on a (consciously) unknown aspect of my private life—my having a handicapped son. The treatment thereafter centered on the patient's identification with my child (as someone “disabled") and on the meaning of her having dreamt something so personal about her therapist.     

Modifications to the Technique of Analysis of BPD Adolescents

In this article I discuss certain modifications in technique that I applied working with borderline adolescents that enabled me to preserve the therapeutic bond and which, in my opinion, allowed me to obtain successful results. The differences with classical analysis are clear cut and concern, for example, the setting, the frequency of sessions, the nature of the transference, and modes of interpretation. It is important to keep our dialogue with the adolescent alive and avoid long silences that can be destructive. Part of the analyst’s work, in fact, consists in loaning his/her “images” (the product of his/her mind or imagination) to the concreteness of the patient. In the session these images seize something that is already present in the adolescent’s narrative as a creative hint to be developed that the analyst sees in the dialogue and deposits as a seed in his/her mind and which gives rise to a fruit produced by the analytical couple.     

Momentums of Meeting

ABSTRACT

In this article, I attempt to engage questions about the momentums of the moments of meeting formulated by Lou Sander as propitious for early development. I wanted to portray observations that grapple with the intersection between psychic change and complex dynamics, like imagistic confluence with verbalized interaction, embodied recognition from parent to child, and affecto/libidinal communication between patient and analyst. The focus is on four different directions for comments: (1) Some links to my own clinical practice and research; (2) An instance of “confluence of visual image between patient and analyst”, a moment of imagistic meeting, as understood through self-analysis by an open-minded analyst, including the discovery of “the importance of unsuccessful empathy in learning and growing”; (3) A study of “engrossment,” exemplifying the ways in which the earliest moments of “recognizing” ones infant, can engender joyful, expansive affects, with enhancement of self-image in fathers; and (4) The continuing generative momentum of Lou Sander’s participation within the Boston Change Process Study Group.     

The patient's transference experience of the analyst's gender: Projection,factuality, interpretation,or construction

The constructivist/relational perspective has challenged the analyst's emotional superiority, her omniscience, and her relative removal from the psychoanalytic dialogue. It at first appears to be antithetical to treatment approaches that emphasize the analyst's holding functions. In this essay I examine the holding model and its resolution from a relational perspective. I propose that the current discomfort with the holding function is related to its apparent, but not necessarily real, implications. I discuss the analyst's and patient's subjectivity during periods of holding. I believe that the holding process is essential when the patient has intensely toxic reactions to “knowing”; the analyst and is therefore not yet able to stand a mutual analytic experience. During holding, the patient experiences an illusion of analytictic attunement. This requires that the analyst's dysjunctive subjectivity be contained within the analyst, but not that it be abandoned. Ultimately, it is the transition from the holding position toward collaborative interchange that will allow analyst and patient explicitly to address and ultimately to integrate dependence and mutuality within the psychoanalytic setting and thereby engage in an intersubjective dialogue. The movement toward mutuality will require that the analyst of the holding situation begin to fail in ways that increasingly expose her externality and thus her subjectivity to the patient.     

The Vocation of Depth Psychotherapy

During the last years of my training as an analyst, from 1980 to 1985, I was in analysis with Dr. Edward Edinger. I remember well my first session; I had come to ask him if he would supervise one of my clinical cases. He told me that my father complex was in such an unconscious state, I would probably hear everything he said to me as critical. I asked if he would work with me analytically and he said that was a possibility.     

The Unobtrusive Relational Analyst

I describe an unobtrusive relational approach to the psychoanalytic treatment of nonalive and nonspeakable states and ways of being. I build upon a contemporary relational sensibility that values the intersubjective engagement of analyst and patient and the enactment of dissociated and unformulated states, together with the concepts of regression and the unobtrusive analyst central to the work of the British independent analysts, with a special focus on Michael and Enid Balint. I stress that in being unobtrusive, the analyst is not neutral or abstinent, but deeply engaged and becomes the analyst the patient needs. A case is offered as an account of analytic work that was enhanced and made possible by my engaged but unobtrusive presence, and the privileging of the patient's own idiom, object relating and early developmental needs. I offer a contemporary rendition of regression that encompasses mutuality, regulation and accompaniment. I suggest a concept of “benign regressive mutual regulation” and outline and differentiate some of the influences from the contemporary psychoanalytic field.     

Response to Safran: The Development of Critical Psychoanalytic Sensibility

Jeremy D. Safran feels that my views regarding the relative merits of case studies and systematic empirical research are unnecessarily polarizing. I feel that, on the contrary, I'm offering bridges between my perspective and those of researchers on psychoanalytic process and outcome in two ways. One is through my own constructivist critique of traditional positivist case studies and theorizing based upon clinical experience. The second is through conceptualizing the place of systematic research within a constructivist paradigm. I am arguing that its place can be no different than that of case studies. Both generate possibilities for any particular analyst or analytic therapist to have in mind as he or she works with a particular patient at a particular moment. Safran locates the destructive effects of scientism with “biologically oriented researchers and cognitive therapists.” In my view, it might be convenient if the problem could be located exclusively with them, but the fact is that psychoanalytic researchers, as I demonstrate, are working largely within the same paradigm as their adversaries in the research world. That paradigm erroneously privileges systematic research as hypothesis-testing, whereas case studies are relegated to the status of anecdotal, hypothesis-generating work. I describe what I call “nonlinear constructivist learning” as the kind of “generalization” that case studies can yield and that is optimal for our field.     

Political Divide in the Consulting Room*

This paper addresses a treatment relationship that tests the analyst’s capacity for empathy within an impinging political context. It involves a Ferenczian “relaxation of technique” within the analytic frame, while the analytic couple attempts to negotiate a polarized transference and countertransference. Specifically, within a long-term treatment imbued with positive transference, my patient becomes openly outraged by my insensitive anti-Trump remarks. Increasing confrontations around the expression of political views illuminate our otherness. He complains of psychic ostracism within a liberal cultural context, which tolerates no divergence from mainstream liberal ideas or discourse. I come to embody the oppressive other: the liberal “thought police”, “silencing” him for his perspective. Empathic breaches between us take center stage: how I don’t see the world as he does, and don’t see or hear him.     

Crash: What We Do When We Cannot Touch: Commentary on Paper by Meira Likierman

This commentary aims to show the congruence and difference between Likierman's position on recognizing otherness and working with enactment and her relational, intersubjective position. Differences in my reading of the case include stressing the repetition of early attachment trauma, the level of implicit procedural relating, and the patient's contribution to the shared third of rupture and repair. I try to show that enactments arise not merely because the patient is able to pull the patient into forbidden behavior but because the dissociated parts of the patient pull the analyst into dissociation even when the analyst is acting “properly.” The rupture or collision—the “crash”—that the patient helps to formulate represents an opportunity to see the life-giving element in what we, analysts along with patients, inevitably also experience as frightening and even life-threatening.