Plea for a Measure of Imagination: Commentary on Paper by Harvey Peskin

In responding to Harvey Peskin's important paper, “Man Is a Wolf to Man,” I further deconstruct his proposition “what therapeutic neutrality is to psychic reality, the therapeutic witness is to the recovery of social reality.” This statement calls into question two principles of the orthodox Freudian canon, one theoretical and one technical. Beyond the stimulus barrier, traumatic reality collapses psychic reality, conscious and unconscious fold into one another, reality and fantasy merge, and nightmares are made flesh. In attempting to impose psychic reality on a traumatic experience, then, classical psychoanalysts disavow a significant portion of human experience. Technically, the analyst's neutrality or failure to acknowledge the significance of historical reality condemns the survivor to further dehumanization as her dehumanizing experiences go unmarked in treatment. Peskin contends that the need to have experience validated, to have a witnessing analyst before an interpreting one, arises not only in matters of extreme traumatization but in everyday life. Illustrating the importance of this claim with an example from my own life, I propose that extreme traumatization takes a different kind of therapeutic engagement, one that is beyond professional obligation; a moral imperative that requires imagination when recognition is not enough. I add a further caveat that in cases of extreme traumatization, rather than privileging a search for psychic reality or even historical reality, some contemporary analysts privilege an exploration of the treatment relationship, failing to recognize that in such cases historical reality must initially take precedence over an emphasis on the intersubjective.     

Review Essay: Constructivism with a Human Face

Irwin Hoffman's book Ritual and Spontaneity includes, but goes well beyond, his series of seminal papers—written over the past several decades—developing a psychoanalytic, constructivist perspective. A new, existential framework depicts what Hoffman calls the “psychobiological bedrock” at the core of the human process of constructing meaning—the lifelong effort to create a livable, subjective world in face of our ever present sense of loss, suffering, and, ultimately, mortality.

This review describes Hoffman's encompassing, existential perspective and discusses how, within this framework, he uses his dialectical sensibility to frame our understanding of both parenting and analysis as “semisacred” activities. The “dialectic of ritual and spontaneity”—the vital clash between disciplined adherence to the analytic frame and personally expressive deviations from it—represents the creative tension between the “magical” dimension of analytic authority and the healing influence of a genuinely expressive human relationship. Hoffman's perspective on the self-interested, “dark side” of the analytic relationship is compared with Winnicott's views on the vital, therapeutic role of “hate” and the paradoxical process by which the patient comes to “use” the analyst.

Unlike most postmodernist “constructivists,” Hoffman openly reveals his underlying belief in certain “transcultural, transhistorical universals”—his “psychobiological bedrock.” In acknowledging these “essentials” (assumptions about human nature) that in some form are integral, yet often hidden, elements of any system of thought, Hoffman saves his own dialectical constructivism from falling into dichotomous (constructivist vs. essentialist) thinking.     

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.     

Immigration: The “Illegal Alien” Problem

ABSTRACT

The present paper explores the “immigration crisis” both in the United States and in countries around the world. Consideration is given to what is typically absent in public discourse—that is, that immigration is inflected with race, class, ethnicity, religion, and language. Drawing on the work of several leading scholars in philosophy and linguistics, with particular attention to how metaphor shapes thinking, the “immigration problem” is unpacked to examine the issues embedded within its characterization as a “crisis” and for whom that might be so. Examined as well are the larger sociopolitical issues beyond the worldwide public outcry about securing borders. The paper rests analysis of both how the immigrant “other” is characterized and the larger sociopsychological significance of that characterization within the idea of the social unconscious. Finally, the paper explores the role of the group analyst as “citizen therapist” in expanding empathic engagement among groups affected by the huge migration flows. Included are recommendations for the role the group analyst may play in addressing the issue of immigration in our groups and communities.     

THE FATE OF AGGRESSION IN MASO‐MASOCHISTIC RELATIONSHIPS

This paper examines an underexplored dimension of interpersonal relating: the relationship formed between two individuals who relate to each other in masochistic ways. The common assumption is that a sadist forms an alliance with a masochist, and that a balance is struck between an individual who is “one up” and another who is “one down.” However, relationships are frequently established between two people who both experience themselves as chronically “one down,” each playing victim to the other's aggression. This paper explores disavowed aggression in this type of couple, the implications of this disavowal for treatment, and the sadomasochistic reverberations within the therapist.     

Masks and Faces in the Setting at the Time of Coronavirus

The “health emergency” forced analysts to seek new ways of continuing with analysis. The article focuses, in particular, on the changes brought about in the setting by the presence of the sanitary mask, following a line that begins with the theme of the “mask” in the collective uses of human cultures, and develops through the Jungian concept of persona, as opposed to the “face” that may convey an authentic image of oneself. A clinical vignette illustrates the issues that the mask raises in the setting by obstructing the communication of emotions. When there is no transformative processing of concrete data, “unmasking” can also lead to an uncanny encounter and to moments of darkness and confusion in analysis, when the analyst experiences the kind of “unconscious identity” between therapist and patient that Jung defined as nigredo. The article is intended as a contribution to the analytic community's current reflections on the new and unforeseen challenges encountered in analysis at the time of the Coronavirus. It is possible to learn from these experiences with a view to integrating new elements and thus modify one's own internal setting, the compass with which each analyst orientates himself.     

Fear and Shame in an Israeli Psychoanalyst and His Patient: Lessons Learned in Times of War

Living in the midst of a war presents unique challenges to ongoing psychotherapeutic treatment. This paper focuses on the ever-present threat of fracture to the analytic frame and the limited ability of the therapist to create a safe, insulated environment— a reliable container—in which to work, while coping with a violent external reality. Using an intrapsychic lens, as well as an interpersonal one, the dynamics of both the analyst's and the patient's fear and shame are brought into focus. This delicate balance is illustrated through two cases: one occurring during the First Gulf War (1991) and the second taking place during the Second Lebanon War (2006). In both cases, fear and shame cause a stalemate in the psychotherapeutic process. The analyst recalls his active duty as a soldier during the Yom Kippur War (1973). These memories and their attendant acknowledgement of fear and shame by the analyst, as well as his analysand's “supervisory” comments, gradually dissolve the knot and repair the rupture in the analytic process. The ability to fully experience fear, shame, and helplessness is at the core of psychic health, a health once destroyed by dissociation and denial of these feelings. This ability to experience fear and shame is the psyche's antidote to mental breakdown. Following discussion of the two case studies, this paper seeks to illustrate how the very structure of a society, in this case Israel, can codify societal defense mechanisms against emotions like fear and shame, exacerbating the very problems it seeks to assuage.     

Minderwertigkeitsgefühl und Machtstreben als Koproduktion?

At least analysts consider our own therapeutic approach as the preferable method, even if seen as very difficult. These difficulties are easier to understand from the viewpoint of intersubjectivity and interaction when looking at the origins of the problems as well as at the therapeutic process. Therapists seem with such patients to be more quickly tangled up in the field of the own ambivalence in relating, of omnipotence phantasies, illusions of independency and the striving for recognition as it is the case with other patients. Organising the practice along their own needs, the often devaluative diagnostics, the superior role of the therapist and the economic dependence of the analyst, even if covered up by the health care system, all that is a provocation for narcissistic patients, just as their seeming unrelatedness and lack of motivation, their pseudo-autonomy and the hardly bearable devaluations amount also to a provocation for the analyst. He/she is irritated about his/her usual role. From our theoretical point of view, we consider the narcissistic disturbance as a coproduction with the contribution of the therapist beyond his/her own idiosyncratic parts on the basis of the disawoed dimensions of grandiosity in our profession. Such narcissistic “interaction figures” are unavoidable and even necessary in practice. Relational experiences made in a presymbolic phase should become verbalizable through the entangled acting-out (unconscious communication) of both participants. The analysis of coproductions then, the recognition of the respective contributions, the patient‘s experience of equality and difference pave the way for developments in direction of more workable compromises in the narcissistic conflict area between being oneself and relating to others.     

Wirkung vorgeburtlicher und früh-nachgeburtlicher Umwelteinflüsse auf Gehirn und Psyche

The psyche of a human being is formed in strict correlation with the development of the brain. Genetic, epigenetic regulatory and prenatal influences through the brain of the mother as well as postnatal influences, predominantly as early childhood attachment experiences are all intertwined with each other. This takes place at three “limbic levels”: a lower level at which the infantile temperament resides, a middle level of early childhood impressioning experiences and an upper limbic level of socialization. The cognitive language level develops in a relatively independent manner. At the three limbic levels six psychoneural systems are operative, namely the stress processing, the self-calming, the impulse inhibiting, the motivation, the attachment and the reality and risk perception systems. Mental disorders are characterized throughout by disorders of the first two systems, predominantly in the form of greatly increased cortisol levels and greatly reduced serotinin levels. These then induce deficits in other systems; however, in less severe cases compensatory processes can occur via an attachment-related increased release of oxytocin. Similar processes also occur within the “therapeutic alliance” in the patient-therapist relationship.     

Of Innocence and Experience: Commentary on Paper by Stuart A. Pizer

In providing the background to a pivotal session, Stuart Pizer reveals his clinical work as an unsupervised neophyte, prior to his own analysis and analytic training. These early therapeutic efforts were flawed, leaving Pizer at times “grimacing with mortification 26 years after the fact.” But they were also extraordinarily helpful to the patient. Schaffer discusses the challenge of supervising similarly talented beginners: how does one teach psychoanalysis without desiccating a treatment? How does one teach a relational approach, with no “basic model” and few rules, to a beginning analyst infused with an unformulated, yet often passionate, sense of what is “curative”? Pizer recognizes that were he to meet the same patient today, he would not conduct the same treatment. Now trained and analyzed, not to mention more cautious and “worldweary,” Pizer would not do what he did then. But what if he were the supervisor then? Schaffer concludes her discussion by asking Pizer how he, now a seasoned analyst, would supervise his early therapist self.     

Self-Disclosure and Vulnerability

Abstract

Based on the theoretical assumption and clinical observation that projective identification is a natural, constant element in human psychology, clinical material is used to illustrate how projective identification centered transference states create situations where acting out of the patient's phantasies and conflicts by both patient and therapist is both common and unavoidable. Because they are more obvious, some forms of projective identification encountered in clinical practice are easier for the analyst to notice and interpret. Other forms are more subtle and therefore difficult to figure out. Finally, some forms, whether subtle or obvious, seem to create a stronger pull on the analyst to blindly act out.

In some psychoanalytic treatments, one form of projective identification might embody the core transference. In other cases, the patient might shift or evolve from one level of this mechanism to another. Some patients attempt to permanently discharge their projective anxiety, phantasy, or conflict into the analyst. There is a patent resistance to re-own, examine, or recognize this projection. Some of these patients are narcissistic in functioning, others are borderline, and many attempt to find refuge behind a psychic barricade or retreat (Steiner 1993). In other forms of projective identification, the patient enlists the analyst to master their internal struggles for them. This occurs through the combination of interpersonal and intra-psychic object relational dynamics. This “do my dirty work for me” approach within the transference can evoke various degrees of counter-transference enactments and transference/counter-transference acting out.

Another form of projective identification, common in the clinical setting, is when a patient wants to expand the way of relating internally, but is convinced the analyst needs to validate or coach the patient along. This is why such a patient may stimulate transference/counter-transference tests and conduct practice runs of new object relational phantasies within the therapeutic relationship. Over and over, the patient may gently engage the analyst in a test, to see if it is ok to change their core view of reality. Depending on how the analyst reacts or interprets, the patient may feel encouraged to or discouraged from continuing the new method of relating to self and object. The patient's view of the analyst's reactions is, of course, distorted by transference phantasies, so the analyst must be careful to investigate the patient's reasoning and feelings about the so-called encouragement or discouragement. This does not negate the possible counter-transference by the analyst in which he or she may indeed be seduced into becoming a discouraging or encouraging parental figure who actually voices suggestions and judgment.

All these forms of projective identification surface with patients across the diagnostic spectrum, from higher functioning depressive persons to those who are more disturbed paranoid-schizoid cases. Whether immediately obvious or more submerged in the therapeutic relationship, projective identification almost always leads to some degree of acting out on the part of the analyst. Therefore, it is critical to monitor or use the analyst's counter-transference as a map towards understanding the patient's phantasies and conflicts that push them to engage in a particular form of projective identification.     

Not starting psychotherapy is more often initiated by the therapist than the patient

The phenomenon of not starting psychotherapy is seldom investigated. The present study of psychotherapy in the Swedish mental health services differentiates between patients applying for and being offered psychotherapy but choosing not to start (n = 69), patients recommended to receive no treatment, another type of treatment or treatment at another clinic (n = 133), and therapy starters (n = 1294). After the initial assessment, nearly twice as many patients did not start based on the therapist’s decision than on the patient’s. Cases of not starting psychotherapy decided by the therapist were more frequent among patients whose occupational status was less stable, presented a danger to others, had lower levels of initial therapeutic alliance, and by therapists with lower levels of psychotherapy training and those at less structured and more unstable clinics. Patients choosing not to start therapy had lower levels of mental ill-health than both starters and therapist-initiated nonstarters. The most frequently presented reason for a patient-initiated decision to not start therapy was “patient wished another treatment or therapist,” whereas the most common therapist-initiated reason was “recommended or referred to another treatment or clinic”.     

WHAT IS EFFECTIVE IN PSYCHOANALYTIC PSYCHOTHERAPY? SOME THINGS CHANGE,SOME STAY THE SAME

As a reflection on two roundtable discussions published in the American Journal of Psychoanalysis in 1957 and 1965, the author seeks to provide historical context for what has taken place within the culture, within the profession, and within himself over this period of time. The struggle to define “effectiveness” is addressed and an argument made for the inclusion of empirical research into our work, but with simultaneous appreciation for the difficulty in objectively defining and measuring what takes place within the therapeutic relationship. This difficulty is hypothesized, in part, to be a function of the non-verbal and preverbal experiences of both patient and therapist.     

Thinking Differently Principles of Process in Living Systems and the Specificity of Being Known

As a way of integrating emerging knowledge of biological systems, developmental process, and therapeutic process, we identify principles in the process of exchange between organism and its context of life support that are present at all levels of complexity in living systems, from the cellular to the organization of consciousness. These principles range from specificity, rhythmicity, recurrence, and pattern to coherence, wholeness, and a relative unity in the organization of component parts. By proposing that these principles are also governing the exchange between mother and infant as they negotiate a sequence of essential tasks of adaptation, or “fitting-together” between them over the first years of life, the author suggests that the biological level becomes integrated with the developmental. A sequence of adaptive tasks extends from specificity of recognition in the newborn state, to recognition of inner awareness, purpose, and intention—shaping conscious organization. The bridge to the therapeutic level is constructed as therapist and patient build increasingly inclusive and coherent moments of recognition between themselves at the level of conscious organization, which act as corrective experiences, bringing the patient's own senses of “true self” and of “agency-to-initiate” to new levels of validity and competence.     

WHAT LEADS TO BASIC CHANGE IN PSYCHOANALYTIC THERAPY? A ROUND TABLE DISCUSSION

At the Round Table discussion William V. Silverberg speculated that insight and experience in the interaction between patient and therapist are two main factors in change in psychoanalytic therapy. The two factors work hand in hand, according to Silverberg. Insight contributes to the uncovering of the existence of unconsciously held convictions and “life experience” is the trust that develops between patient and therapist, helped by the good will of the analyst. Silverberg calls this the “silent” aspect of psychoanalysis. The trustworthiness of the therapist serves to confirm the new insight and to enable the patient to act upon it. Insight is an understanding, experienced in the process of dealing in new ways with old situations.     

Roles of Engagement: Commentary on Paper by Richard Almond

Richard Almond's discussion on the benefits of attending to the tension between what he refers to as analyst role and nonrole behaviors is quite stimulating and highlights important issues within the world of psychoanalysis. Although appreciating Almond's efforts to add clarity and perspective to the discourse on relational analytic activity, I point out the ways in which dichotomizing the analytic endeavor into “role” and “nonrole” behaviors can be limiting. It is proposed that prioritizing the tension between these polarities as mutative does not encourage the “spaces” between these role and nonrole behaviors to be maximally used, minimizes the interactive component, and privileges observing over experiencing. It is also contended that an affectively alive analyst, including one in the midst of enactments is acting within role. A clinical example is used to demonstrate that neither interpretation nor interaction should be privileged in terms of therapeutic action.     

Narrative Writing and Soulful Metaphors Commentary on Paper by Barbara Pizer

The author posits that Pizer's use of both narrative and lyrical style is not typical in psychoanalysis, whose scholarly tradition tends to favor a denser, more academic style of writing. The ways in which psychoanalysts read these two forms of writing are mirrors of one another. Both kinds of reading are forms of discipline; both forms of writing are necessary in psychoanalysis. The author also writes that Pizer's “nonanalytic third” does not have to be a “good” thing like a poem; it can be almost anything important to the analyst. The nonanalytic third is a soulful metaphor that can be used to create alternatives to rigid experience. Because rigidity in psychoanalytic relatedness is usually the result of problematic unconscious involvements between analyst and patient, the nonanalytic third can be significant in the negotiation of enactments.     

Therapeutic popularity and personality: Association between peer therapist nominations and the “Big Five” personality factors

The “Big Five” personality factors of three groups of psychology students differing in popularity as therapist among their peers were compared (n=33). In agreement with earlier research, popular therapists are “agreeable”, “conscientious” and “stable”. However, popular therapists are not “surgent/extravert” and especially not “dominant” and “talkative”. No support was found for the hypothesis that similarity in “agreeableness” or dissimilarity in “surgency” (the complementarily hypothesis derived from interpersonal theory) predicts therapist popularity. However, similarity between client and therapist in “stability” was predictive of nominations for therapist. On the assumption that therapist popularity predisposes good therapeutic alliances, the results indicate that therapists agreeableness, conscientiousness and emotional stability are relative to success in therapeutic interventions.     

The Impossible Ideal: A Patient-Oriented Therapy

Abstract

Langan R. Proteus Reprised. Int Forum Psychoanal 1997;6:45-49. Stockholm, ISSN 0803-706X.

Proteus was the mythical Greek sea-god able to change his shape at will. In the Odyssey, King Menelaos manages not to release his wrestler's hold on the mercurial trickster, and theory can, at last, return home. The myth has sundry and changing applications to the living experience of what goes on between patient and psychoanalyst. In one sense, the analyst's job is to be like Proteus, escaping the transferential grip whereby the patient tries to pin the analyst into characterological shapes of the past. In another sense, the patient is Proteus, and the analyst's job is to hold firmly to the process of future change, refusing to settle for one fixed version of selfhood. In yet another sense, both patient and analyst become Proteus, experiencing fluidly present senses of self as an inner subjective “I,” as an intimately relational “Thou” with “Thee,” and objectively, as one Other among others. Additionally, the myth insinuates within the psychoanalytic situation a potential transcendence of time.     

Transference symptom

Transference symptom is a hazy notion in Freud's writings. The notion is presented here as a particular moment in the crystallization of the transference neurosis. It results from a double cathexis of the analytic frame and the analyst resulting in a symbolic distortion that is represented plastically within the session, as occurs in dreams. The transference symptom proceeds from two different preconscious cathexes, one attached to the reality of the frame, the other to the drive linked to the analyst. A psychic space is thereby opened up for interpreting both the resistance and the unconscious derivatives of infantile conflict. The transference symptom is a compromise formation that includes the analyst and questions the countertransference stance. Three different analytic situations give rise to transference symptoms according to the relative balance between frame and process in the analytic encounter. The concept is compared with enactment.