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.     

The Analyst's Theoretical Persuasion and the Construction of a Conscientious Analysis: Commentary on Paper by Meira Likierman

Likierman's paper is an exemplary demonstration of the exquisite attention to the patient's unconscious that is typical of many of the finest analysts, and of British object relationalists in particular. This attention facilitates the analyst's containment and eventually, interpretation, of the disturbing psychic elements, in the classic Kleinian sequence.

Likierman's use of the term intersubjectivity in relation to this process is contrasted with its use in relational theory, where the analyst's active participation is affirmatively stressed along with her more absorbent receptivity. Likierman's own use of Kleinian clinical theory is regarded ambivalently: On one hand, it supports the rigorous pursuit of reflection that is featured in her account; on the other, it carries a tone of severity and unacknowledged self-reproach.     

State of the Hope: The New Bad Object in the Therapeutic Action of Psychoanalysis

Until recently, most psychoanalytic conceptualizations of the analyst as a new object have tended to equate newness with good experience and safety. Recent papers in the relational literature have explored not only the therapeutic value, but also the inevitability of the patient's experience of the analyst as bad, as well as the analyst's participation in this experience. This author examines the multifarious nature of hope, goodness, and badness in the clinical situation. The patient gets to know not only elements of his or her own self that are held by the analyst, but also ways in which the patient holds elements related to the particulars of the analyst's person in the analytic situation. Shifts in American psychoanalysis regarding conceptualizations of the analyst as a new object are examined. Limitations of a bifurcated approach to goodness and badness in clinical conceptualizations are also explored.     

Early trauma and affect: the importance of the body for the development of the capacity to symbolize

In this paper I aim to outline the importance of working clinically with affect when treating severely traumatized patients who have a limited capacity to symbolize. These patients, who suffer the loss of maternal care early in life, require the analyst to be closely attuned to the patient's distress through use of the countertransference and with significantly less attention paid to the transference. It is questionable whether we can speak of transference when there is limited capacity to form internal representations. The analyst's relationship with the patient is not necessarily used to make interpretations but, instead, the analyst's reverie functions therapeutically to develop awareness and containment of affect, first in the analyst's mind and, later, in the patient's, so that, in time, a relationship between the patient's mind and the body, as the first object, is made. In contrast to general object‐relations theories, in which the first object is considered to be the breast or the mother, Ferrari (2004) proposes that the body is the first object in the emerging mind. Once a relationship between mind and body is established, symbolization becomes possible following the formation of internal representations of affective states in the mind, where previously there were few. Using Ferrari's body‐mind model, two clinical case vignettes underline the need to use the countertransference with patients who suffered chronic developmental trauma in early childhood.     

Should Analytic Patients Be “Created”? Reflections on Arnold Rothstein's Psychoanalytic Technique and the Creation of Analytic Patients

Abstract

The five points of Arnold Rothstein's interesting monograph are each discussed and critiqued in this article. In particular, Rothstein is commended for his commitment to expanding the availability of an intensive, psychoanalytic treatment for a broad spectrum of patients who may often be very difficult to engage. Rothstein also accounts for difficulties in engaging analytic patients from obstacles in the attitudes of analysts such as a latent lack of conviction about the efficacy of psychoanalysis and from overly restricted stereotypes about the spectrum of appropriate patients. He recommends a flexibility of technique and accommodation to the needs of patients with which this author agrees.

Others of Rothstein's observations and recommendations seem more problematic. Specifically, issue is taken with his suggestion that analysts attempt to provide a trial of psychoanalysis for all nonpsychotic patients and to begin on a less intensive basis only within the frame or interpreting prospective patients' objections as a resistance. This author also disagrees with Rothstein's interpretation that patients resist the offer of a psychoanalysis out of a self-defeating masochistic enactment that needs interpretation. Case examples are provided that belie this overly generalized interpretation. Additionally, this author critiques the metapsychological assumptions underlying this particular mode of interpreting a reluctance to begin psychoanalysis.

While commending Rothstein's therapeutic goals and recommended flexibility of technique, this author would also stress a fundamental concern about the patient's conscious and unconscious experience of the analyst's agenda. In other words, rather than working toward the analyst's goal of establishing a psychoanalytic situation, emphasis is placed instead on the basic right of patients to proceed in a manner that respects their sovereignty over how intensively they may choose to work. Therefore, in contradistinction to Rothstein's suggestions, it is recommended that the analyst's primary focus should be to provide an availability to work on the patient's conflicts and developmental needs with a respect for the timing of their emergence and expression within a treatment frame that invites but does not prematurely elicit and confront. By proceeding in this way a patient's salient dynamics will be allowed to emerge “organically” instead of being hastened prematurely in reaction to the analyst's insistence on the Tightness of a particular schedule or manner of proceeding. This author believes that with this approach more, rather than fewer, patients will be able to accept the recommendation of an intensive psychoanalytic treatment.     

An Independent Theory of Clinical Technique

The history of Independent analysis in the British Psychoanalytical Society is reviewed. The Independent Tradition, as an approach to psychoanalysis, is distinguished from the organisational grouping in the British Society that is the Independent Group. The Independent Tradition emphasises what differentiates human beings rather than how they exemplify general principles. This derives from Freud through Ferenczi. Ferenczi's stress on the quality of the patient's experience, on the need for analysts to be aware of the effect on themselves of the analytic process, and on the need for restraint in interpretation are all characteristically Independent aspects of analytic technique. Later Independent thinkers have developed these themes further. Especially important is Enid Balint's idea that theory mediates the analyst's creative imagination. The analytic setting infuses ordinary human interaction with psychoanalytic awareness, and another function of theory is to imbue with psychoanalytic understanding the use of everyday language. Independent clinical technique is primarily a way of listening. Regression is accepted, and free association valued as being in itself a vehicle of psychic growth. A central idea is that the analyst is an analytic object to be made use of by the patient. Several clinical examples illustrate the functioning in practice of these concepts.     

The analyst's narrative function: Inventing a possibility

This article describes a psychic function common to analysts that was gradually revealed through clinical work with children. It is a psychic quality derived from function α, which involves analysts’ capacity for reverie – their narrative function. The author presents two clinical situations where this function developed in the analytic field in relation to patients’ difficulty in symbolizing. In the first case there was an early traumatic experience unavailable for representation. The analyst lent the patient her ability to represent and produced a narrative that made it possible to create a world of phantasies and transform nightmares into ‘dreamable’ dreams. In other words, she removed the quality of unbearable, irrepresentable reality that characterized those raw experiences encrypted in the psyche. In the second case the analyst's narrative function sought to connect with the isolation, the shell that housed a child suffering from an autistic disorder whose ability to represent had not been established. The analyst provided meaning for the patient's repetitive, stereotyped play, thus weaving the child's subjectivity and gradually introducing a notion of alterity. The author seeks to show how this function, in the thematic construction of the session, facilitated both the working‐through of a traumatic situation (with the ability to share representations) and the constitution of the psychic fabric.     

Shades of Mark Twain: Commentary on Paper by Steven H. Cooper

The author considers Cooper's notion of the pluralistic third from several angles as Cooper's use of the term covers a range of applications from that of an internal supervisor to the use of ideas from psychoanalytic traditions other than one's own in evaluating one's clinical work. The impression created of the American situation is contrasted with the institutionalized pluralism of the British Psychoanalytical Society since the Second World War. The author believes that the theoretical question of the analyst's accountability to a professional authority is overdetermined in the paper because the clinical material is dominated by the patient's problems in facing up to parental authority. A crucial enactment is seen as starting at the analyst's first contact with the patient, which seems to subvert the analyst's capacity to be an authority figure. The analyst finds a working relationship with his own psychoanalytic authority in the second session of the analysis but seems to lose it through an overextension of the ideas of “play,” self-questioning, and the seeking of agreement between patient and analyst. The author considers the clinical material from the point of view that his peer supervision group would take.     

Affective Experiences and Honesty in the Interaction: Discussion of Holly Levenkron's Paper

Anchoring her views in the work of Benjamin and other American relational authors, Levenkron asserts that intersubjective relatedness in which there is recognition of separate realities is essentially the only form of relatedness. Framing growth as coming about through the recognition of another's subjectivity provides a basis for “confrontation” and for a more direct injection of the analyst's subjectivity into the analytic encounter. More specifically, it fosters the expression of the analyst's subjectivity from what this author calls the “other-centered” and “self” perspectives.

In contrast, the recognition of selfobject and caretaking relatedness positions the analyst to express directly aspects of the analyst's subjectivity pertaining to mirroring, idealizing, and twinship selfobject needs. Kohut and classical self psychologists have delineated selfobject needs and the selfobject dimension of relatedness and transference and have emphasized the consistent use of the empathic listening/experiencing perspective. American relational theorists have delineated intersubjective relatedness and the usefulness of the other-centered listening/experiencing perspective. This author focuses on an integrative theory including three forms of relatedness and different listening/experiencing perspectives. Different listening/experiencing perspectives and forms of relatedness fundamentally influence analysts' affective experiences within the analytic encounter as exemplified in Levenkron's case.     

Language and Intersubjectivity: Multiplicity in a Bilingual Treatment

This paper explores the psychodynamics of analytic work conducted between a French patient and an American analyst who are both bilingual in French and English. The depth of the patient's early traumatic relational history is initially bound and cloistered in French, her mother tongue. The author argues that through the symbolization of a series of initially dissociated enactments a transitional space is created in the treatment, facilitating the integration of the patient's (and analyst's) early French-speaking selves. Language is considered as a container for both dissociative and associative forms of multiplicity, as it serves to mediate an external and internal intersubjective expansion both between and within patient and analyst.     

A mismatch of meaning and intentionality between analyst and analysand

In this paper, I will consider a type of misunderstanding in the analytical dialogue and the possible unconscious motivations underlying this. I will also make reference to the patient's use of the analyst's words for the purpose of narcissistic enactment and will explore the extent of the analyst's involvement in this. The subjects of misunderstanding and narcissistic enactment will be dealt with in relation to a patient's way of processing certain interpretations at the beginning of analysis and the concealment of her way of processing the analyst's words. By contributing dreams and other significant material in the sessions, the patient gradually revealed her phantasies which enabled the analyst to uncover the possible factors which determined her particular attribution of meaning to the analyst's words and her retention of information about how she had initially construed his interpretations.     

The Analyst's Anticipatory Fantasies: Aid and Obstacle to the Patient's Self-Integration

In this paper I explore instances of enactment related to the analyst's feelings and fantasies about how analysis will proceed. As I discuss a patient who was developing a new capacity to experience conflict, I explore how the analyst's fantasies about the impact of his interpretations may be utilized in helping him to elaborate and understand the patient's unconscious fantasies and identifications and unintegrated feeling states. In so doing, we sometimes discover how we are unwittingly influencing or avoiding understanding our patient's own version of their psychic catastrophe. As we develop language where there was previously no integrative language for the patient's internalized and interactive version of catastrophe, we always project particular kinds of expectations into the therapeutic situation.     

Projective identification,containment and sojourn in the psyche: Clinical notes on a specific type of transference-countertransference interaction

Abstract

This paper suggests that the interplay between transference and countertransference is considered to be a valuable channel of communication. The author puts an emphasis on the containing function of the analyst. The patient strives for an experience of an object (analyst) that tolerates and copes with the patient's projections. There are some moments when analysts feel themselves to be invaded, controlled or abused by their patient's products. As Bion has postulated, this situation takes the form of a sojourn in the analyst's psyche. Clinical vignettes are given to provide support for the ways in which the analyst contains and elaborates the projections of the patients in his or her own mind and the therapeutic role that these processes have.     

Field of Vision: Radical Uncertainty and the Analyst's Conduct: Commentary on Paper by Donnel B. Stern

There is a relationship between biography and theory. The analyst's ideas or formulations about his patients—theories really—must be determined, to some degree, by the certain and uncertain impact of his own history. Harry Stack Sullivan brought psychoanalysis squarely into the ambit of the relational/historical world by insisting that the mind is thoroughly and inherently social. In doing so, he staked a claim for the link between history, that is, social experience, and personhood. Our personalities and our theories are social-historical constructions. In relation to this, some differences between the interpersonal/relational and Bionian concepts of field theory are provided. One important difference pertains to the role of the analyst's conduct. Two meanings of conduct—to behave or to organize behavior—are at the center of what distinguishes the interpersonal/relational view of the analyst's position in the field from the Bionian view. For the relational analyst, action in the analytic field, including enactment, is conduct, and conduct is always bidirectional. The analyst, then, is a medium to alter, to reconstruct the self. He does not provide experience, he is experience. The form of an analytic exchange gives shape to the field and its content.     

Private Terrors Sexualized Aggression and a Psychoanalyst's Fear of Her Patient

This clinical paper explores the meanings and evolution of an analyst's reaction of fear in relation to her patient's sexualized aggression. From both an intrapsychic and an intersubjective perspective, the author analyzes the coconstruction of this transference—countertransference phenomenon. Case vignettes illustrate the author's attempts to address her patient's sexualized aggression while struggling to free herself from the feelings of intimidation and fearfulness stirred by his sadomasochistic fantasies and patterns of interaction. The analyst's unconscious identification with the patient's disowned femininity and narcissistic vulnerability is seen as central to this countertransference “stranglehold.” Release from the analyst's masochistic position comes through a shift in her own affective participation. The importance of the analyst's recognizing her own unconscious contributions to this sadomasochistic dynamic is emphasized and elaborated. Discussion also focuses on the relevance of gender to the issue of countertransference fear, as illustrated in this particular male patient—female analyst dyad.     

The patient's transference experience of the analyst's gender: Projection,factuality, interpretation,or construction

The constructivist/relational perspective has challenged the analyst's emotional superiority, her omniscience, and her relative removal from the psychoanalytic dialogue. It at first appears to be antithetical to treatment approaches that emphasize the analyst's holding functions. In this essay I examine the holding model and its resolution from a relational perspective. I propose that the current discomfort with the holding function is related to its apparent, but not necessarily real, implications. I discuss the analyst's and patient's subjectivity during periods of holding. I believe that the holding process is essential when the patient has intensely toxic reactions to “knowing”; the analyst and is therefore not yet able to stand a mutual analytic experience. During holding, the patient experiences an illusion of analytictic attunement. This requires that the analyst's dysjunctive subjectivity be contained within the analyst, but not that it be abandoned. Ultimately, it is the transition from the holding position toward collaborative interchange that will allow analyst and patient explicitly to address and ultimately to integrate dependence and mutuality within the psychoanalytic setting and thereby engage in an intersubjective dialogue. The movement toward mutuality will require that the analyst of the holding situation begin to fail in ways that increasingly expose her externality and thus her subjectivity to the patient.     

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.     

Discussion: Toward a social‐constructivist view of the psychoanalytic situation

The three papers by Modell, Aron, and Greenberg are discussed in terms of their relationship to a new paradigm for understanding the psychoanalytic situation. The paradigm is called social‐construct‐ivist to capture both the idea of the analyst's participation and the idea of construction of meaning. It is argued that these theorists, as well as many of the authors they cite as part of a broad movement in the field, do not consistently meet the criteria for this paradigm, although they seem to be aiming for it. An important source of inconsistency and confusion derives from the confounding of the two axes: drive‐relational and positivist‐constructivist. Many relational theorists who hold fast to the idea that analysts can grasp the truth of both their own experience and that of the patient are no closer to the constructivist point of view than was Freud. The call by Aron and Greenberg for greater attention to the patient's resisted experience of the analyst's subjectivity is discussed in terms of its potential benefits and problems. The ritualized asymmetry of the psychoanalytic situation is said to have important functions, including prevention of excessive involvement and protection of the unobjectionable positive transference and of a degree of idealization. Modell's notion of paradox, which makes the therapeutic relationship seem “real”; and “unreal”; at the same time, is seen as a special instance of the always precarious social construction of reality. It is argued, moreover, that the social and individual aspects of experience are interdependent. Neither is reducible to the other, and both should be understood, like many other issues in the new paradigm, in terms of a dialectical interplay of figure and ground in experience.     

BORGES IN MY OFFICE: THE ANALYSIS OF A MAN DWELLING OUTSIDE OF TIME

This article weaves together two threads: the intricacies of the analysis of a difficult‐to‐reach yet extraordinary patient and the literary works of Jorge Luis Borges, which played a significant role in the analysis as a source of inspiration, enriching the analyst's reverie and opening up new psychic spaces. The authors demonstrate the analyst's recourse to several of Borges's stories in order to enrich his own inner world and to better understand the analysand. Some of these stories are briefly presented through the analyst's dialogue with them, and there is a discussion of their function in facilitating the process of working through issues of time, memory, mortality, and identity, contributing to the enhancement of the patient's ability to come face to face with the unwanted, split‐off parts of his self and of reality.