Technique as a Case-Specific Problem: Reply to Commentaries

Seligman's appreciative response to the discussions of his paper is most concerned with the issues raised in Leon Kleimberg's critique of his “modifications of technique.” The dialogue between Kleimberg's and his point of view, with the latter echoed as it in Case and Dent's and Frosch's, reflects a number of key convergences and divergences between the American relational perspective and the British Independents'. Both approaches rely on a fundamentally dyadic perspective that stresses how the analyst's work is fundamentally shaped in response to the patient's internal objects. At the same time, although he is sympathetic to Kleimberg's concerns, he questions the idea of technique as a fixed set of uncontaminated practices. Instead, he endorses the North American relational idea that whatever the analyst does in the name of “technique” cannot be extricated from the transference-countertransference in which it is implicated. From this point of view, technical decisions are most likely to be experienced by the patient, and very often by the analyst, as inevitably reflecting one aspect of another of the patient's internal object world from within the phanstasmatically organized matrix of each analytic relationship. In addition, he is concerned that analysts' rigidly adhering to “technical” positions will reduce their likelihood of being effective with the widest range of patients, an increasing number of whom may not accept the traditional analytic practices. The mentalization concept, although not guiding his decisions in the case, is useful in describing many such situations.     

Unrecognized Posttraumatic Stress Disorder as a Treatment Barrier for a Gang-Involved Juvenile Offender

This study examines the case of GH, an 18-year-old Latino male participating in an employment-based delinquency intervention for gang-affiliated youth. Although postintervention measures revealed that GH showed gains on key outcomes (i.e., delinquency, employment), he experienced sporadic treatment setbacks (e.g., work absenteeism, fighting) that disrupted his progress. A comprehensive psychological assessment suggested that his aggressive, illegal behavior and difficulty maintaining employment could have been influenced by previously undiagnosed posttraumatic stress disorder (PTSD). Excerpts from counseling sessions illustrated how reactive aggression, hypervigilance, sleep disruptions, and emotional numbing could have interfered with treatment gains and ultimately contributed to GH's re-arrest. Implications for early, accurate identification of PTSD in delinquency interventions for gang youth are discussed.     

THE VALUE OF UNCERTAINTY

The author discusses some of the characteristics of Roy Schafer's contributions to psychoanalysis that he finds most valuable, such as his openness to uncertainty, his anti‐reductive view of analytic constructions, his unique formulation of the analyst's role, and his close attention to how the patient engenders particular emotional reactions in the analyst. The author also presents a clinical vignette illustrating the value of the analyst's tolerance of uncertainty in the face of the patient's push for interpretations, explanations, and reassurance.     

Coping with ambiguity and uncertainty in patient-physician relationships: I. Leadership of a physician

A patient-physician relationship provides a milieu for a patient to achieve healing, solace, and reintegration of personhood. A patient's primary physician assumes a leadership role in that regard, coordinating and facilitating a regimen of analysis and therapy. The quality, quantity, and rapidity of technological advancements in the delivery of medical care, render any individual physician incomplete in terms of his ability to provide total care. Consequently, a succession of professional and paraprofessional personnel must be involved to maximize the care rendered. Nevertheless, a patient's primary physician must fulfill a leadership role as he coordinates consultations and interprets the data they provide, placing it in the appropriate situational context for his patient as part of a collective and mutual decision-making process. A patient's primary physician must be acknowledged to possess the power and authority to effect the care provided, as he must also accept the accountability, duty, obligation, and responsibility for the result of that care. By these means ambiguity and uncertainty are mitigated.     

Between listening and expression

This paper sets out to conceptualize what goes on in the analyst's mind as he listens—and expresses something—to the patient. Bion's ideas of approaching the patient's O, without memory and desire, are discussed. An alternate, more permissive, attitude to desire is suggested. This is based on the idea that containment, instead of denoting a dyadic interaction between mother and child, is a process which links the child to a begetting couple, thus a triad. Containing the patient corresponds, in the unconscious, to thinking about a sexual couple in a mutually beneficent interaction. Since the patient's anxiety, in his unconscious, parallels a frightening primal scene, containment is viewed as a continuous translation of a primitive primal scene into a mature act of love. A specific kind of genital desire is thus necessary for containment. This finds expression in the analyst's resonance with the patient. Clinical material from an analysis with a 7-year old boy is provided.     

MY FATHER,MYSELF

This essay presents material from the second analysis of an offspring of two Holocaust survivors, each of whom lost a child during the war. The first analysis (Kogan 2003 ) focused primarily on the patient's relationship with her mother. This second analysis revolves around the elaboration of the complex and painful father–daughter relationship, centering on the events surrounding the death of the patient's father. The discussion includes an exploration of the father's deferred action on account of his Holocaust trauma, which he passed on to the next generation; the break in the idealized paternal representation; and the daughter's identification with her father's disavowed aggressive aspects. It also examines some of the unique transference and countertransference problems that arose, mainly because patient and analyst belonged to the same traumatized large group.     

Fear of breakdown and the unlived life

Winnicott's Fear of breakdown is an unfinished work that requires that the reader be not only a reader, but also a writer of this work which often gestures toward meaning as opposed to presenting fully developed ideas. The author's understanding of the often confusing, sometimes opaque, argument of Winnicott's paper is as follows. In infancy there occurs a breakdown in the mother–infant tie that forces the infant to take on, by himself, emotional events that he is unable to manage. He short‐circuits his experience of primitive agony by generating defense organizations that are psychotic in nature, i.e. they substitute self‐created inner reality for external reality, thus foreclosing his actually experiencing critical life events. By not experiencing the breakdown of the mother–infant tie when it occurred in infancy, the individual creates a psychological state in which he lives in fear of a breakdown that has already happened, but which he did not experience. The author extends Winnicott's thinking by suggesting that the driving force of the patient's need to find the source of his fear is his feeling that parts of himself are missing and that he must find them if he is to become whole. What remains of his life feels to him like a life that is mostly an unlived life.     

Lay theories of delinquency

This paper is concerned with the range, structure and determinants of lay people's implicit theories of delinquency. The different explicit psychological and sociological theories were reviewed as were studies on lay beliefs about crime and delinquency. After pilot interviews in which people were asked to list what they believed to be the major causes of delinquency, over 350 people completed a questionnaire in which they rated 30 explanations for their importance in explaining delinquency. The results showed numerous sex, age and voting differences. Conservatives tended to blame a person's poor education for his or her delinquency, while Labour voters tended to explain delinquency in terms of societal factors. A factor analysis revealed six clear explanation types for delinquency some of which were clearly related to explicit theories. Results were discussed in terms of the psychology of explanations and the relationship between explicit and implicit theories. Implications of this research were also noted.     

Social criticism in the process of interpretation (discussion)

Abstract

The author comments on Horst Petri's case presentation and gives reasons why he sees social criticism within the process of interpretation as inappropriate. Firstly he contradicts Petri's view of the severity of his patient's illness. He thinks a supportive therapy was not appropriate and he would have treated her by using conflict centered interpretations. Secondly he assumes that the analyst's social criticism forms an alliance with the analysand which excludes essential issues from the analytic work. And thirdly he reminds us that psychoanalysis doesn't spare a supposedly progressive attitude from criticism. Within the framework of psychoanalytic theory, the relativity of all value judgements forbids the analyst to tie himself down in the way Petri suggests.     

Clinical applications of Matte Blanco's thinking

Ignacio Matte Blanco (1908–1995) left very few specific indications about the applications of his theoretical notions to his interpretative style. The author shows how he uses Matte Blanco to formulate some of his own interpretations. The first part of the paper uses clinical vignettes to illustrate some of Matte‐Blanco's concepts. Their theoretical vocabulary is thus made explicit. Then two psychoanalytic sessions are discussed at greater length, together with one from a therapy, so that the use of Matte‐Blanco's notions can be seen clearly, allowing for a fresh perspective on areas of psychoanalytic theory, particularly dreams, psychopathology viewed according to the proportions of asymmetrical and symmetrical functioning in the patient's bi‐logical mental system, the multidimensionality of the unconscious, the structural unconscious, the emotion‐thought relationship, projective identification, resistance, and negative therapeutic reaction. The practical consequences of all this are elaborated, particularly the ensuing possibility of ‘thinking with the patient' in the session. This enables the patient to introject a form of mental functioning in which the asymmetrical mode is not invaded by the symmetric mode (a parallel can be seen here with the Bionian concept of dialogue between the psychotic and non‐psychotic parts of the mind).     

Light and color in a void: The analysis of a special needs child

This clinical report comes from the five year, four day a week analysis of a male child. What is special is that this treatment is of a child with marked mental retardation. I have retained this nomenclature because that is how Ricardo's parents described his mental capacity. What they meant was that he was greatly impaired in his cognition and this could be seen in Ricardo's severe cognitive, social, behavioral, and relational improprieties. I have privileged the function of psychoanalytic understanding and the role of transference to bring about modifications in this child's internal world. And I have considered the patient's psychotic mental state to be in need of psychoanalytic treatment not withstanding his psychosis's connection to his cognitive handicap. I have also added information I have received after the analysis, information that demonstrates continued integration coming from the analytic process. Owing to Ricardo's limited mental capacities, this article advances clinical information that is not often found in analyses of children. There are possibly many other children like him who nonetheless would benefit from dynamic psychoanalytic understanding. On the other hand, I shall not discuss this matter theoretically, even though some theoretic considerations are necessary. Clinical practice and the transferential relation are this report's principal material.     

Transformation of Narcissism and the Intersubjective Therapeutic Exchange

Abstract

Clinicians and researchers have redefined adolescence and depression in adolescence and no longer consider depression as typical of “normal” adolescence. Depression during the teenage period is differentiated from a depressed mood, replete with misery and anguish, and depression proper, i.e., a real illness with specific symptoms which are depressive equivalents. These symptoms often include aggressivity, substance abuse, school refusal, and delinquency. A detailed case presentation is offered of a 17-year-old depressed, substance abusing adolescent who shares his lyrics and heavy metal rock music in sessions, thereby transforming his aggression and narcissism. Use of self psychology and intersubjectivity theory stimulated the formation of a therapeutic alliance and a corrective selfobject relationship, with this young patient's subsequent gains in self-regulation, decreased temper eruptions, and school involvement.     

3 Culture and Ego-Ideal in Suicide: An Adult Case

A case is presented in which the patient's self-expectations, arising from his ego ideal, were violated by a conflict with his wife, who came from a different culture and did not share his marital and family values. When she left him he was devastated, not only by the loss of his family, but by the destruction of his ideal vision of himself as a husband and father. A dangerous suicide attempt followed. The psychodynamic formulation of the case and the treatment that followed from it are discussed.     

From pilot fish to analyst: Finding a path between symbiotic and autistic defences

This paper presents the clinical case of a patient with autistic features. One of the main difficulties in his treatment was the particular rapid rhythm of his projections, introjections and re‐projections that constrained the analyst's capacity for reverie and hindered the use of effective projective identification processes. These alternating defensive constellations lead either to an expelling autistic barrier or to an engulfing symbiotic fusion. Their combination can be seen as the expression of a defence against an unintegrated and undifferentiated early experience of self that was in this way kept at bay to prevent it from invading his whole personality. Maintaining the symbiotic link, in which I kept included by staying partially fused to what was being projected and using my analytic function in a reduced way, helped to relate to what was in the patient's inside. Leaving this symbiotic link let my interpretations appear to ‘force’ their way through the autistic barrier. Yet as the process developed they allowed to show the patient how he ejected me and what was happening in his inside, behind his autistic barrier. So I found myself on the one hand accepting the symbiotic immobilization and on the other hand interpreting in a way that seemed forced to the patient, because it implied a breaking of the symbiotic position. The inordinate speed of projections and introjections could thus be interrupted, creating a space for awareness, reflection and transformation, and allowed the emergence of a connection between the patient's inside and outside. In the course of treatment I realized that this kind of dual defence system has been described by the late Argentinian analyst José Bleger. He assumes the existence of an early “agglutinated nucleus” that is held together by a psychic structure he calls the “glischro‐caric” position, in which projective identification cannot take place because there is no self/object differentiation. I have considered the rapid and fugitive use of projection and re‐introjection I met in my patient to be a manifestation of the dual defence system Bleger describes. Although he does not specifically mention this particular vicissitude of operative defences he does give hints about a rhythm in the patients’ projections and introjections.     

At Death's Door: Therapists and Patients as Agents

This paper explores the interrelationship between patients' exercise of will to make advances in an analysis and their readiness to forgive their analysts for their human limitations. There is a thin line between idealization of the analyst, probably a necessary component of the process, and resentment of the analyst for his or her privileged position in the world and in the analytic situation itself. The patient's “progress” emerges as a kind of reparative gift, one that implicitly overcomes the patient's tendency to withhold such change out a sense of chronic, malignant envy. Particularly poignant in terms of its potential to elicit the patient's reparative concern is the situation in which the analyst is struggling with his or her mortality because of aging or life-threatening illness. In this essay two clinical vignettes are presented to illustrate some of the issues that this situation poses. One begins with an elderly patient appearing at the door of the analyst's (the author's) home the day of his return from the hospital after coronary bypass surgery. The other begins with an analyst who is terminally ill appearing at the door of a patient who is threatening suicide. The two stories are compared in terms of their implications for human agency, the exercise of will, and the coconstruction of meaning in the face of mortality in the analytic process.     

THE ANALYST'S WAY OF BEING: RECOGNIZING SEPARABLE SUBJECTIVITIES AND THE PENDULUM'S SWING

Whether the analyst finds the patient's emerging transference affectively tolerable or intolerable plays an important role in the analytic couple's negotiation of the configuration that the transference‐countertransference relationship ultimately assumes. If the analyst is deeply repelled by transference‐related roles to which he is assigned, patient‐ascribed attributions, or projection‐drenched interactions, he may react in violent protest, engaging in enactments that say more about his separable subjectivity than about the intersubjective situation. While there has been a recent trend to view enactments as a crucial aspect of psychoanalytic technique, this trend risks overlooking the way in which the analyst's way of being comes into play in the treatment.     

Report on a Panel Discussion on Interpretation

A case is presented where the patient's early experiences of violence and neglect have resulted in a defensive organization that has protected him against intolerable anxiety, at the cost of development and growth. In the analytic setting, the patient withdrew into his perverse fantasy world, an area of relative peace where he had omnipotent control, whenever contact with the analyst within a “room for relatedness” was experienced as threatening or frustrating. His avoidance of contact with the analyst was also an avoidance of reality, and proved to be a strong obstacle to progress in the treatment. During the terminal phase, he was forced to face reality and it seemed then that some widening of his psychic reality took place.     

Self‐analysis and the development of an interpretation

In spite of the fact that Freud's self‐analysis was at the centre of so many of his discoveries, self‐analysis remains a complex, controversial and elusive exercise. While self‐analysis is often seen as emerging at the end of an analysis and then used as a criteria in assessing the suitability for termination, I try to attend to the patient's resistance to self‐analysis throughout an analysis. I take the view that the development of the patient's capacity for self‐analysis within the analytic session contributes to the patient's growth and their creative and independent thinking during the analysis, which prepares him or her for a fuller life after the formal analysis ends. The model I will present is based on an over lapping of the patient's and the analyst's self‐analysis, with recognition and use of the analyst's counter‐transference. My focus is on the analyst's self‐analysis that is in response to a particular crisis of not knowing, which results in feeling intellectually and emotionally stuck. This paper is not a case study, but a brief look at the process I went through to arrive at a particular interpretation with a particular patient during a particular session. I will concentrate on resistances in which both patient and analyst initially rely upon what is consciously known.     

Rechtliche Grundlagen der psychosomatischen Rehabilitation Auswirkungen auf die Psychotherapeut-Patient-Beziehung

The legal foundation of psychosomatic rehabilitation, which amounts to more than half of all inpatient psychotherapies performed in Germany, includes the duty of the patient to cooperate, the pre-condition that there is a chance for increasing or restoring patient’s ability to work, and the obligation for therapists, to perform a socio-medical rating of patient's ability to work as well as a judgement about his/her credibility concerning the asserted handicaps and disabilities. All this has an influence on the relationship between psychotherapist und patient and leads to problems in the treatment especially of those patients, who wish to retire. For the psychotherapist not only counter—transferences may be difficult to handle but also role conflicts resulting above all from the challenge being simultaneously psychotherapist and medical expert, who has to rate patient's ability for work and his credibility. To keep capacity of acting, the psychotherapist should reflect these issues and make them transparent for the patient. Sufficient supervision is very important. This will not only improve patient's, but also pension scheme's profit.     

Commentary on Paper by Steven Cooper

In this discussion of Steven Cooper's paper, it is argued that, although Cooper's desire to hold himself “accountable” in his work with patients is laudable, the “pluralistic third” approach that he employs gives rise in his doing so to several difficulties in the way that it is described in the paper. The vivid clinical material that Cooper provides to illustrate his approach is used as a starting point to offer an understanding of what transpired between analyst and patient, which although convergent with Cooper's formulations in some respects nevertheless follows a very different line of thinking in other areas. Broadly speaking, it is suggested that although these divergences arise from many sources—a discussion of which is beyond the scope of this contribution—one particular issue involved is a rather different understanding of the role of early internalized object relations in the patient's psychic life and the way these get lived out at many levels in the treatment situation. It is further argued that Cooper's conceptualization of the approaches of schools different from his own appears somewhat circumscribed and this detracts from his desire to make an authentic comparison between his way of working and those of other schools, something that is called for by his proposed pluralistic third method of keeping himself accountable. This is not considered surprising given the difficulties inherent in our becoming adequately familiar, in more than just an intellectual way, with the approaches of schools different from our own, especially when wide divergences are involved between schools.