The real person of the analyst and his role in the process of psychoanalytic cure

This paper focuses on the real relationship with the analyst in the psychoanalytic situation as an aspect of the therapeutic process that leads to change. The role of free association, clarification, and interpretation of the transference are taken for granted as major activities of the analyst, and the real relationship with him is seen as a complementary but important ingredient for change. In particular, his emotional availability determines the climate of analysis. The concepts of neutrality, anonymity, and abstinence, though of importance as guideposts in the conduct of an analysis, have conceptual limitations that not infrequently bind the analyst in a stance that is not useful for the progress of the analysis. On occasion, confirmation by the analyst of the verity of an experience in the patient's early life facilitates the analytic process. This occurs particularly in situations of early trauma, but at times may include chronically traumatic early life experiences. An important motivating force in analysis is the patient's unconscious wish to find the ideal parent absent in early life experience, a wish that is experienced and ultimately analyzed. This is to be distinguished from a defensive idealized transference. Psychoanalytic developmental psychology contributes to our understanding of how the real person of the analyst, his emotional availability, his responsiveness at particular times, his attitude toward action and progressive change in the patient, affect the therapeutic process that leads to change.     

The therapeutic relationship as a paradoxical experience

The therapeutic relationship exists within multiple levels of reality—including that of ordinary life and that of the therapeutic frame. This interplay between these two levels of reality gives rise to paradoxical experiences for both participants. Certain “principles”; or “rules”; of technique can be understood as a means of enabling the therapist to cope with what is usually referred to as “boundary”; issues. It is essential that the analyst or therapist demonstrate capacity to shift playfully from one level of reality to another. The “rule”; of abstinence and the asymmetry of desire that exists between the two participants are discussed. Gratification within the therapeutic frame is paradoxical in that gratification at one level of reality leads to privation at another level of reality. These paradoxical experiences for both patient and analyst are examined in relation to projective identification and to the analyst's countertransference.     

The Jerusalem TeleRehabilitation System, a new low-cost, haptic rehabilitation approach.

Survivors of brain injury or stroke can improve movement ability with intensive, supervised practice. Since the hours of supervised therapy with a physical or occupational therapist are limited, telerehabilitation will enable patients to greatly expand the hours that they practice therapeutic exercises. The Jerusalem TeleRehabilitation System (JTRS) consists of patient and therapist systems plus a central server and database connected via the internet. The system can work in two modes: (1) a cooperative mode in which the therapist and patient are online at the same time, and (2) a stand-alone mode in which the patient uses the system on his own. In both cases, the system will monitor the status and progress of the patient and various parameters of his movement abilities, and prepare reports for the patient and for the therapist. From the clinic, the therapist will be able to change the screen seen by the patient and change the level and types of tasks, as needed. Compared to existing systems, our system will have the following advantages: (1) inexpensive and easy to use; (2) remote monitoring and control of the patient's computer by the therapist in the clinic; (3) more detailed analysis of patient status and progress; (4) a "smart" system which self-adapts to the patient's capabilities in real time, increasing or decreasing the difficulty of the exercise as needed; and (5) a central, international database which, by gathering data on many patients over time, will provide the basis for "smart" therapy and will also facilitate coordinated multicenter research studies.     

Toward optimum group placement from the perspective of the self or self-experience

This paper offers referring and prospective group analysts/therapists a way of conceptualizing optimum placement. This approach, using the charts provided, will aid in determining the patient's current needs based on past and present selfobject functions, deficits/ derailments, and traumatizations. The charts also offer the group analyst/therapist a tool with which to evaluate the present selfobject functions, impingements, and traumatizations that may be available in a prospective group to determine whether the match is appropriate or whether group should be the treatment modality of choice. When the interviewing analyst/therapist has taken all of the current and past selfobject functions and traumatizations into account, the patient can be expected to benefit from the most growth-enhancing placement available.     

Developments in cognitive neuroscience: II. Implications for theories of transference

An integration of psychoanalytic theory with contemporary developments in cognitive neuroscience offers a useful perspective on long-standing controversies about the nature of transference, and a better understanding of the precise mechanisms by which transferential processes occur. Contemporary psychoanalytic views of transference are reviewed, and the many processes that constitute transference are described. Two issues that have emerged in different guises for several decades-the role of the analyst in eliciting transference, and the nature of "real" and "transferential" components of the therapeutic relationship-are reconsidered in the light of concepts such as connectionist networks. Although a useful analytic stance is one that allows the patient's enduring dynamics to dominate the analytic field, it is suggested, anonymity is neither a cognitive possibility nor the driving force behind most transference reactions, and the distinction between "real" and "transferential" perceptions is one of therapeutic interest, not of mechanism. Certain features of the analytic situation make some dynamics more likely than others to enter the treatment relationship, notably those related to authority, intimacy and attachment, and sexuality. Transference reactions are best understood as constructed from a combination of the patient's enduring dispositions to react in particular ways under particular conditions; features of the analytic situation and of the analyst; and interactions between patient and analyst. These reactions do not unfold ineluctably from the patient's mind in the consulting room, nor are they cognitive constructions of the patient-analyst dyad or co-constructions of relatively equal partners exerting their influence on the analytic field.     

What does the analyst want? Free association in relation to the analyst’s activity, ambition, and technical innovation

The author traces the history of free association, the "fundamental rule," through the Freud-Ferenczi relationship and controversy. The use of "activity," first proposed by Freud in 1910 with phobic and compulsive patients, was then championed by Ferenczi in the early twenties. The goal of activity was to enhance-or, more accurately, "to force"--the associations into the analysis. Subsequently, Ferenczi reversed himself, concluding that his analysis was re-creating the traumatic parental environment which originally caused the patient's neurosis. The far-reaching results of Ferenczi's change of heart included a redefinition of countertransference and added the techniques of "indulgence" and "relaxation" to soften Freud's emphasis on "abstinence" and "frustration. A vignette from the analysis of a dangerously self-destructive bulimic patient illustrates the value of free association in helping a patient feel understood by the analyst without pressure to give up her symptoms. Constantly monitoring his therapeutic ambition, the analyst demonstrates the value of free association in enhancing the patient's understanding of herself and of the survival value of her symptoms. This vignette highlights the fact that the analyst's therapeutic ambition makes freedom to associate even more difficult for the patient and inevitably intrudes on the analyst's evenly hovering attention. Of course for the analyst to have a therapeutic wish is necessary and desirable but for the analyst to demand change promotes compliance and hidden rebellion which limits the analysis.     

The role of the analyst in the analytic cure during times of chronic crises

The role of the analyst in psychoanalytic treatment during periods of chronic crises is illustrated with material from two case studies. The first clinical vignette shows an analyst able to stay with fears evoked in the patient by the traumatic external reality, even as the analyst tried to explore with the patient an inner universe that handled this reality in unique ways. The second case study focuses on how the analyst's countertransference during this period of chronic crises, which she was experiencing along with the patient, made it difficult for her to contain the patient's fears and anxieties, because of the threat to her own existence, as well as to her identity as an analyst. In this second case the analyst, out of denial of the external situation, focused blindly on the patient's internal reality in order to counteract her own sense of passivity and helplessness in the confrontation with death and destruction. She clung to "classical" analysis by trying to analyze the patient's defenses, work them through, etc., thus making so-called analytic interpretations rather than staying with the patient's fear, as well as her own, and helping the patient more directly. A turning point came with the birth of the analyst's granddaughter; fear for the new arrival's safety made the analyst sharply aware that it is impossible to ignore external reality, that it must be given a place both in everyday life and in analysis. This awareness enabled the analyst to contain the patients' fears, which helped him feel more supported and facilitated change.     

Thoughts on medication and psychoanalysis: a lay analyst's view

The issues involved in split analytic treatments-where a second person manages the patient's medication-are discussed from the point of view of a developmentalist and lay analyst. Case material is presented to illustrate the interplay of medication with other elements of the psychoanalytic situation. Medication and its effects, it is argued, should be accorded no special status apart from other interventions and enactments in an analysis. Some see medication and psychoanalysis as parallel processes, two separate and unintegrated theoretical systems, and recommend shifting back and forth between models of the mind or becoming "bilingual"; against this view, it is argued that anything the analyst does will affect the patient's thoughts, fantasies, and even physiology in individual ways, and only attention to analytic material can reveal what an intervention means in a specific case. Success in split treatment depends on a collaborative therapeutic alliance among patient, analyst, and consultant. Because there is as yet no theory that bridges psychoanalysis and psychopharmacology, analysts must talk of these matters as incompletely synthesized and regard them as part of the challenges that make psychoanalysis the exciting, impossible profession it is.     

The illumination of history

Formulations regarding the patient's history have not only played an important part in understanding the patient, but interpretations explicitly linking the present with the past have been seen as central to the therapeutic process. In this paper the author considers the role of historical reconstruction in bringing about psychic change. He emphasizes the therapeutic value that lies in the exploration of the way the patient's history is embodied in his internal object relationships, becoming manifested in the transference-countertransference relationship. The author presents clinical material which he suggests allowed the analyst to follow the way the patient's internal object relations, coloured by her history, became expressed and played out in the sessions. He suggests that, when these processes can be followed and addressed in the present, this may lead to a diminution in the underlying anxieties. This can thus promote psychic change by freeing the patient's capacity to achieve a sense of connection with her history, and to tolerate the meaning of what emerges, which illuminates both the present and the past.     

Neediness and narcissistic defensive action

Action-prone patients are difficult for most analysts to treat. The author describes patients who act in treatment by pressuring themselves and the analyst to get rid of what is wrong, to change the imperative, life-and-death qualities of need into something else. Viewing neediness in treatment as narcissistic defensive action helps the analyst address the patient's pressured flight away from focusing on the need of the analyst and toward action aimed at riddance. Ghent's (1992, 1993) views on neediness are discussed and seen to be complemented by a view of action as protection against narcissistic vulnerability. Analysts' intolerance, vulnerabilities, and needs with such patients are considered.     

Exploring a patient's shift from relative silence to verbal expressiveness: Observations on an element of the analyst's participation

By tracing a portion of close process of a patient's shifts from a relatively silent and inhibited stance to one in which he is beginning to verbalize more about his experience and fantasy, I will illustrate some tensions between the analyst's role as facilitating expressiveness and as occupying a place in the patient's internalized world. Since the analyst's functions as facilitator and as internal object (often an obstacle to the patient's expressiveness) are sometimes in conflict with one another, it is important for the analyst to be able to work internally with this conflict as he works with his patient. Splitting processes between these two functions may provide the analyst with cues related to the patient's and the analyst's resistance to understanding the patient's communication of unconscious conflict and the patient's recruitment of the analyst into the patient's internalized world.     

Object Relationships—Symmetry and Asymmetry: Commentary on Paper by Anthony Bass

Current understanding of the process of therapy and development focuses on the interactions between the partners. The interaction is a negotiation of differences and of change. The equilibrium of the relationship is inevitably subject to frequent destabilizations, by virtue of normal developmental processes, life events such as losses, and the divergence of aims as each process unfolds.

The destabilizations are pivotal to the creation of new states. If a newly emerging state is to be advantageous for the development of the infant or the health of the patient, the associated toxic affects have to be tolerated and dealt with openly. If the analyst defensively hides, opportunities for change will be lost and the old patterns will persist. The therapist and patient, like the parent and child, are engaged together in this mutually altering process.     

My Psychoanalytic Journey

In this article I describe the evolution of my psychoanalytic thought and my current perspective of psychoanalysis, after almost a half century of professional practice. For the most part, three ideas have guided this evolution: (1) considering the patient’s mind as the major source of knowledge; (2) my firm belief that the patient–analyst dialogue, taken from the Gadamerian point of view, is the best way to have access to the patient’s mind and also to that of the analyst himself; and (3) the notion that the mind constitutes an open, dynamic, and nonlinear system in constant interaction with the environment that surrounds it. In my writings, I have tried to show that the therapeutic action in the psychoanalytic process is formed by the therapist–patient interaction. I also propose that psychoanalysis must endeavor to be a social therapy, even as it treats individuals, and go beyond what is purely instinctual so as to emphasize what is particular to human beings and sets us apart from the other animal species.     

What's true and whose idea was it?

In this paper, the author explores the idea that psychoanalysis at its core involves an effort on the part of patient and analyst to articulate what is true to an emotional experience in a form that is utilizable by the analytic pair for purposes of psychological change. Building upon the work of Bion, what is true to human emotional experience is seen as independent of the analyst's formulation of it. In this sense, we, as psychoanalysts, are not inventors of emotional truths, but participant observers and scribes. And yet, in the very act of thinking and giving verbally symbolic 'shape' to what we intuit to be true to an emotional experience, we alter that truth. This understanding of what is true underlies the analytic conception of the therapeutic action of interpretation: in interpreting, the analyst verbally symbolizes what he feels is true to the patient's unconscious experience and, in so doing, alters what is true and contributes to the creation of a potentially new experience with which the analytic pair may do psychological work. These ideas are illustrated in a detailed discussion of an analytic session. The analyst makes use of his reverie experience-for which both and neither of the members of the analytic pair may claim authorship-in his effort to arrive at tentative understandings of what is true to the patient's unconscious emotional experience at several junctures in the session.     

Eating Disorders: A Bond between Medicine,Culture and Psychoanalysis

Action in connection with the therapeutic process is often equated with acting out. The subtle behaviour that belongs to ?the complicated system of transmitting and receiving unconscious signals? (Sandler), with which the patient attempts to make the analyst behave as the object of transference or to fulfill an unconscious desire, is also described as acting out or micro-acting out (Treurniet). This fine-grained action, however, means nothing; it is not symbolic or communicative action. Its intention is, rather, to trigger effects and induce interactions. It occurs not only on the side of the analysand but also on that of the analyst, and is part of the unconscious communication in the therapeutic process. Presented here are some of the various interactive ways and means with which the analyst is prompted into unconscious action and certain, unnoticed, ways in that he turn ?treats? the patient. The analyst's action responses can bear the character of interpretations with which he may unintentionally reveal how he regards the behaviour of the patient.     

Building Blocks Toward Contemporary Trauma Theory: Ferenczi 's Paradigm Shift

In laying down the building blocks of contemporary trauma theory, Ferenczi asserted that trauma is founded on real events and that it occurs in the interpersonal and intersubjective dynamics of object relations. He stressed the significance of the presence or lack of a trusted person in the post-traumatic situation. After the trauma, the loneliness and later the isolation of the victim represent a serious pathogenic source. In the traumatic situation, the victim and the persecutor/aggressor operate differing ego defense mechanisms. Ferenczi was the first to describe the ego defense mechanism of identification with the aggressor. Ferenczi pointed out the characteristic features of the role of analyst/therapist with which (s)he may assist the patient in working through the trauma, among them being the development of a therapeutic atmosphere based on trust, so that the traumatic experiences can be relived, without which effective therapeutic change cannot be achieved. For the analyst, countertransference, as part of authentic communication, is incorporated into the therapeutic process. These are the key building blocks that are laid down by Ferenczi in his writings and appear in later works on trauma theory.     

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.     

Self-Disclosure and Vulnerability

Abstract

Based on the theoretical assumption and clinical observation that projective identification is a natural, constant element in human psychology, clinical material is used to illustrate how projective identification centered transference states create situations where acting out of the patient's phantasies and conflicts by both patient and therapist is both common and unavoidable. Because they are more obvious, some forms of projective identification encountered in clinical practice are easier for the analyst to notice and interpret. Other forms are more subtle and therefore difficult to figure out. Finally, some forms, whether subtle or obvious, seem to create a stronger pull on the analyst to blindly act out.

In some psychoanalytic treatments, one form of projective identification might embody the core transference. In other cases, the patient might shift or evolve from one level of this mechanism to another. Some patients attempt to permanently discharge their projective anxiety, phantasy, or conflict into the analyst. There is a patent resistance to re-own, examine, or recognize this projection. Some of these patients are narcissistic in functioning, others are borderline, and many attempt to find refuge behind a psychic barricade or retreat (Steiner 1993). In other forms of projective identification, the patient enlists the analyst to master their internal struggles for them. This occurs through the combination of interpersonal and intra-psychic object relational dynamics. This “do my dirty work for me” approach within the transference can evoke various degrees of counter-transference enactments and transference/counter-transference acting out.

Another form of projective identification, common in the clinical setting, is when a patient wants to expand the way of relating internally, but is convinced the analyst needs to validate or coach the patient along. This is why such a patient may stimulate transference/counter-transference tests and conduct practice runs of new object relational phantasies within the therapeutic relationship. Over and over, the patient may gently engage the analyst in a test, to see if it is ok to change their core view of reality. Depending on how the analyst reacts or interprets, the patient may feel encouraged to or discouraged from continuing the new method of relating to self and object. The patient's view of the analyst's reactions is, of course, distorted by transference phantasies, so the analyst must be careful to investigate the patient's reasoning and feelings about the so-called encouragement or discouragement. This does not negate the possible counter-transference by the analyst in which he or she may indeed be seduced into becoming a discouraging or encouraging parental figure who actually voices suggestions and judgment.

All these forms of projective identification surface with patients across the diagnostic spectrum, from higher functioning depressive persons to those who are more disturbed paranoid-schizoid cases. Whether immediately obvious or more submerged in the therapeutic relationship, projective identification almost always leads to some degree of acting out on the part of the analyst. Therefore, it is critical to monitor or use the analyst's counter-transference as a map towards understanding the patient's phantasies and conflicts that push them to engage in a particular form of projective identification.