When Avoidance Is Mutual Regulation: Disorganized Attachment and Analytic Attunement

This paper looks at and counters the notion that the analyst’s reluctance to know, to comprehend and interpret, the fuller meaning of a patient’s behavior is a countertransference avoidance. Drawing on attachment theory and infant research that has not yet been fully integrated into the clinical literature, the author believes that the movement from enactment to the expression of dissociated feeling is a process that leads to the creation of previously unknown meaning within an analytic impasse. The infant research literature and the literature on disorganized attachment is referenced to elucidate aspects of the clinical process. The clinical material presented involves the analyst’s failure to engage a patient’s chronic lateness, a failure that represented a mutual avoidance. The meaning of this enactment was locked in the patient’s traumatic past and could not be transmuted into new relational experience until the analyst had emerged from her own dissociative state. The therapeutic space created by their mutual avoidance, contrary to being a stalemate, became a protective space that held the meaning that was hibernating in dissociation. For the patient, the dissociated memory of traumatic abuse was linked, actually and symbolically, to her pervasive lateness. What was represented in the chronic lateness was discovered by analyst and patient together, along with the feelings engendered by “waiting.”     

Sadism,Penetration, and the Negotiation of Desire: Commentary on Paper by Csillag

The author takes up Csillag’s idea of sadism as the wish to penetrate in the context of a patient who withholds from his analyst. With such a patient, the analyst has to bear the strain stemming from a lack of both satisfaction and recognition–the feeling of not having an impact. The defenses against sadism are examined along with the absence of intentionality in both clinical cases presented, an absence that places sadism in the realm of something that is unconscious or preconscious. Alternative views are offered on the enactment between Csillag and her patient with a focus on the unspoken negotiation of desire and (drawing on Fairbairn) the analyst’s attempt to breach her patient’s closed system of internal objects.     

From Dead to Alive: Desire,Dissociation and Passion in the Analytic Dyad

When patients present in a deadened state, the analyst may feel a sense of futility and shame in his efforts to have impact. This may cause him to withdraw and contribute to an enactment in which both participants purge themselves of wanting anything from the other, sapping the treatment of purpose and aliveness. The author presents a model in which the analyst can reawaken his desire for recognition and connection and utilize it to introduce the patient to his or her own dissociated longings. This involves fortitude on the therapist’s part, since he must withstand the rejection that had caused him to withdraw in the first place, and also be sensitive to the patient’s fear of retraumatization. But if the analyst can do this, he can not only break through the impasse, but enliven the patient and infuse the treatment with a sense of purpose and hope.     

Accompaniment in Jazz and Psychoanalysis

The author explores a fundamental role of the analyst as improvisational accompanist. This role requires a dedicated attention to the shared rhythmic dimension of the interaction, a mode of psychoanalytic attention of embodied self-awareness and sensitivity–that is, embodied attunement to the pulse of the interaction. Directed action follows by providing various forms of accompaniment that depend on the nature of the patient’s needs and emotional state. By refining our accompaniment to meet clinical situations and challenges, we enlarge the range of analytic engagement. Using examples from jazz, the way the rhythm section finds the right form of accompaniment to support the soloist’s creativity and unique voice, the analyst similarly accompanies his or her patient, providing a temporal framework, a pulse that affirms emotionally shared states, recognition, differentiation, and creative expression. Various forms of analytic accompaniment include steady and present beat, an unobtrusive and loose presence, an interactive and conversational presence, or disruptive rhythms. From experiences of solid support and recognition, accompaniment can fuel the patient’s improvisations, allowing him to move away from the analyst and create a clearer differentiated voice. As the patient separates, he ventures out into new or difficult territory, the analyst’s presence is there following.     

The Risks of Therapist Passivity and the Potentials of Constructivist Influence

Francesca Colzani’s rich report of her sensitive work with Elisa highlights the therapist’s struggle with the issue of the exercise of power and authority bearing on the patient’s choices. It is suggested that sometimes the analyst poses her dilemma in dichotomous terms, choosing, in effect, between coercion and passivity. Also, it is argued that moral choices can be obscured by a turn to medicalization, diagnosis and treatment, of the patient’s “condition.” An alternative is proposed in which the analyst may offer constructive suggestions imbued with her subjectivity—her experience of conflict and uncertainty—leaving Elisa room for the exercise of her own responsible agency. In finding her own voice, the analyst may awaken selves or aspects of self of the patient that might otherwise remain dormant, potentially to her detriment. An example of an interpretation of projective identification, with self-disclosure on the analyst’s part, is proposed that might encourage collaborative reflection on a seemingly dissociative dimension of Elisa’s way of being and relating.     

Emotional Communication and the Unconscious in the Analytic Setting

ABSTRACT

One type of unconscious communication is conceptualized as a form of emotional communication, the channel of communication that conveys information about a person’s emotional state through the nonsymbolic expression of feelings and is experienced as feeling in the receiver. Some of the analyst’s feelings are attuned responses to the patient’s unconscious communications; others are disjunctive and related only to the analyst’s unconscious. Attuned feelings can be identified by their congruence—similarities, consistencies, and analogies—with the patient’s verbal material, which reveals the meaning that the analyst’s feeling has within the patient’s subjectivity. Attuned feelings also have a meaning within the analyst’s subjectivity. Two cases are discussed, one in which the analyst experiences the patient’s unconscious communication within the symbolism of one of her own childhood memories. The other illustrates the risk of confusing disjunctive feelings emanating from the analyst’s own unconscious with unconscious communication from the patient.     

On psychic elements in a case of autistoid perversion

The paper explores the formation of psychic elements from an epistemological point of view, drawing on the work of Bion to examine a clinical case of autistoid perversion. Distinguishing the qualification of psychic elements from the realization of pre‐conceptions, the paper argues that psychical elements are constituted through a mutually shared experience of presence, and so they should be understood in a paradoxical way – through being‐O and transformations into K. These ideas are explored via a clinical case concerning a patient with an autistoid–perverse organization. The patient had been denied any bodily contact with her parents during her first year of life due to an infection; in later life she exhibited an autistoid coprophilic perversion. During the course of her treatment, as it became possible to break down the autistoid organization, the nameless contents surfaced in a mutually shared experience of presence. The analyst was able to hold on to their meaning, which was unavailable to the patient. The absent analyst, however, turned into the mother who ‘put the child down’ and was experienced by the patient as a suicidal threat. In being‐O, the analyst was able to endure the paradox of being the one who ‘put her down’ in order not to put her down; the paradox of being‐O functioned as a container for the destructive objectal dimension of the state of ‘being put down’.     

Vitalizing Enactment: A Relational Exploration

Drawing from her extensive work with deeply disturbed children Alvarez (2012) theorized a form of intervention termed “vitalization” in which the analyst actively reaches out to contact and “reclaim” her most inaccessible patients, engaging them in the world of emotions and relationships. In this paper I consider Alvarez’s ideas through the lens of Relational thought, reconceptualizing vitalization as a unique form of enactment that can draw the analytic dyad from deadened impasse into enlivened contact. In vitalizing enactment embryonic affects, hopes, and longings find expression and are potentiated for patient and analyst alike. This is a view of enactment as a progressive and creative lived experience, rather than an unconscious collision to be survived and symbolized. I contextualize vitalizing enactment in relation to Alvarez’s original formulations as well as relevant contemporary theories and present a clinical vignette to illustrate this paper’s themes.     

Hörräume – Klanghüllen

In psychoanalytic research little attention has been given to one of the analyst’s chief instruments, namely his/her voice, although, apart from a few exceptions, the patient has to rely mainly on the acoustic channel in the course of the psychoanalytic process. The author presumes this to be a sign of a collective resistance among analysts which protects them against an unsettling idea: Our utmost restraint notwithstanding, it is in our voice that our physical nature materializes, that our presence is felt in a sensory way thus affecting our patients. An attempt is undertaken to show to what extent the analyst’s voice as a part of the atmosphere in the analyst’s practice affects the patient physically, thus making it possible for him/her an aesthetic experience, which may as a sensory perception lead to changes of the habitual ways of perception and thus to new experiences. Using the concept of “The Performance” devised by Fischer-Lichte, a lecturer in the theory of drama, the author explains to what extent meanings are created by both participants of a psychoanalytic process: Fischer-Lichte regards the aesthetics of performance as aesthetics of presence which arouse the sensation of physical presence. If the patient’s focus on the voice is not merely interpreted as a means of defence against comprehending the semantic meanings of the words, but is accepted as a necessary transition stage leading to re-animating the patient’s conception of reality, then a new listening and performing horizon is opened where the presence of other things can be experienced.     

Treating Patients with Symptoms—and Symptoms with Patience: Reflections on Shame,Dissociation, and Eating Disorders

I offer the view that the symptom picture found in most patients with eating disorders, as well as in the symptomatology of many other so-called difficult patients, is the end result of prolonged necessity in infancy to control traumatic dysregulation of affect. I propose that the central issue for an eating-disordered patient is that she is at the mercy of her own physiologic and affective states because she lacks an experience of human relatedness and its potential for reparation that mediates self-regulation. She is enslaved by her felt inability to contain desire as a regulatable affect and is thus unable to hold desire long enough to make choices without the loss of the thing not chosen leading to a dread of self-annihilation. Trauma compromises trust in the reparability of relationship, and for symptoms to be surrendered, trust in reparability must be simultaneously restored. Because felt desire is the mortal enemy of an eating-disordered patient, this fact becomes a central dynamic in the analytic field, leading analyst and patient into a struggle over who shall hold the desire and whether the issue of control over food is allowed to become a subject for negotiation. I discuss the inevitability of the analyst's own dissociative reactions in response to the patient's internal war over desire and control, and the different types of interpersonal enactments into which an analyst is drawn. In this tension, as illustrated through clinical vignettes, analyst and patient slip in and out of a constantly shifting array of self-states and thereby have an opportunity to coconstruct a transitional reality within which the patient's impaired faith in the reliability of human relatedness can be restored, and eating can become linked to appetite rather than to self-protection.     

Thoughts on the limits of a mutual technique*

Ferenczi’s appreciation of the inherently mutual nature of the analytic encounter led him, and many who followed, to explore the value of mutual openness between patient and analyst. Specifically, Ferenczi saw the analyst’s openness as an antidote to his earlier defensive denial of his failings and ambivalence toward the patient, which had undermined his patient’s trust. My own view is that, while the analyst’s openness with the patient can indeed help reestablish trust and restore a productive analytic process in the short term, it also poses long-term dangers. In certain treatments it may encourage “malignant regression”, where the patient primarily seeks gratification from the analyst, resulting in an unmanageable “unending spiral of demands or needs” (Balint, 1968, p. 146). I suggest that an analyst’s “confessions”, in response to the patient’s demand for accountability, can sometimes reinforce the patient’s fantasy that healing comes from what the analyst gives or from turning the tables on his own sense of helplessness and shame by punishing or dominating the analyst. In such situations, the patient’s fantasy may dovetail with the analyst’s implicit theory that healing includes absorbing the patient’s pain and even accepting his hostility, thus confirming the patient’s fantasies, intensifying his malignant regression and dooming the treatment to failure. When malignant regression threatens, the analyst must set firmer boundaries, including limits on her openness, in order to help the patient shift his focus away from expectations of the analyst and toward greater self-reflection. This requires the analyst to resist the roles of rescuer, failure, or victim—roles rooted in the analyst’s own unconscious fantasies.     

Identification with the aggressor and the ‘normal traumas’: clinical implications

Ferenczi's (1933) surprisingly unknown concept of identification with the aggressor – an abuse victim's ‘eliminating’ her own subjectivity and ‘becoming’ precisely what an attacker needs her to be – has radical implications for our understanding of analytic technique. Its very frequent occurrence also forces us to broaden our understanding of what constitutes trauma. Ferenczi saw the experience of ‘traumatic aloneness’ or ‘emotional abandonment’ as the key element of trauma, since this is what enforces the traumatic responses of dissociation and identification with the aggressor. Identification with the aggressor operates in the analytic relationship in both patient and analyst. This has various consequences, including the structuring of the relationship through unconscious collusions – mutually coordinated, defensive identifications designed to help both participants feel secure. This view of the analytic relationship has clinical implications in at least four areas: the understanding of the patient's free associations, which may reflect the patient's compliance with the analyst's wishes rather than the contents of the patient's own unconscious; the need for some kind of mutuality of analysis; the traumatizing potential of the analyst's authority; and the tendency of some patients to take blame and responsibility reflexively, as a way of protecting the analyst.     

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.     

A Postscript to Panel Discussion of Gianni Nebbiosi’s “The Smell of Paper: On the Usefulness of Musical Thought in Psychoanalytic Practice”

Gianni Nebbiosi’s paper, “The Smell of Paper: On the Usefulness of Musical Thought in Psychoanalytic Practice,” explores many levels of the analyst’s clinical sensibility. These include the finding of a patient in the mind of the psychoanalyst, the discovery of new points of creative inflexion in developing metaphors with a patient who is frightened of symbolic meaning, the use of countertransference analysis to explore the analyst’s points of resistance to helping his or her patient, and the development of a creative shared frame of reference between patient and analyst that emerges from the patient’s unconscious life.     

What’s So Great About Authenticity Anyway? The Therapeutic Function of an Analyst’s Lie

How can we understand moments when the analyst lies to her patient? When it’s not the patient’s lying at issue but the analyst’s? When we suddenly find ourselves being deliberately disingenuous in the analytic hour? When our commitment to authenticity conflicts with the patient's need to create and sustain certain fantasies about us? Psychoanalytic literature typically focuses on the dynamics of the patient’s lie but rarely is the analyst's authenticity questioned. Are there times when the analyst might choose to lie in order to preserve herself, as well as, the relational bond? The complexity of this “choice” is explored and the erosion of an analyst’s authenticity unpacked during the final days of a difficult treatment.     

Death Is Nothing at All: On Contemplating Non-Existence. A Relational Psychoanalytic Engagement of the Fear of Death

This paper engages the secular mind’s struggle with mortality from a relational perspective. It critically reviews the legacy of Freud’s refusal to grant mortality psychic significance and the ways in which the fear of death has consequently been understood theoretically and addressed clinically. Analytic omnipotence is foregrounded as an impediment to the kind of intersubjective engagement that minds need from other minds in grappling with the loss of the self through death. A clinical illustration is used to explore the ways in which the analyst found himself relating with a patient around her extreme fear of death, which over the course of treatment became modified into a more bearable anxiety about her own mortality. A conceptual framework is offered to account for these changes, emphasizing the analyst’s personal relationship with mortality as a crucial variable in how the fear of death is engaged psychoanalytically. The author calls for a revisionist psychoanalysis that allows for death’s centrality in both theory and practice.     

Seeing,mirroring, desiring: The impact of the analyst’s pregnant body on the patient’s body image

The paper explores the impact of the analyst’s pregnant body on the course of two analyses, a young man, and a young woman, specifically focusing on how each patient’s visual perception and affective experience of being with the analyst’s pregnant body affected their own body image and subjective experience of their body. The pre‐verbal or ‘subsymbolic’ material evoked in the analyses contributed to a greater understanding of the patients’ developmental experiences in infancy and adolescence, which had resulted in both carrying a profoundly distorted body image into adulthood. The analyst’s pregnancy offered a therapeutic window in which a shift in the patient’s body image could be initiated. Clinical material is presented in detail with reference to the psychoanalytic literature on the pregnant analyst, and that of the development of the body image, particularly focusing on the role of visual communication and the face. The author proposes a theory of psychic change, drawing on Bucci’s multiple code theory, in which the patients’ unconscious or ‘subsymbolic’ awareness of her pregnancy, which were manifest in their bodily responses, feeling states and dreams, as well as in the analyst s countertransference, could gradually be verbalized and understood within the transference. Thus visual perception, or ‘external seeing’, could gradually become ‘internal seeing’, or insight into unconscious phantasies, leading to a shift in the patients internal object world towards a less persecutory state and more realistic appraisal of their body image.     

The “Once and Future” Focus of a Relational Psychoanalysis: Discussion of “Vitalizing Enactment”

In this discussion of Amy Schwartz Cooney’s paper (this issue) I focus on the current interest in relational theorizing on the analyst’s proactive role vis-à-vis her patient, that is, what she actually does for or gives to her patient. I consider the role of the analyst’s own internal “bad” objects in facilitating or inhibiting the therapeutic process. I end with a set of theoretical propositions about the ways in which an intense and deadening shame can lead to dissociation and/or repression of hopeful fantasies about the future.     

The body one has and the body one is: Understanding the transsexual’s need to be seen

The transsexual individual confronts the analyst with a disturbing otherness. How this otherness is understood, that is, how the analyst ‘looks’ at the patient through her distinctive theoretical lens impacts, in turn, on the patient’s experience and what transpires between them. In this paper the author outlines a developmental model rooted in attachment and object relations theory to provide one alternative way of ‘looking’ at some of these patients’ experiences in the clinical setting. It is suggested that in some cases of transsexuality the primary object(s) did not mirror and contain an early experience of incongruity between the given body and the subjective experience of gender: it remains unmentalized and disrupts self‐coherence leading to the pursuit of surgery that is anticipated to ‘guarantee’ relief from the incongruity. Through an account of work with a male to female (MtF) transsexual who underwent surgery during her five years of psychotherapy, the author explores how a focus on the transsexual’s experience of ‘being seen’, that is, of being taken in (or not) visually and mentally by the object in their state of incongruity, affords another window through which to approach the transsexual’s experience in the transference–countertransference dynamics.     

The reality of the other: Dreaming of the analyst1

The author discusses the obstacles to symbolization encountered when the analyst appears in the first dream of an analysis: the reality of the other is represented through the seeming recognition of the person of the analyst, who is portrayed in undisguised form. The interpretation of this first dream gives rise to reflections on the meaning of the other’s reality in analysis: precisely this realistic representation indicates that the function of the other in the construction of the psychic world has been abolished. An analogous phenomenon is observed in the countertransference, as the analyst’s mental processes are occluded by an exclusively self‐generated interpretation of the patient’s psychic world. For the analyst too, the reality of the other proves not to play a significant part in the construction of her interpretation. A ‘turning‐point’ dream after five years bears witness to the power of the transforming function performed by the other throughout the analysis, by way of the representation of characters who stand for the necessary presence of a third party in the construction of a personal psychic reality. The author examines the mutual denial of the other’s otherness, as expressed by the vicissitudes of the transference and countertransference between analyst and patient, otherness being experienced as a disturbance of self‐sufficient narcissistic functioning. The paper ends with an analysis of the transformations that took place in the analytic relationship.