Reflections on the role of the analytic setting in the light of COVID-19

There have been many reflections, both individual and collective within our Institutes, on the effects on our work with patients caused by COVID-19 and the requirement to move suddenly from the setting of our own consulting rooms to working with patients online (see also, the previous issue of this Journal). This paper focuses on what we have learned from these experiences that can add to our knowledge about the role of the setting in analytic work. Drawing on Bleger’s (1967) seminal paper highlighting the usual setting as a mute projection carrier for primitive wishes and affects, the paper explores how different patients have reacted to the loss of the analyst as the guardian of the setting and in particular as an embodied presence. Some key questions and challenges for both patients and analysts during the pandemic, when ‘the setting begins to weep’, are explored.     

Finding our way in perplexity: the meanings of sex in the analysis of a gay man.

As preconceptions about the meaning of sexual orientation are increasingly abandoned, analysts are left with the question of how these matters are to be addressed in clinical work. These problems are explored as they emerged in analytic work between a "gay" man and a "straight" analyst. Emphasis is placed on how the search for personal meaning is impacted by the intellectual and social context inhabited by analyst and patient.     

External and internal reality: The impact of the current socio‐economic crisis on the analytic dyad

This paper addresses the impact of the current economic crisis on the psychic functioning of the patient and the analyst, their relationship and collaboration. This intrusion of ‘external reality’ is multidimensional, and thus with multiple meanings. The critical role of the economic factor brings various dimensions of money into play, such as self‐preservation, power as well as aspects of psychosexual development. In addition, the crisis involves symbolic loss of basic ideals such as honesty and social responsibility. Patient and analyst are affected in similar and different ways in their respective roles as well as according to the specific intrapsychic functioning of each. Moreover, unique characteristics of the crisis often create a crisis in the analysis. In order to avoid deformation of the analytic relationship, the analytic dyad must examine and work through the multiple meanings of the crisis as well as the meaning of the impact of the crisis on the analytic relationship for both patient and analyst. This complex transference‐ countertransference interplay poses specific challenges to the analyst. After discussion of these issues, clinical material is presented that demonstrates how they appear in analytic practice today.     

Confidentiality and paradox: the location of ethical space

Implicit in Jung's alchemical metaphor of the vas bene clausum is the idea of an analytic frame with a space inside it for something vital, a relationship between two selves, to develop. For this to happen, analysts must respect their patients' rights to confidentiality. The paper explores the analyst's state of mind and the intrapsychic processes that are constellated when struggling with ethical dilemmas about issues of confidentiality in analytic work. The author suggests that at times when analysts consider breaking confidentiality, there is often a disturbing inner conflict between their moral principles (codes of ethics) and their internal personal ethical attitude. At these difficult moments, the mutuality of the work and the vas bene clausum can be significantly disrupted. The analyst tries to find a third position, a mental and emotional ethical space where the subjective and the objective, the ethical and the unethical can become more companionable bedfellows.     

Working at the “Intimate Edge”: Intersubjective Considerations—Comments on “A Case Study of Power and the Eroticized Transference–Countertransference”

Working from the premise that as analysts we are always vulnerable to unconscious collusion and enactment, and that this has radical implications for how we conceive of the analytic process, I try to illustrate how the process of working at the “intimate edge” of the analytic relationship, and explicitly engaging what goes on intersubjectively between patient and analyst expands the analytic process and the analytic possibilities. I especially focus on how deconstructing interactive enactment can help to access unconscious aspects of what might be in play in relation to the issues of power and eroticized transference–countertransference under discussion here, and how this process itself can become the medium of the work and the focus of therapeutic action.     

The analyst's anxieties in the first interview: Barriers against analytic presence

To answer the questions: why don't more people enter analysis and how do we get more people to do so? Attention is drawn to anxieties in the analyst that become obstacles to the initiation of analysis. The main focus of the paper is how to understand why analysts, irrespective of patient characteristics, seem to have resistances against embarking on analysis. Being a meeting between strangers the consultation activates strong emotional reactions in both parties. One way of coping is defensively to diagnose, assess and exclude instead of being present as an analyst. The analytic frame of a consultation is ambiguous, and a secure analytic function is needed in order to meet the openness and unpredictability of this frame. A fragile psychoanalytic identity is seen as central to analysts' failure to create an analytic practice; it takes years to develop and maintain a robust analytic function, and analytic work continues to cause disturbing emotional reactions in the analyst. Analysts' vulnerable identity is also linked to the history of psychoanalysis that has fostered an ideal of analytic practice that is omnipotent and impossible to reach. Therefore it is no wonder that attempts to reach a convinced recommendation of analysis can become diverted in the process of consultation. Confronting these inner impediments in order to strengthen the analytic identity is suggested as a better way to get more analytic patients than to keep looking for so‐called analysability in patients.     

1. On note taking

In this paper the author explores the theoretical and technical issues relating to taking notes of analytic sessions, using an introspective approach. The paper discusses the lack of a consistent approach to note taking amongst analysts and sets out to demonstrate that systematic note taking can be helpful to the analyst. The author describes his discovery that an initial phase where as much data was recorded as possible did not prove to be reliably helpful in clinical work and initially actively interfered with recall in subsequent sessions. The impact of the nature of the analytic session itself and the focus of the analyst's interest on recall is discussed. The author then describes how he modified his note taking technique to classify information from sessions into four categories which enabled the analyst to select which information to record in notes. The characteristics of memory and its constructive nature are discussed in relation to the problems that arise in making accurate notes of analytic sessions.     

Technical challenges faced by the immigrant psychoanalyst

This paper delineates the technical challenges faced by immigrant analysts. These include (i) maintaining cultural neutrality toward "native" patients, (ii) wondering about the patient's motivations for choosing an ethnoculturally different analyst, (iii) scanning the patient's associations for interethnic clues to deeper transferences, (iv) negotiating the dilemmas posed by conducting analysis in a language other than one's mother tongue, and (v) avoiding shared projections, acculturation gaps, and nostalgic collusion in working with homoethnic immigrant analysands. While by no means irrelevant to the clinical work of non-immigrant analysts, these tasks seem to have a greater importance for the immigrant analyst. Brief clinical vignettes are offered to illustrate these propositions and to highlight the tension between the universality of fundamental intrapsychic and relational configurations, on the one hand, and the nuances of cultural and linguistic context, on the other.     

The Ideal Patient and the Realities of Clinical Work

As candidates, and later as practicing analysts, we filter the idea of what patients, analysts, and the analytic process should look like through our own ego ideal. Literature that is often stilted toward a theoretical ideal further muds the picture. Finally, we are often confused by the quest for the perfect patient who meets the criteria for analyzability outlined by our training institute, our supervisors, our teachers, and our own demanding superegos. This paper examines several cases of clinical work that falls far short of any ideal. However, these realistic snapshots of day-to-day clinical work are too important to be ignored as simply failed cases with unanalyzable patients. Often, even the briefest of clinical encounters enrich the analyst's understanding of human functioning and occasionally benefits the patient as well. If the analyst uses the analytic stance with all of his patients, a useful analytic discourse may take place with some of them. These cases are not standard or complete analytic treatments, but the results are often valuable to the practitioner and potentially helpful to the patient.     

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

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

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

On becoming a psychoanalyst

One has the opportunity and responsibility to become an analyst in one's own terms in the course of the years of practice that follow the completion of formal analytic training. The authors discuss their understanding of some of the maturational experiences that have contributed to their becoming analysts in their own terms. They believe that the most important element in the process of their maturation as analysts has been the development of the capacity to make use of what is unique and idiosyncratic to each of them; each, when at his best, conducts himself as an analyst in a way that reflects his own analytic style; his own way of being with, and talking with, his patients; his own form of the practice of psychoanalysis. The types of maturational experiences that the authors examine include situations in which they have learned to listen to themselves speak with their patients and, in so doing, begin to develop a voice of their own; experiences of growth that have occurred in the context of presenting clinical material to a consultant; making self-analytic use of their experience with their patients; creating/discovering themselves as analysts in the experience of analytic writing (with particular attention paid to the maturational experience involved in writing the current paper); and responding to a need to keep changing, to be original in their thinking and behavior as analysts.     

The Mutuality of Change and Personal Growth in Analytic Relations: Commentary on Paper by Lauren Levine

This discussion explores the ways in which the multiple roles that analysts assume in their training years and beyond (analyst, patient, supervisor, supervisee, student, and teacher) are complementary and mutually enhancing. I suggest that our patients' personal growth, expanded and enhanced sense of self, and healing of old wounds are integrally linked to our own. Our work with our patients informs our personal analytic work, which expands our work with patients, deepening our capacity for knowing ourselves and others, in a continuous mutually enriching loop of psychoanalytic exploration.     

When theory and practice diverge: gender-related patterns of referral to psychoanalysts.

This study tests the hypothesis that female analysts, relative to male analysts, receive a disproportionately small percentage of male referrals. Referral patterns for 170 analysts from four institutes accredited by the American Psychoanalytic Association were examined. One thousand, five hundred and ten patients referrals were studied. The findings were extremely robust and offered dramatic confirmation of our hypothesis. The major implications of the study are as follows: (1) Women analysts receive relatively few adult male referrals, making it difficult for them to gain requisite clinical experience with men. (2) Analysts and nonanalysts alike demonstrate a reluctance to refer male patients to female analysts. (3) Adult referrals, including those made by analysts, are significantly influenced by the issue of gender match between patient and analyst. (4) Analysts' behavior with regard to making referrals does not correspond to explicit clinical theory regarding how analysts make referrals--specifically, the extent to which gender influences the referral process is not adequately described by theory. We believe that these findings are of some concern from the standpoint of analytic education and that they also raise questions regarding unacknowledged aspects of how gender match between patient and analyst enters into clinical decision making.(ABSTRACT TRUNCATED AT 250 WORDS)     

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 Psychoanalytic Other: Commentary on Paper by Helen K. Gediman

Dr. Gediman locates the intersection of modern Freudian and relational theory in the arena of what she calls the “disclosures of everyday analysis” (p. 242). She suggests that because Freudian analysts, like their relational colleagues, work intersubjectively, relational theory does not itself embody a paradigm shift away from the Freudian model. I disagree. Relational theories assume that the analyst's work is inevitably informed by the relational context in a way that precludes clinical certainty. Gediman, however, believes that the analyst is capable of separating her countertransference response from her subjectivity and thus can interpret from a position of clinical certainty. Each set of theoretical assumptions is associated with a somewhat different analytic stance and analytic ideal. Freudian analysts aim for a position of “methodological neutrality” that relies on considerable certainty in the countertransference while giving the analyst plenty of room within which to use her subjectivity. The relational ideal concerns the analyst's capacity to enter into an asymmetrical treatment relationship and to tolerate the uncertainty generated therein.     

Hearing voices: the fate of the analyst's identifications.

Using detailed clinical examples, the author illustrates the function of conscious and unconscious identifications with former training analysts, supervisors, teachers, and theorists in the mind of the working analyst. As compromise formations, analytic identifications are the product of loving and aggressive wishes, defenses against those wishes, and self-punitive trends that accompany the analyst in the work. The analyst's stance at any given moment has an identificatory history that may become conscious at certain times with certain patients. While the analyst's identifications modify over time, following a predictable developmental path, they are never fully given up, but consciously and unconsciously remain an active part of the analyst's inner life. During the clinical hour they are responsive to both the analyst's and the patient's conflicts, and they coexist in a dynamic reciprocal relationship with the patient's inner life.     

On Relational Hierarchy: Friends or Parents? Discussion of Lisa Director and Robert Grossmark

Two very successful clinical experiences are presented to illustrate each analyst’s preferred ways of engaging clinically with patients. In my discussion I contend that analysts’ preferred theories of therapy often drive the nature and texture of analytic engagement and that each analyst works best in the context of embracing those cherished theories. More specifically, I attempt to contrast psychoanalytic traditions that, on one hand, situate the analyst in a hierarchical parental role and, on the other hand, conceive of the analyst as more of a flawed peer.     

The psychoanalyst: On becoming more human than otherwise

Classical psychoanalytic technique, which called for the role of the analyst to be a scientific observer, removed from interaction with the patient, imposed such restrictions on the analyst that often his or her simple human responsiveness to the patient was curtailed. Harry Stack Sullivan revolutionized the field by introducing the concept of “participant observation,” and others of his time made similar observations. Gradually, over the years, analysts have become more real, more human, and more interactive with their patients. Contrary to classical opinion, this departure from the original technique does not interfere with analytic work, and, in fact, enhances it, if the analyst monitors and analyzes the reactions of patients to this more human engagement. Examples are provided to support this conclusion. Murray Krim is a supervising analyst at the William Alanson White Institute, Adjunct Associate Clinical Professor of Psychology in the Postdoctoral Program at Adelphi University, and supervisor at the Institute for Contemporary Psychotherapy.