The elusive concept of the psychoanalytic process

Although the term psychoanalytic process is frequently used, there is no consensual definition of its meaning. Some authors use it to designate a recognizable set of experiences within psychoanalysis. Others, a majority, use it as a synonym for the entire psychoanalytic experience, describing in detail what analysts do to achieve their goals. A range of views may be found between these extremes. A distinction is drawn here between the structure and content of the psychoanalytic process, which is regarded as a specific, definable entity--a red thread--within the psychoanalytic treatment experience as a whole, consisting of a microprocess and a macroprocess. The former is predominantly an amalgam of the patient's and the analyst's highly subjective experiences and entanglements, while the latter is predominantly an amalgam of the infantile and childhood origin of the patient's difficulties, as well as the analyst's conception of these difficulties based on a preferred theory. These ideas are used to formulate a definition of the psychoanalytic process based on clinical experience and are traced here primarily through lessons learned from a patient, Mr. K, over the course of a long and arduous analysis.     

Concurrent individual and individual-in-a-group psychoanalytic psychotherapy

This paper's thesis is that concurrent individual-in-a-group and individual psychoanalytic psychotherapy can be conducted in conformance with psychoanalytic principles of treatment as well as can individual psychoanalytic psychotherapy alone. American psychoanalysts have shown little interest in group psychotherapy, probably because of earlier criticism that transference is diluted by the greater reality of the therapist in group psychotherapy. This is a misconception extrapolated from the mirror model of dyadic analytic technique. The criticism was formulated during a period when that model was prominent and there was little awareness that the actual personal relationship between patient and analyst played an important facilitating role in the dyadic analytic process, including providing a basis for investiture of transference. Also, the criticism was based on one-session-per-week group psychotherapy, whereas concurrent individual-in-a-group and individual psychoanalytic psychotherapy utilizes two group sessions plus one or two individual sessions per week, enabling a more intensive patient-therapist relationship. Concurrent group and individual psychoanalytic psychotherapy constitutes a contribution to the widening scope of application of psychoanalytic treatment.     

Psychoanalytische Beiträge zur Behandlung in der forensischen Psychiatrie

Two psychoanalytic treatments are described for patients suffering from severe personality disorders who have killed. These treatments have been conducted in a high security hospital and are part of the overall treatment plan for any patient. Structural changes can emerge in the course of long-term continuous treatment which is conducted within the framework of a multidisciplinary team under conditions of physical security. These changes are described and clinically illustrated using the model of mental structure of the Operationalized Psychodynamic Diagnostics (OPD) system. The traumatic effect of “improvement” is emphasized as well as the risk of further enactment of lower severity. The latter might however trigger considerable anxiety in those who are contributing to the care of these patients. This is of importance for the gradual steps of integrating the patient back into the community. The psychoanalytic contributions are considered as necessary immunization against the contagiousness of these disturbances in these settings and also can help clinical teams to have more realistic prognostic expectations.     

Further observations on the psychoanalytic process

The psychoanalytic process remains a fascinating and valuable concept, albeit an incompletely understood and controversial one. The author reviews the ideas in his 1984 essay and looks back on some of the critiques and proposals that followed that paper. He suggests that the concept of the psychoanalytic process is viable and useful despite its shortcomings. Consideration is given to the goals of psychoanalytic treatment as they relate to the "process" and how the "process" may be helpful in determining whether or not a patient is "in" analysis.     

Process‐orientated psychoanalytic work in initial interviews and the importance of the opening scene

From the very first moment of the initial interview to the end of a long course of psychoanalysis, the unconscious exchange between analysand and analyst, and the analysis of the relationship between transference and countertransference, are at the heart of psychoanalytic work. Drawing on initial interviews with a psychosomatically and depressively ill student, a psychoanalytic understanding of initial encounters is worked out. The opening scene of the first interview already condenses the central psychopathology – a clinging to the primary object because it was never securely experienced as present by the patient. The author outlines the development of some psychoanalytic theories concerning the initial interview and demonstrates their specific importance as background knowledge for the clinical situation in the following domains: the ‘diagnostic position’, the ‘therapeutic position’, the ‘opening scene’, the ‘countertransference’ and the ‘analyst's free‐floating introspectiveness’. More recent investigations refer to ‘process qualities’ of the analytic relationship, such as ‘synchronization’ and ‘self‐efficacy’. The latter seeks to describe after how much time between the interview sessions constructive or destructive inner processes gain ground in the patient and what significance this may have for the decision about the treatment that follows. All these factors combined can lead to establishing a differential process‐orientated indication that also takes account of the fact that being confronted with the fear of unconscious processes of exchange is specific to the psychoanalytic profession.     

Selecting a patient or initiating a psychoanalytic process?

The defences provoked in the analyst by the anxieties associated with the difficult tasks of ‘assessment’ and ‘selection’ for psychoanalysis can result in a tendency to think in terms of ‘hurdles to be cleared’ by potential psychoanalytic patients, rather than ‘opening the gates’. This can result in a diminution of the analyst's capacity to enlist and sustain a psychoanalytic stance. Only within a psychoanalytic frame can a meaningful psychoanalytic process unfold, at all stages of a potential patient's movement from their first contact through to, possibly, entering into an analysis. The author illustrates the value of this thinking by describing the work of the London Clinic of Psychoanalysis where there has been a shift of emphasis in psychoanalytic consultation towards working with individuals on their potential to initiate a psychoanalytic process, and away from the sole aim of ‘selection of a suitable patient’. In this paper, the author notes that when institutional culture and practice supports psychoanalytic identity, this makes it more possible to recognize and articulate the anxieties provoked by the ‘emotional storm’ inevitable in psychoanalytic consultation, and the draw towards unhelpful enactment that may otherwise obscure the initiation of a psychoanalytic process that may or may not result in analytic treatment. Illustrative case material from the Clinic is presented.     

Curious bedfellows: Psychoanalytic understanding and old age psychiatry

SUMMARY

The author outlines an approach to assessment, or as she prefers to call it, psychoanalytic consultation, in the Health Service. This involves giving the patient an experience of the analytic process, which they can then assess in a way, while the assessor gains information about a number of categories that can be thought of hierarchically, which inform the advice given the patient and the referrer about management and treatment. The safety of the patient is paramount, as psychoanalytic psychotherapy is a powerful and disruptive treatment. However it is argued that, on the whole, ‘suitability for psychotherapy’ should be on the basis of exclusion rather than involving the patient passing a sort of ‘suitability test’. The latter may enable public psychotherapy services to deny the incompleteness of what they are able to offer.     

Transference focused psychotherapy: overview and update

This paper describes a specific psychoanalytic psychotherapy for patients with severe personality disorders, its technical approach and specific research projects establishing empirical evidence supporting its efficacy. This treatment derives from the findings of the Menninger Foundation Psychotherapy Research project, and applies a model of contemporary psychoanalytic object relations theory as its theoretical foundation. The paper differentiates this treatment from alternative psychoanalytic approaches, including other types of psychoanalytic psychotherapy as well as standard psychoanalysis, and from three alternative non-analytical treatments prevalent in the treatment of borderline patients, namely, dialectic behavior therapy, supportive psychotherapy based on psychoanalytic theory, and schema focused therapy. It concludes with indications and contraindications to this particular therapeutic approach derived from the clinical experience that evolved in the course of the sequence of research projects leading to the empirical establishment of its efficacy.     

Countertransference—Transference seen from the Point of View of Child Psychoanalysis

This paper explores the ‘point of interaction’, that interface where the psyches of the patient and analyst meet. The author examines what is activated in the analytic pair at the point of interaction, with a particular focus on the mental activity of the patient and analyst. This exploration of the mental activity of the patient and analyst is from a theoretical position that combines contemporary Freudian and Kleinian perspectives on the therapeutic process. The author concludes that the capacity for mutuality in both the patient and analyst rests upon a part of the mind that is connected to a certain aspect of the Oedipus complex. Finally, the point of interaction is also discussed as a place where there is a potential meeting of minds around divergent methods and applications of psychoanalytic treatment. Clinical material is presented to illustrate these points.     

Being a psychoanalyst: An everyday audacity1

This paper is the work of fi ve psychoanalysts who came together as a group in order to refl ect on their work as analysts. How are we analysts to identify the unconscious resistances that may sometimes hold us back from offering psychoanalysis to some patients? Do these resistances sometimes hamper the inner freedom that we require in order to maintain a psychoanalytic focus once that process is under way? How do we manage from time to time to overcome these resistances or, better, make use of them in order to develop our understanding of the unconscious dynamics that create the link between analyst and patient? The authors discuss these issues with particular reference to clinical situations taken from classic psychoanalytic treatment cases during which the analyst had to fi nd within him‐ or herself the audacity to be a psychoanalyst. Each clinical situation is different: preliminary interviews, in the course of the actual treatment, issues that emerge in the training of candidates. One of the signifi cant features of this group lies in the fact that the participants are at different stages in their development as psychoanalysts (student, associate member, full member, training analyst). This means that their experiences complement one another and encourage a discussion of issues such as how psychoanalysis can be passed on, and the relationship between supervisor and supervisee.     

PATIENT‐ANALYST “WITHNESS”: ON ANALYTIC “PRESENCING,” PASSION,AND COMPASSION IN STATES OF BREAKDOWN,DESPAIR, AND DEADNESS

This paper focuses on the analyst's “presencing” (being there) within the patient's experiential world and within the grip of the psychoanalytic process, and the ensuing deep patient–analyst interconnectedness, as a fundamental dimension of analytic work. It engenders new possibilities for extending the reach of psychoanalytic treatment to more disturbed patients. Here patient and analyst forge an emergent new entity of interconnectedness or “withness” that goes beyond the confines of their separate subjectivities and the simple summation of the two. Using a detailed clinical illustration of a difficult analysis with a severely fetishistic‐masochistic patient, the author describes the kind of knowledge, experience, and powerful effects that come into being when the analyst interconnects psychically with the patient in living through the process, and that relate specifically to the analyst's compassion.     

Freud's Irma dream and the origins of psychoanalysis

This paper investigates Freud's Irma dream as a response, in part, to the publication of Studies on Hysteria (Breuer & Freud, 1893-1895). As such, Freud's dream and associations reveal a great deal regarding the origins of psychoanalysis. The preamble to the dream reflects Freud's concern with the ground rules and boundaries of the psychotherapeutic technique that he was in the process of developing. This paper cites evidence for Freud's concerns regarding the consequences of alterations in these basic tenets. The Irma dream and Freud's associations also convey a deep and apparently unconscious concern within Freud in respect to the concept of transference, which he may have realized on some level had been used to defensively deny disturbing inputs by the therapist into the treatment situation and patient. The dream may be understood also as reflecting a deep sense of concern regarding unrecognized harmful effects of psychoanalytic psychotherapy and Freud's concern that the treatment process might be more destructive than helpful. The curative aspects of psychotherapy are viewed in terms of action-discharge rather than insight. In all, this reanalysis of the Irma dream focuses on Freud's unconscious conflicts, fantasies, and anxieties at a time when he, along with Breuer, presented a burgeoning psychoanalytic treatment modality to the professional world.     

Conceptual framework from the Paris Psychosomatic School: A clinical psychoanalytic approach to oncology1

This article presents further clinical material from the Paris Psychosomatic School ( Aisenstein, 2006 ). The Freudian foundations of psychosomatics are detailed and post-Freudian developments focusing on the contribution of the Paris Psychosomatic School are outlined, in particular, the somatizing process as a result of regression and the somatizing process as a result of drive unbinding. The authors argue that the latter possibly gives rise to progressive and serious illness leading to death. The relationship of classical psychoanalysis to psychotherapeutic treatment from the angle of the Paris school is commented on. The authors then turn to two clinical presentations of women suffering from breast cancer. The method of evaluating the patients’ capacities for undergoing psychotherapeutic treatment and their mental capacity for healing is discussed. The face-to-face psychoanalytic treatment undertaken with the second case is discussed. Finally, the authors recall Freud’s insistence after 1920 on the opposition of the life drives and the death drives, which placed self-destruction at the centre of psychic functioning. They conclude that current research in biology and medicine, notably research concerning programmed cell death, will converge with psychoanalytic psychosomatics to illuminate somatizing processes and demonstrate the relevance of psychoanalytic treatment to patients who are capable of mental reorganization in the course of their illness and medical treatment.     

Identifications Annealed,Adhesive and Political: Commentary on Paper by Nina Farhi

Farhi's fascinating paper pays tribute to and extends those segments of Milner's clinical work that Milner hesitated to theorize explicitly herself. Seeking to understand the latter, I trace psychoanalytic politics in general and the history of Milner's relationships with Winnicott, Klein, and Riviere in particular to explore how her dutiful compliance to the rigid taxonomy of psychoanalytic power of her time bore on the trajectory of her becoming an analyst with a mind of her own. It is in accounting for how she struggled to disentangle herself from that web, that we discover how Milner was able to creatively refashion her work with her patient Susan, a process by which Susan was greatly impacted.

Following the trail of Farhi's ideas around this process and considering her thoughts around their psychic meanings for both analyst and patient, I explore their clinical implications. I focus on the transferential iterations of these dynamics to consider Farhi's suggestion that an annealed bond needs to be established in the treatment of patients who have, early in life, failed to develop annealed identifications. This opens up questions around how such bonds can malignantly colonize the analyst's mind and psychic reality, raises questions of self-care in the analyst and contributes to prognostically anticipating certain sets of enactments in the course of long-term psychoanalyses.     

Werkzeugkasten des psychodynamischen Psychosetherapeuten

The authors describe the modification of the classical psychoanalytic treatment technique, which was developed in the past decades to treat people with schizophrenic psychosis. The technique which can be used in modified psychoanalytic as well as other psychodynamic settings, was adjusted to the specific problems which occur in the psychotherapy of patients with schizophrenia. This specific modified psychotherapy deals with a paradigmatic experience in the therapeutic relationship to reduce traumatic fear and to overcome interpersonal and intrapsychic dilemmas. This modification increases the possibility to reconstruct the personal history of the psychosis in a dialogical process together with the patient.     

How treating psychoanalysts respond to psychotherapy research constraints.

The psychoanalytic community increasingly recognizes the importance of research on psychoanalytic treatments, yet a significant number of psychoanalysts continue to believe that research is either irrelevant to psychoanalysis or impossible to accomplish. Psychoanalysts who accept the value of research express concern that intrusions required by research protocols create significant distortions in the psychoanalytic process. The authors, all psychoanalysts, are studying the outcome of a brief (twenty-four-session) psychodynamic treatment of panic disorder. They report their experiences and struggles with the intrusions of videotaping, working with a treatment manual, and time-limited treatment. This research process required them to question old beliefs and to confront feelings of disloyalty toward their analytic training and identity, particularly with regard to keeping a "clean field" and routinely performing long-term analysis of character. The therapists' psychoanalytic knowledge, however, emerged as crucial for them in managing specific research constraints. Despite concerns about providing inadequate treatment, therapists were found to engage patients with psychoanalytic tools and focus in vibrant and productive therapies that led to significant improvements in panic symptoms and associated quality of life. The authors suggest that psychoanalysts have been overestimating the potential damage of research constraints on psychoanalytic process and outcome.     

COLLABORATING WITH THE UNCONSCIOUS OTHER

The analysand's capacity for making use of psychoanalytic treatment has been a subject of importance since the beginning of psychoanalysis. The author addresses an aspect of the difficulty encountered by analysands in achieving a psychic state that allows the creative use of free association, dreams, parapraxes and other spontaneous phenomena occurring during the course of treatment. He suggests that a very specific state of mind is essential to both the psychoanalytic process and the creative process. Using theoretical concepts derived from Freud, Klein and Bion, he develops the idea of an internal object relationship, 'the collaboration with the unconscious other', which forms the basis for both creative thinking and the psychoanalytic function of the personality. Creative thinking is distinguished from artistic endeavour and discussed as a universal potential, on which growth in psychoanalysis depends. The term 'unconscious other' is meant to signify the subjective experience of a foreign presence within oneself from which both spontaneous creative inspiration and involuntary psychic phenomena are felt to emanate. The author presents clinical material to suggest that paranoid-schizoid and depressive anxieties form obstacles to collaborating with the unconscious other, and must be worked through in order to achieve an analytic process.     

Long-Term Psychoanalytic Therapy as a Life-Saving Procedure

A dramatic long-term psychoanalytic treatment of a psychotic character disorder is presented in detail. This patient began therapy with a long standing history of an eating disorder for which she had received many hospitalizations and forms of treatment without any success. She was in a deep despair and as a last resort agreed to a psychoanalytic therapy. During the many years of treatment the eating disorder completely resolved but was replaced by a series of very dangerous accidents that occurred each time she was betrayed and disappointed by a boy friend. This went on pari passu with a deepening understanding of her childhood and her psychodynamics but the middle of the therapy was very stormy and required tenacious efforts to maintain the treatment. The self-destructive behavior was traced to early and profound childhood disappointments and a sense that these were her fault because she was so unlovable and therefore deserved punishment. A dangerous stalemate developed in the treatment after a number of years. The analyst presented the case to colleagues several times and wrote it up in detail, which enabled him to understand his own countertransference and resolve it. This resulted in a dramatic change in the patient and a very favorable and happy ending to this very difficult treatment after 15 years. Although the author believes all patients in psychoanalysis should be approached with as neutral and objective a stance as possible, emphasizing free association and dream material in order to interpret the crucial childhood determinants of the patient's psychopathology, in cases such as psychotic character disorders the outcome clearly also depends on interpersonal factors. The case illustrates the deep partly conscious and partly unconscious interaction between a patient and her analyst over many years of treatment and the profound effect this has on the outcome. It underscores the importance of patients being allowed to heal in their own way and in their own time without intrusion or interference from the analyst. It also demonstrates the crucial importance of long-term psychoanalytic therapy as a life-saving procedure in cases where it is appropriate in spite of the great amount of time and expense involved.