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

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

Finding the neutral position: patient and analyst perspectives

In light of current debates between classical and intersubjective schools of psychoanalysis, the challenge posed by the latter to such basic concepts as the analyst's neutrality, anonymity, and abstinence is taken up. It is maintained that the term neutral position is today more germane and meaningful than the term neutrality, which frequently has been taken to prescribe the analyst's posture. It is proposed that for each patient the neutral position is uniquely sited and that it is incumbent on the analyst to find its location. The neutral position is defined within the context of the interaction between analyst and patient. The concept is therefore compatible with--indeed it is essential to--an intersubjective or relational orientation. The manifold reasons, conscious and unconscious, why the analyst is vulnerable to leaving the neutral position are considered. The patient's reaction to the analyst who has left the neutral position and the analyst's clinical use of this reaction are discussed.     

Empathy and the unconscious

The author examines the complex relationship between the concepts of empathy and unconscious, including exploration of topical, structural, and dynamic aspects; and the risk of oversimplification of empathy is discussed. Two clinical examples are then presented to demonstrate some of the complex factors that may contribute to or hinder the development and utilization of empathy by the analyst, many of which lie outside the analyst's conscious awareness.     

Taking time: the tempo of psychoanalysis

In this article the author argues that in order to be psychoanalysis, the 'here and now' technical approach needs to be firmly grounded theoretically and technically in a practice that includes the notion of reverie or its equivalent. The author has argued previously that the analyst's theory is the essential 'third' of the two-person analytic situation. She now suggests that it is specifically the theories of temporality and the attitude of 'evenly suspended attention' or its more contemporary development, 'reverie', that are the crucial aspects of that theory. She refers to these essential aspects as the 'theory in practice' in so far as they are more than a technical approach or a theory of practice but reflect directly a particular analyst's internalisation of the whole psychoanalytic theoretical corpus. While she believes this to be an essential component in any true psychoanalysis, in developing her argument the author looks at situations in which the analyst is particularly prone to forgo this temporal aspect, as is the case when patients show an absence of symbolic thinking within the analytic situation. In fact, with those patients reverie and the visual images it produces within the analyst's mind offer perhaps the only hope of a meeting ground between the concrete and the symbolic and the possibility of avoiding an impasse. Impasse, she suggests, has at its root the absence of reverie as a third and temporal element, inevitably giving rise to concrete thinking on the part of patient and analyst and so to a situation that cannot evolve.     

THE CONCEPT OF OBJECTIVE COUNTERTRANSFERENCE AND ITS ROLE IN A TWO-PERSON PSYCHOLOGY

Objective countertransference comprises those feelings the analyst experiences with the patient that are repetitions of feelings from the patient's life outside the analysis. It is viewed as being induced by the patient and is understood in the context of the patient's life, not the analyst's. The concept is used to understand the relationship of some of the analyst's feelings to recurrent interpersonal patterns in the patient's life. It has often been viewed as being incompatible with a two-person psychology. Here, in contrast, it is argued that objective countertransference is only one current within the analyst's total emotional response to the patient, and that it should be conceptualized as a component of a broader two-person psychology. However, the use of objective countertransference as a conceptual tool highlights aspects of the analytic relationship that differ from those emphasized in current two-person models. A case example is analyzed from both perspectives to illustrate their similarities and differences. Although the concept of objective countertransference can enrich the analyst's understanding of certain dimensions of the analytic relationship, it is not a theory of technique and it is not wedded to any particular style of psychoanalytic intervention.     

Id analysis and technical approaches

The author argues that the technical advances stemming from Freud's (1923) introduction of the structural theory permit a more naturalistic and specific approach to analyzing unconscious conflict, thus facilitating id analysis. The earlier topographical technique underestimated the role of suggestion; often, it entailed interference with patients' capacity for self-observation, as well as with the exploration of their own drive derivatives. In order to illustrate the type of id material obtainable with a contemporary ego psychology approach, the author presents clinical vignettes and commentaries. It is recognized that clarifications, defense interpretations, and Gray's close-process interventions may need to be adapted to different cultural milieus.     

This art of psychoanalysis

It is the art of psychoanalysis in the making, a process inventing itself as it goes, that is the subject of this paper. The author articulates succinctly how he conceives of psychoanalysis, and offers a detailed clinical illustration. He suggests that each analysand unconsciously (and ambivalently) is seeking help in dreaming his 'night terrors' (his undreamt and undreamable dreams) and his 'nightmares' (his dreams that are interrupted when the pain of the emotional experience being dreamt exceeds his capacity for dreaming). Undreamable dreams are understood as manifestations of psychotic and psychically foreclosed aspects of the personality; interrupted dreams are viewed as reflections of neurotic and other non-psychotic parts of the personality. The analyst's task is to generate conditions that may allow the analysand-with the analyst's participation-to dream the patient's previously undreamable and interrupted dreams. A significant part of the analyst's participation in the patient's dreaming takes the form of the analyst's reverie experience. In the course of this conjoint work of dreaming in the analytic setting, the analyst may get to know the analysand sufficiently well for the analyst to be able to say something that is true to what is occurring at an unconscious level in the analytic relationship. The analyst's use of language contributes significantly to the possibility that the patient will be able to make use of what the analyst has said for purposes of dreaming his own experience, thereby dreaming himself more fully into existence.     

The interpretive attitude

From its start, psychoanalysis took as its primary goal the gaining of insight, and the analyst's interpretations as its primary technique for achieving that goal. Multiple factors, including the destructive impact of wild analysis and a growing appreciation of noninterpretive analytic functions, have brought those first principles into question. The author posits a conceptual division of the analyst's interpretive functions into declarative interpretations (content) and a procedural interpretive attitude (underlying process).The interpretive attitude is presented as crucial and central to psychoanalytic work, relevant and effective even when matters touching on preverbal issues are addressed.     

1. On note taking

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

Life-threatening illness in the analyst

The literature on practicing throughout a life-threatening illness is reviewed and important differences about attitudes toward self-disclosure are understood by noting a division between two perspectives on transference: "one-body" and "two-body" views. The analyst's use of self-disclosure is informed by the prominence given the interpretation of transference as against that given the patient's needs in the collaborative relatedness supporting the therapeutic alliance. Themes and illustrative clinical vignettes are presented from the author's own experience practicing during such an illness. Three phases of working during illness are delineated, each somewhat different regarding the analyst's state, and hence patients' needs and reactions. Recommendations are made regarding conditions that make it possible to work effectively during a life-threatening illness. The analyst needs help from his or her own analyst to make the clinically and sometimes ethically appropriate decisions about practice; while this is important in instances in which the analyst recovers, it is essential should the analyst become terminal and face more certain death.     

The analyst's caseload as a family: transferences to fellow patients

This article draws attention to a topic that has been mostly ignored in our literature: the manifold transference meanings of our patients' reactions to our other patients. Central aspects of the patient's transference may be displaced onto the analyst's other patients. The author includes clinical examples of hospitalized patients, where such transferences to other patients are often more dramatic and obvious, as well as examples from neurotic patients, where such transferences may be less dramatic and may tend to resolve more readily through interpretation. The displacement of transference feelings onto the analyst's other patients also has important implications for training analyses, where analysands are likely to have multiple relationships with the analyst's other analysands, supervisees, and students.     

What the analyst does not hear

In the clinical situation, the analyst fails to hear more than he or she hears and spends much time working in the dark. The author raises questions about how we can take cognizance of that state of affairs in our thinking about analytic work. A clinical example illustrates how, in an analytic atmosphere, a patient will correct an analyst's failure to hear. Some ideas are offered about how to maximize the patient's participation in that effort. The author suggests that the problem may not fall precisely under the heading of technique so much as reflecting the analyst's attitude.     

When the analyst is physically ill: Vicissitudes in the analytical relationship

Something that happened to one of the authors recently led them to refl ect upon what the analyst's falling ill may represent and the problems it may give rise to in the analytic relationship. Such an eventuality injects a massive dose of the analyst's personal reality into the analytic space, thereby allowing the patient a glimpse of images of vulnerability, frailty and loss, and mobilizing emotions, fantasies and defences in both the analyst and the patient. The authors' survey of the literature ranges between two different theoretical perspectives intrapsychic and intersubjective that, in their most radical formulations on technique, call for maintaining either the strictest neutrality and anonymity or symmetrical relationality. In both cases, that which is denied is the unconscious communication that enables the analyst, irrespective of his conscious intentions, to allow either parts of himself or inner objects of the patient to act in the relationship. In closing, the authors shall illustrate the concept discussed through three clinical vignettes.     

Elements of analytic style: Bion's clinical seminars

The author finds that the idea of analytic style better describes significant aspects of the way he practices psychoanalysis than does the notion of analytic technique. The latter is comprised to a large extent of principles of practice developed by previous generations of analysts. By contrast, the concept of analytic style, though it presupposes the analyst's thorough knowledge of analytic theory and technique, emphasizes (1) the analyst's use of his unique personality as reflected in his individual ways of thinking, listening, and speaking, his own particular use of metaphor, humor, irony, and so on; (2) the analyst's drawing on his personal experience, for example, as an analyst, an analysand, a parent, a child, a spouse, a teacher, and a student; (3) the analyst's capacity to think in a way that draws on, but is independent of, the ideas of his colleagues, his teachers, his analyst, and his analytic ancestors; and (4) the responsibility of the analyst to invent psychoanalysis freshly for each patient. Close readings of three of Bion's 'Clinical seminars' are presented in order to articulate some of the elements of Bion's analytic style. Bion's style is not presented as a model for others to emulate or, worse yet, imitate; rather, it is described in an effort to help the reader consider from a different vantage point (provided by the concept of analytic style) the way in which he, the reader, practices psychoanalysis.     

The analyst's excitement in the analysis of perversion

The author believes that unconscious sexual excitement in the transference and countertransference is an especially problematic aspect of the analysis of perverse character pathology and that perverse sexual gratifi cation deserves a more prominent position in the clinical theory of analyzing perversion than that which has been assigned tacitly through analysts' routine focus on the defensive and destructive dynamics of perversion. He presents clinical material from the analysis of a perverse patient that illustrates the role of excitement in the transference perversion established in this analysis; and he asserts that gratifying perverse enactments occurring in the transference perversion can appear not only as conscious or unconscious excitement in the transference but also, at times most clearly, as the analyst's excitement. The author suggests that using a clinical theory that supports the analyst in understanding his excited responses as perverse countertransferences-i.e. evoked excitement complementary to the sexual component of a perverse transference-will assist him in locating and thinking about gratifying, perverse excitement in the transference where it is most usefully analyzed. Finally, he discusses some of the reasons why analysts might deny, suppress or otherwise avoid perverse countertransferences and in so doing contribute to sustaining perverse resistances.     

The analyst's theory: A third source of countertransference

The author asserts that the analyst's theory, personal and/or academic, is an important source of countertransference which complicates our traditional understanding of the analyst's emotional responses as being constructed from a mix of his transferences and the patient's effects on him. From this perspective, theory - because it has no intrinsic relevance to the essential phenomena of individual analytic processes - may be a confounding, as well as a necessary, factor in clinical work. Although the analyst's theory might be conceptualized as a component of his personality that shapes his emotional reactions to a patient, the author believes that there is a valuable increment of conceptual clarity and additional clinical utility to thinking about a more direct role of theory in the process of countertransference formation. He uses aspects of the clinical analysis of narcissistic resistances to illustrate how some theories might predispose an analyst to confounding unconscious enactments by generating either positive or negative countertransferences which can be used defensively by the patient and/or analyst. He also illustrates how, in some contexts, an analyst's theory might attenuate potentially informative countertransference reactions and interfere in this way with the analyst's apprehension of the patient's psychic functioning. Finally the author addresses the importance of 'fit' between an analyst's working theory and a patient's psychopathology, and considers implications of his ideas for psychoanalytic training and practice.     

Employing multiple theories and evoking new ideas: the use of clinical material

In this paper, I wish to illustrate how working with a patient who had a certain kind of narcissistic difficulty led me to develop particular clinical strategies to facilitate the development of a sturdier sense of self, greater affect tolerance and modulation, the diminution of harshness of her superego, and the ownership of projected parts of herself, and to decrease paranoid ideation. I call upon concepts from various theoretical schools of psychoanalysis to make sense of the dynamic intricacies of the patient's psychological organization as they revealed themselves in the analytic process. These conceptualizations of the patient's difficulties and of clinical interventions to address them result in a hybrid theory of both theory and technique. What transpired in the clinical work also led me to propose an additional way to understand this kind of patient's difficulties with accepting interpretations or any view that differed from the patient's subjectivity. I am proposing that 'otherness' itself, rather than only specific conflictual aspects of the self, is disowned. It is the analyst's empathic stance toward all that is repudiated--the specific disowned aspects of the self and 'otherness' itself--along with empathy for the patient's conscious state that will enable reinternalization and ultimately healing.