On talking-as-dreaming

Many patients are unable to engage in waking-dreaming in the analytic setting in the form of free association or in any other form. The author has found that 'talking-as-dreaming' has served as a form of waking-dreaming in which such patients have been able to begin to dream formerly undreamable experience. Such talking is a loosely structured form of conversation between patient and analyst that is often marked by primary process thinking and apparent non sequiturs. Talking-as-dreaming superficially appears to be 'unanalytic' in that it may seem to consist 'merely' of talking about such topics as books, films, etymology, baseball, the taste of chocolate, the structure of light, and so on. When an analysis is 'a going concern,' talking-as-dreaming moves unobtrusively into and out of talking about dreaming. The author provides two detailed clinical examples of analytic work with patients who had very little capacity to dream in the analytic setting. In the first clinical example, talking-as-dreaming served as a form of thinking and relating in which the patient was able for the first time to dream her own (and, in a sense, her father's) formerly unthinkable, undreamable experience. The second clinical example involves the use of talking-as-dreaming as an emotional experience in which the formerly 'invisible' patient was able to begin to dream himself into existence. The analyst, while engaging with a patient in talking-as-dreaming, must remain keenly aware that it is critical that the difference in roles of patient and analyst be a continuously felt presence; that the therapeutic goals of analysis be firmly held in mind; and that the patient be given the opportunity to dream himself into existence (as opposed to being dreamt up by the analyst).     

On Seeing What Is Not Said: The Concrete Mode of Psychic Functioning and the Development of Symbolization

This paper examines the difficulties that arise with patients who experience a compromised capacity in working on a symbolic level when ensnared in specific transference/countertransference entanglements. In these kinds of situations, patients often operate in what is referred to as the concrete mode of psychic functioning in which there is an inability to think psychologically about their own mind, as well as the minds of others. Similarly, the analyst often has trouble thinking with the patient in processing the actions between them, unable to recruit the patient’s mind in becoming a thinking couple together. Having exhausted conventional technique and interventions in trying to observe the enactment with the patient, the author argues that the analyst’s ability to grab hold of fleeting associations and memories that have not been fully processed not only expands his own mind but also facilitates symbolic functioning in the patient’s mind. By using the imagistic and sensorial substrates of these remembrances to further symbolize personal experiences, the analyst may gain entrée into the patient’s mental life.     

Transformations in hallucinosis and the receptivity of the analyst

Bion describes transformation in hallucinosis (TH) as a psychic defence present in elusive psychotic scenarios in which there is a total adherence to concrete reality: as the hallucinatory activity which physiologically infiltrates perception and allows us to know reality, setting it off against a background of familiarity; and then, surprisingly, as the ideal state of mind towards which the analyst has to move in order to intuit the facts of the analysis. When hallucinosis is followed by ‘awakening’, the analyst gains understanding from the experience and goes through a transformation that will inevitably be transmitted to the analytic field and to the patient. In this paper I illustrate Bion's concept and underline its eminently intersubjective nature. Then I differentiate it from two other technical devices: reverie, which unlike hallucinosis does not imply the persistence of a feeling of the real, and Ferro's transformation in dreaming, i.e. purposeful listening to everything that is said in the analysis as if it were the telling of a dream. Finally, I try to demonstrate the practical utility of the concept of transformation in hallucinosis in order to read the complex dynamics of a clinical vignette. Though not well known (only two references in English in the PEP archive), TH proves to be remarkably versatile and productive for thinking about psychoanalytic theory, technique and clinical work.     

The analyst's implicit alpha-function, trauma and enactment in the analysis of borderline patients

The present paper discusses situations in which patient and analyst are involved in obstructive collusions, non-dreams-for-two, shaping enactments. Specifically, it describes explosions in the analytical field, acute enactments, which the analyst assigns, at first sight, to his faulty conduct. The subsequent amplification of the analytical dyad's capacity of symbolization makes the analyst investigate his presumed fault. The present work shows how acute enactments revive traumatic situations that were concealed by previous obstructive collusions, or chronic enactments. During chronic enactments unconscious exchanges occur between the dyad, in which the analyst provides implicit alpha-function to the patient, little by little recovering the traumatized parts. When there is enough recovery, the protective collusion is undone and the trauma is revived as acute enactment. This revival will not be traumatic because there are mental resources ready at hand to symbolize it. These situations are articulated with borderline patients. The patient clings to the analyst, using him as a protective shield against reality traumas. The implicit and explicit alpha-function exerted by the analyst contributes to the processing and symbolization of this reality, recovering the injured mind and elaborating the trauma. So the patient creates a triangular space to dream and think.     

The body of the analyst and the analytic setting: Reflections on the embodied setting and the symbiotic transference

In this paper the author questions whether the body of the analyst may be helpfully conceptualized as an embodied feature of the setting and suggests that this may be especially helpful for understanding patients who develop a symbiotic transference and for whom any variance in the analyst's body is felt to be profoundly destabilizing. In such cases the patient needs to relate to the body of the analyst concretely and exclusively as a setting ‘constant’ and its meaning for the patient may thus remain inaccessible to analysis for a long time. When the separateness of the body of the analyst reaches the patient's awareness because of changes in the analyst's appearance or bodily state, it then mobilizes primitive anxieties in the patient. It is only when the body of the analyst can become a dynamic variable between them (i.e. part of the process) that it can be used by the patient to further the exploration of their own mind.     

Perverse modes of thought

Subtle, nonpsychotic disturbances in thinking may cause significant impairment of intellectual functioning and interfere with a patient's capacity to make use of psychoanalytic treatment. As these come under interpretive scrutiny, the intellectual exchange between patient and analyst may emerge as a theater for the enactment of perverse sexual fantasies. In this paper, the author describes these disturbances in thinking and proposes a model that explains their underlying structure and their link to the associated fantasies. Interpretation and working through of the condensed part-object and whole-object transferences that emerge in the analysis of these forms of thinking may lead to some measure of clinical improvement.     

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.     

Back to the future

Significant components of psychoanalytic technique, and the theory that underlies it, seem to remain buried in our past, but are central to the growth of psychoanalysis as a treatment method based on understanding a patient's mind. By updating technique based on a theory of mind with structure, the author views the increasing freedom of the patient's mind as central to the curative process, and takes the position that in interpretive work, the analyst needs to pay more attention to the patient's capacity to meaningfully receive and integrate the analyst's interventions.     

Thinking with,and about,patients too scared to think: Can non‐interpretive maneuvers stimulate refl ective thought?

Patients incapable of higher-order (symbolic) thinking can often not tolerate evidence of the analyst's separate existence, particularly when that 'otherness' becomes evident in the process of the analyst's refl ecting upon and interpreting how the patient experiences or represents the analyst. The patient's intolerance of the analyst's efforts to think (refl ect upon and interpret) renders the usual psychoanalytic maneuvers employed to stimulate refl ective thought ineffective with such patients. Such patients have to learn to tolerate multiple perspectives before they can allow the analyst, or themselves, to think in the other's presence. The author presents two clinical vignettes that illustrate how the analyst's efforts to think about the patient were experienced by the patient as both intolerably distancing and as rejecting of an aspect of the patient's subjective reality. Working psychoanalytically with such patients requires the analyst to forgo the use of narrow interpretations that elucidate unconscious meanings and motives in favor of alternate technical maneuvers capable of facilitating the development of symbolic thinking and refl ective thought (insightfulness). These maneuvers include a demonstration of the analyst's willingness and ability to withstand (rather than 'interpret away') how he is being psychically represented by the patient, without becoming destroyed by, or lost within, the patient's characterization of him. Beside modeling a tolerance of alternate perspectives of one's self, other non-interpretive maneuvers that help facilitate the development of self-refl ective thought include: stimulating the patient's curiosity about the workings of his own mind by identifying incompletely understood behaviors or reactions worthy of greater psychological understanding, and insinuating doubt about the adequacy of the patient's explanations of such phenomena.     

Orientation,containment and the emergence of symbolic thinking

Orientation is viewed in this paper as an important dimension of containment for the development of thinking. Orientation refers to the particular positioning in space and time of mother and infant so they can find one another and then containment can take place. Bion's container–contained model for the development of thinking is based on the capacity of the mother's mind to function as a ‘home’ for the infant's primitive projections. Containment and orientation are explored in relation to an ancient Greek object called ‘σ?μβολον’ [symbolon], which I use here as a metaphor for the early negotiation between mother and infant to achieve a correct matching to each other's orientation. This is then mobilized and re‐enacted between analyst and patient in the psychoanalytic process. Orientation as part of the container–contained model enables us to view the development of thinking from a new perspective with greater integration of cognitive and emotional aspects. The clinical implication of the concept of orientation is explored in relation to the process of engagement/disengagement between analyst and patient and is illustrated by clinical material.     

Finding the depressed object in the obsessional: a clinical study

In this paper the author explores the clinical significance of the presence of a depressed internal object in a patient with marked obsessional features, dominating the patient's internal world and restricting relations in external life. After discussing important aspects of the contribution of Freud and later writers to the study of obsessional neurosis, the author provides clinical material that shows the patient's tormented relationship to a feared depressed object that was manifested in the transference. Developing her argument, the author suggests that if the analyst does not fully grasp the primitive anxieties of the underlying state of mind she can be prone to enter into an aggressive enactment with the patient's sadistic superego. This kind of enactment may arouse excitement and triumph in the patient, but actually confirms his doubts and fears about the capacity of his object to contain him.     

Full and empty spaces in the analytic process2

In this paper the author discusses two categories of patients which differ in terms of the impact they have in the countertransference. On the one hand, there are patients who create an empty space in the analyst's mind. The response they provoke is a kind of depressive feeling that remains after they leave. The patient may bring dreams and associations, but they do not reverberate in the analyst's mind. The experience is of dryness, a dearth of memory, which may‐at times‐leave the analyst with a sense of exclusion from the patient's internal world. At the other extreme, there are patients who fill the consulting room. They do that with their words, dreams and associations but also with their emotions and their actions. The experience is that the analyst is over‐included in the patient's world. They have dreams that directly refer to the analyst and the analyst feels consistently involved in the patient's analysis. The pathway through which the analyst can understand both these types of patients is via the countertransference or, to put it another way, the analyst's passion. In ‘Analysis terminable and interminable’ Freud suggested that the bedrock of any analysis is the repudiation of femininity. The author believes this statement may be viewed as lying at the crossroads of the discussion about the limits of the theoretical and clinical psychoanalytic formulations which she refers to. In the examples presented the author relates the repudiation of femininity in its connections to the gaps implicit in psychoanalytic understanding.     

The Case of David: on the Couch for Sixty Minutes,Nine Years of Once-a-week Treatment

This paper illustrates a unique case of object relations psychoanalytic psychotherapy on a once-a-week treatment basis. The work of developmental mourning that would be thought to require two to five sessions a week was accomplished on a once-a-week basis. The analyst adjusted the treatment hour, in this one case, to 60 minutes, as opposed to the 45- or 50-minute hour. When treatment began, the analyst made an intuitive judgment to increase the patient's one session a week--which the patient made clear was all he was ready to do--to 60 minutes. The analyst made time in her practice for this 60-minute session and has continued with the patient using this format for 9 years of treatment. This had led up to the current stage of treatment, which has been so critical to the patient's self-integration process.     

THE ANTEROOM: A CAMERA OBSCURA FOR GRASPING ASPECTS INVISIBLE IN THE CLASSICAL SETTING

The anteroom ¹ , ² is not only an architectural space, but also a location in the field where analyst and patient meet in a different frame of mind from the therapeutic attitude that characterizes their relationship in the consulting room. Drawing a parallel with the variations in perception generated by the camera obscura in the experience of a painter, the author investigates how new aspects of the conscious and unconscious relationship between analyst and patient can emerge within a different setting. Observation of these variations suggests the possibility of regarding the setting no longer as an invariant of the field, but instead as one of the factors that can actively mold the analytic relationship.     

Raiding the inarticulate: The internal analytic setting and listening beyond countertransference

The analytic setting exists not only externally but also internally as a structure in the mind of the analyst. The internal analytic setting constitutes an area of the analyst's mind where reality is defined by unconscious symbolic meaning. Clinical examples illustrate how a secure internal setting allows flexibility in the external setting without sacrifice of its analytic quality. The internal setting can help analysts listen inwardly to themselves in a way that is free-floating with regard to their internal processes. This points beyond usual ideas of countertransference. An analytic encounter may stir up elements that belong to the analyst's psyche which, rather than impeding the analysis, can actively enrich it. Seamus Heaney's writings evoke comparisons between listening to poems and listening to patients, and a week in a patient's analysis is described in relation to these themes.     

The Reconstruction of Psychic Trauma

The author discusses the difficulties that arose in the analysis of a female patient suffering from a delusional disorder, where traditional criteria of suitability for psychoanalytic treatment were initially lacking and had to be established as part of the process. The transference-countertransference interaction came to a deadlock, understood by the analyst as due to the patient’s pathological dyadic relating. She was lacking in her capacity of reflective functioning, and there was no potential space to foster a fruitful therapeutic dialogue between analyst and patient. The analyst adopted a bystander perspective as a vantage point from which to comment on the patient’s narrative, whereby she succeeded in gradually altering the dysfunctional dyadic exchange into an interaction where a triadic perspective was introduced as a means to making possible meaningful communication between patient and analyst. Substantial changes were achieved with this procedure as a point of departure. The case study highlights aspects of dyadic versus triadic functioning of the analytic pair, and serves to illustrate theoretical points pertaining to the ongoing debate between professionals on how the basic structural elements of the analytic relationship should be conceptualised.     

Transcending the caesura: Reverie,dreaming and counter‐dreaming

The author reflects about our capacity to get in touch with primitive, irrepresentable, seemingly unreachable parts of the Self and with the unrepressed unconscious. It is suggested that when the patient's dreaming comes to a halt, or encounters a caesura, the analyst dreams that which the patient cannot. Getting in touch with such primitive mental states and with the origin of the Self is aspired to, not so much for discovering historical truth or recovering unconscious content, as for generating motion between different parts of the psyche. The movement itself is what expands the mind and facilitates psychic growth. Bion's brave and daring notion of ‘caesura’, suggesting a link between mature emotions and thinking and intra‐uterine life, serves as a model for bridging seemingly unbridgeable states of mind. Bion inspires us to ‘dream’ creatively, to let our minds roam freely, stressing the analyst's speculative imagination and intuition often bordering on hallucination. However, being on the seam between conscious and unconscious, dreaming subverts the psychic equilibrium and poses a threat of catastrophe as a result of the confusion it affords between the psychotic and the non‐psychotic parts of the personality. Hence there is a tendency to try and evade it through a more saturated mode of thinking, often relying on external reality. The analyst's dreaming and intuition, perhaps a remnant of intra‐uterine life, is elaborated as means of penetrating and transcending the caesura, thus facilitating patient and analyst to bear unbearable states of mind and the painful awareness of the unknowability of the emotional experience. This is illustrated clinically.     

Thinking Developmentally: Perspectives Following Loewald and Klein

In this article, I explore two perspectives on development that are central to how I think and work as an analyst, one drawn from the work of Hans Loewald and one from Melanie Klein. Loewald turned the usual psychoanalytic way of thinking, rooted in the past, on its head when he theorized that development proceeds by internalization of the parent’s future vision of the child and, by corollary, the analyst’s future vision of the patient. Using a vignette from Klein’s work with 10-year-old Richard, I show how the analyst’s image of the patient’s potential can facilitate growth and development. Melanie Klein also introduced a radical reordering of traditional psychoanalytic theory when she theorized that the mind develops and is structured as positions, not as successive phases. For Klein, the mind is organized in groupings of anxieties, defenses, and object-relations that are in a continuous state of oscillation throughout life independent of chronological age. Through a clinical vignette, I illustrate how one understands a patient differently when development is seen as occuring in momentary shifts between different levels of the personality rather than as stages over time.     

The pressure toward enactment and the hatred of reality.

The pressure toward enactment is investigated in terms of the threats that primitive, pre-thinking states of mind exert on attempts to know and understand. Clinical material and a review of the literature suggest that when the analyst confronts (by thinking) rather than complies (by action) with the hidden demands of omnipotence, he or she triggers and is then subject to the pre-thinking mental realm of concrete sensory bombardment, which can penetrate and obliterate his or her separately thinking mind. One important pressure driving the analyst toward enactment derives from a defensive response aimed at avoiding the threat of such concrete projections.