The Analyst's Necessary Vertigo

The euphemistic phrase “the difficult to reach patient” often refers to work with patients who have serious difficulties relating. The author examines the basic construct of “reach,” its pitfalls, and potentials. In the author's view, often we are talking about patients who do not fully experience their own subjective existence or the existence of others. This requires unusual efforts to “reach” the patient in order for the patient to consolidate a sense of self and other, creating the possibility of reflective relating. In contrast to views that see such psychoanalytic “reach” as associated primarily with the analyst's needs or pathology, the author views the analyst's extraordinary efforts as responsive to the patient's need to move the analyst into the foundations of the analyst's own being.     

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.     

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.     

Therapeutic Passion in the Countertransference

The place of the analyst's “influence” in psychoanalytic theory and practice is explored. There is a current in the literature in which it is welcomed as an aspect of “corrective experience,” although usually legitimized by being forced into the narrow channel of interpretation and understanding. A taboo on influence persists despite theoretical shifts that would seem to clear the way for greater acceptance of its importance. Among other factors, the aversion to influence is traced to its association with hypnotic “suggestion,” which implies little room for the patient's autonomy. Opening the door to embracing the possibility of influence goes hand in hand with, on one hand, the analyst respecting the patient as a competent free agent and, on the other hand, the analyst combining willingness to take a stand with willingness to reflect critically on his or her participation. In that context, and with those caveats, the analyst takes on the responsibility to combat destructive introjects and to become an inspiring, affirmative presence in the patient's life. The analyst's passion for the patient's well-being and for changes that entail the realization of dormant potentials now has its place. Different kinds of expression of therapeutic passion in the countertransference are described and illustrated.     

Final Thoughts on the Case of Pamela and Commentaries

Much gratitude is offered to Drs. Bach and Bromberg for their rich discussions of the case. Some reflections and final thoughts are gathered. The value of the single case study is underlined. The emphases by Bach and Bromberg on the centrality of trauma, failures in recognition, and the healing fostered by acceptance, consistency, and care in the treatment are highlighted. Bach points to the patient's need to regress and to “float in her own subjectivity” in the treatment, to not be impinged on by another “I” in the room. Bromberg's focus is on the need to accept all of the patient's different self states, including the guardian of the weak vulnerable self. Bach highlights the unbalancing of the analyst's narcissistic equilibrium in enactment and Bromberg emphasizes the importance of real and spontaneous engagement. Both point to how such enactments involve a crucial unthought living through of the central trauma itself in the treatment of such patients. The analyst is both in the enactment and a witness to it, allowing for the transformation of traumatic affect and bodily memory. The issue of regression and the concept of the false self are highlighted as topics for further discussion.     

Interior experience within analytic process

In this paper, I consider the feeling of interiority as it evolves within the treatment relationship. A capacity to access and sustain one's interiority reflects a sense of personal solidity within which the validity of subjective process and privacy is taken for granted. When this capacity is relatively undeveloped, individuals rely on the “other”; (including the analyst) to help them contact, elaborate, or manage their affective experience. Quite paradoxically, the analyst's active investigation of dynamic or intersubjective process may obfuscate rather than clarify this core difficulty. I suggest two alternative approaches to the treatment situation that stand in some tension and yet also complement each other. One emphasizes the “active”; investigation of dynamic and dyadic process, wherein the analyst works interpretively and/or around relational issues. The other is organized around the “interior”; dimension of the treatment experience, emphasizing the patient's need to develop or manage her affective process in the relative absence of input from the analyst. Two clinical situations are described, the first illustrating the use of silence with a patient whose difficulties involved affect articulation, and the second involving a patient whose need for affect regulation made her highly dependent on the analyst for soothing.     

A Response to the Contributors

Abstract

In my “response to the contributors” I emphasize that I was moved to write my book in response to the question “Why are so many well-trained colleagues, young and old, having so much difficulty developing satisfying analytic practices?” To answer that question I proposed to explore my experience successfully developing and maintaining an analytic practice.

In attempting to answer the question I inadvertently stumbled upon a revolutionary (with a “small r”) answer to the problem. I discovered, in my attitudes and in my way of working in a consultation and the early phase of an analytic collaboration, a new “concrete puzzle solution” to the problem of how to help a prospective, often reluctant collaborator give analysis a “try.”

My book emphasizes my view that courses on “analyzability” and differential diagnosis are based on psychiatric rather than psychoanalytic diagnostic schema and may interfere with candidates' ability to learn how to create analytic patients.

Since I was a candidate, courses on analyzability have always seemed to me to resemble an exclusive club, deciding whom to exclude and whom to admit, rather than a procedure based on sound clinical experience. Analytic experience has demonstrated that it is not possible in a consultation to predict accurately the outcome of an analysis. To make matters worse, it is probable that an analyst whose mind is focused on the task of evaluating a prospective analysand contributes to creating an environment in which certain patients are experienced as sicker than they might otherwise be.

In spite of the fact that it is not possible in a consultation to predict accurately the outcome of an analysis, many experienced “senior” analysts believe an analyst can and should be evaluative and selective. In their discussions of the subject, they focus primarily on characteristics of the patient rather than the match.

In my book I emphasize that in a consultation there are advantages in focusing on the patient's responses to the idea of engaging in a trial of analysis. The issue of the match and the particular time in their lives are significant from my perspective. The analyst's gender, age, personality, and related state of mind may be as important in effecting the outcome of a trial as any feature of the patient's mind.

My book shifts the emphasis of the focus of inquiry in a consultation from the patient to the analytic couple. It offers a different way of teaching candidates to work with prospective collaborators.     

THE PATIENT'S OBJECTS IN THE ANALYST'S MIND

In every analysis, the analyst develops an internal relationship with the patient's objects—that is, the people in the patient's life and mind. Sometimes these figures can inhabit the analyst's mind as a source of data, but at other times, the analyst may feel preoccupied with or even invaded by them. The author presents two clinical cases: one in which the seeming absence of a good object in the patient's mind made the analyst hesitate to proceed with an analysis, and another in which the patient's preoccupation with a “bad” object was shared and mirrored by the analyst's own inner preoccupation with the object. The use and experience of these two objects by the analyst are discussed with particular attention to the countertransference.     

Crash: What We Do When We Cannot Touch: Commentary on Paper by Meira Likierman

This commentary aims to show the congruence and difference between Likierman's position on recognizing otherness and working with enactment and her relational, intersubjective position. Differences in my reading of the case include stressing the repetition of early attachment trauma, the level of implicit procedural relating, and the patient's contribution to the shared third of rupture and repair. I try to show that enactments arise not merely because the patient is able to pull the patient into forbidden behavior but because the dissociated parts of the patient pull the analyst into dissociation even when the analyst is acting “properly.” The rupture or collision—the “crash”—that the patient helps to formulate represents an opportunity to see the life-giving element in what we, analysts along with patients, inevitably also experience as frightening and even life-threatening.     

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.     

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.     

Dissociation,the Analyst's Vulnerability,and the Body: Review of Awakening the Dreamer: Clinical Journeys by Philip M. Bromberg

This review praises Bromberg's rich and evocative new book for its clinical and theoretical usefulness and elaborates on three broad themes: the analyst's personal role in traumatic enactments, dissociative/addictive uses of the body, and the distinction between life-threatening and developmental trauma. Extending Bromberg's formulations, the author argues that in successful work with trauma survivors, the analyst must be actually (temporarily) traumatized as actual, personal vulnerabilities of the analyst are necessarily engaged. The analyst's vulnerability serves as an internal contact point, opening up a process of unconscious empathy with the patient and providing crucial validation of the patient's experience. The review also explores how bodily processes are used to further dissociation with eating disordered patients and how they become the source of treatment difficulties. When the patient's states of desire have been “detoured” into the body (where they are ruthlessly controlled or attacked) as well as into the relationship with food (where they are temporarily gratified), they are not as available to be mobilized in the analytic relationship. The review also questions Bromberg's assumption that the underlying dissociative mechanisms are the same for life-threatening trauma (or Posttraumatic Stress Disorder) and developmental (or relational) trauma.     

Reply to Commentaries

Questions of historical context resonate with an Independent view of the importance of history. The historical backgrounds of North American and British psychoanalysis are relevant. Some American analysts may be seen as belonging to the Independent tradition, and the relation between Independent analysis in Britain and Relational analysis in America needs further consideration. I ask how far Relational analysis is taking on an institutional identity, and link this to Poland's discussion of “outsiderness.” Responding to Bass's and Berman's comments on my clinical examples I discuss why I sometimes do think analysts need to ascribe meaning to a patient's material. In other instances an analyst will invite the patient more into the process by which meaning evolves between them. To move freely between these positions is central to my view of clinical technique. I express doubts about analysts asking patients for their emotional reaction to an analyst's interventions. This risks being intrusive, and may tend to keep the exchange at the conscious level of a patient's mind. The analytic relationship is an interpersonal one between real people, but the analyst needs also to remain symbolically available as an object of unconscious fantasy and projection.     

A Comparative Assessment of an Analysis of Envy: Commentary on Paper by Julie Gerhardt

This discussion is introduced with emphasis on the need for comparative psychoanalytic studies in our pluralistic psychoanalytic world and describes an approach to such an endeavor. A very brief comment on the extensive literature review is followed by a more detailed focus on the “analysis of envy,” which gradually changed into the analysis of the patient, as a person. The discussant's “empathic entry” into the analyst's mode of listening and responding was simultaneously also applied to the patient's experience, to see how well patient and analyst communicated with each other and whether or not the patient indicated that she felt understood or not. When she did not feel understood, the patient signaled this with an intensification of her envy into furious “envy attacks.” The analyst's “decoding interpretations” implied that the patient was causing her own problems and should not feel the way she did. The analyst discovered this later herself. Her discoveries in the fourth year of the analysis yielded notable changes both in her approach and in the patient's progress. Ultimately, the analyst allowed her subjectivity to enter the analysis and became better amalgamated with her chosen theory, leading to the changes in a progressively more fruitful analysis.     

How the Psychoanalyst Working Primarily with One Person Can Make a Successful Couple Intervention; Or,Why Psychoanalysts Should Not Back Away from Working with Couples

This paper illustrates the value of the individual analyst's deep knowledge of the patient in a couple setting; describes how the analyst informed by many theoretical perspectives decided to work in different modalities (individual, group, couple) with the same patient; and discusses when such additions would have been contraindicated as well as what could have been the consequences if the analyst did not attune to the patient's need for “optimum space” or follow the direction of the patient's creative gestures.     

To Have and to Hold: Thoughts on Admiration/Envy: Commentary on Paper by Joye Weisel-Barth

Using the author's definition of “envy,” I try to separate out fleeting feelings of envy that lead to “admiration” from very disturbing feelings of envy that have to remain hidden because they are so shameful. I try to explore the reasons why it is so unlikely that analysts will feel envy of their patients no matter how rich and famous they may be. Instead, I try to show that this really is a paper on “admiration” and quote the relevant literature on how to distinguish these two affects. A careful reading of the case material shows that the analyst's admiration of her patient's artwork served a very positive role in the treatment of a severely narcissistic man whose self-esteem had plummeted after suffering several losses. It seemed that by being a “container” and “self-object” for a long period, the analyst was able to rescue pieces of the patient's self that he felt were falling through a “colander.” The case is also used as an example of some of the work that started in the 1970s about how to work with narcissistic and nonclassical cases in a noninterpretative manner.