Mutuality*

Ferenczi’s striving for mutuality, a call which Freud didn’t take up, let him explore this concept with his analysands. He thus became the originator of mutual analysis, although with caveats, and of the concept of introjection, another important Ferenczian notion. The analyst’s attitude of knowing the ‘objective’ and independent Truth is changing its orientation into that of a co-construction in the analytic work; here the analyst and the analysand build a third internal world, which they share and which remains their own. Clinical vignettes illustrate the implications of these views.     

Terrified by suffering,tormented by pain*

Ferenczi’s understanding of the primitive defenses required to cope with trauma, such as introjection, identification with the aggressor, atomization and reckoning, supports the author’s clinical observations of patients who introject a pain mother. Introjecting a pain mother assures that the terrorism of the original external event of a suffering mother keeps the internal suffering going, resulting in being tormented by pain. Such an introjection creates technical difficulties for the analyst. A clinical case is presented to demonstrate.     

Commentary on ‘The arms of the chimeras’ by Béatrice Ithier

In this Commentary I will first of all summarise my understanding of the proposal set out by Béatrice Ithier concerning her concept of the ‘chimera’. The main part of my essay will focus on Ithier's claim that her concept of the chimera could be described as a ‘mental squiggle’ because it corresponds to Winnicott's work illustrated in his book ‘Therapeutic Consultations’ (1971). At the core of Ithier's chimera is the notion of a traumatic link between analyst and patient, which is the reason she enlists the work of Winnicott. I will argue, however, that Ithier's claim is based on a misperception of the theory that underpins Winnicott's therapeutic consultations because, different from Ithier's clinical examples of work with traumatised patients, Winnicott is careful to select cases who are from an ‘average expectable environment’ i.e. a good enough family. Moreover, Winnicott does not refer to any traumatic affinity with his patients, or to experiencing a quasi‐hallucinatory state of mind during the course of the consultations. These aspects are not incorporated into his theory. In contrast (to the concept Ithier attempts to advance), Winnicott's squiggle game constitutes an application of psychoanalysis intended as a diagnostic consultation. In that sense Winnicott's therapeutic consultations are comparable with the ordinary everyday work between analyst and analysand in a psychoanalytic treatment. My Commentary concludes with a question concerning the distinction between the ordinary countertransference in working with patients who are thinking symbolically in contrast to an extraordinary countertransference that I suggest is more likely to arise with patients who are traumatised and thus functioning at a borderline or psychotic level.     

Immersion in the surface1

In order to treat patients with a narcissistic structure showing a rigid shell of defence together with a lack of inner differentiation – insufficient subject/object constitution – one has to deal with a split kind of transference. Their compelling need for distance corresponds to their fragile self‐esteem. They feel threatened by the analysis and the analytic relationship. Because the seeming normality of these patients’ thinking and language is deceptive, a variation of psychoanalytic technique to facilitate the work with them is described and explained in detail. To transform their two‐dimensional ‘inner’ world, which functions in a PS modus, it is helpful to show them, with changing viewpoints step by step, their own manoeuvres, misconceptions and manipulative use of language within the analytic relationship. The gratifying extension of their self‐awareness leads to the introjection of the analyst’s alpha‐function. This makes possible a more distinct separation of subject and object representations and a transformation to a three‐dimensional, oedipally structured world with a strengthened capacity to symbolize. This method of working is grounded in Bion’s theory of thinking. A case vignette illustrates a development of this kind.     

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.     

On Leaving Home and the Flight From Trauma

This paper is both autobiographical and clinical—a psychoanalyst's reflections about important transitional moments in his life. Examples of such moments are the cultural blind spot regarding the affect of the Holocaust experience on the hundreds of thousands of survivors who immigrated to Israel after World War II and his own professional disavowal of that experience and his eventual finding of “shared home” in listening to the trauma discourse of Holocaust survivors and to that of other severely traumatized patients. This paper also highlights the importance for the immigrant analyst of presenting the cultural perspective stemming from his own tradition and background, and the one acquired in his new home, side by side and in dialogue with each other. Finally, the author examines how being a trauma survivor and an immigrant informs his work as a psychoanalyst.     

Here and now: My perspective1

In this paper the author describes her particular perspective in doing analytic work. She stresses working in the here and now. For example, making interpretations that grow out of what the patient says or does in the sessions, keeping the patient’s history in mind, but not letting it lead interpretations. The analysis tries to understand why something is being said now, in this way, and what impact it may have or be designed to have in the analytic relationship. The term ‘here’ refers to what is going on between patient and analyst in the room while not leaving out the patient’s immediate reality in the outside world, his everyday life. The word ‘now’ implies awareness of time that is not just of the past and future but of the patient’s situation at the moment in analysis, which is constantly shifting.The author believes that by working primarily in the present the patient will feel more anchored, both patient and analyst can observe what is going on, for example how anxiety arises or decreases, how defences are mobilised or lessen. Both analyst and patient experience movement and change rather than relying on more theoretical explanations.     

Modifications to the Technique of Analysis of BPD Adolescents

In this article I discuss certain modifications in technique that I applied working with borderline adolescents that enabled me to preserve the therapeutic bond and which, in my opinion, allowed me to obtain successful results. The differences with classical analysis are clear cut and concern, for example, the setting, the frequency of sessions, the nature of the transference, and modes of interpretation. It is important to keep our dialogue with the adolescent alive and avoid long silences that can be destructive. Part of the analyst’s work, in fact, consists in loaning his/her “images” (the product of his/her mind or imagination) to the concreteness of the patient. In the session these images seize something that is already present in the adolescent’s narrative as a creative hint to be developed that the analyst sees in the dialogue and deposits as a seed in his/her mind and which gives rise to a fruit produced by the analytical couple.     

Making Music Together: Discussion of Gianni Nebbiosi’s “The Smell of Paper”

Finding life in our patients is a common goal for analysts. Historically this project had been defined as one of freeing unacceptable impulses from their imprisoning defenses with the analyst, via interpretation, then contrasting the patient’s internal fantasied reality with “actual” reality. Untangling fantasy from reality could free the impulses to provide energy for more realistic projects. This imagery stands in stark contrast to the fluidity of a contemporary relational conceptualization of human experience where our inner experience is now understood to be the lens through which we construct our vision of external reality, always a subjective perception. Clinical change—finding life—now depends more on the activation of a generative intersubjective process between patient and analyst, which contributes to the expansion of the patient’s subjective experience. Gianni Nebbiosi’s use of music and of mime to help him feel his way into his patient’s and ultimately into his own similarly defended experience demonstrates the creativity and idiosyncratic clinical approaches that emerge from a contemporary relational orientation. This orientation recognizes the analyst’s subjectivity as a fundamental tool of clinical change—a vehicle through which any theoretical approach will necessarily be shaped. Differing approaches to a clinical situation do not always simply reflect theoretical disagreements; they may also reflect the expression of the particular subjectivity of the analyst.     

Thinking Developmentally: Perspectives Following Loewald and Klein

In this article, I explore two perspectives on development that are central to how I think and work as an analyst, one drawn from the work of Hans Loewald and one from Melanie Klein. Loewald turned the usual psychoanalytic way of thinking, rooted in the past, on its head when he theorized that development proceeds by internalization of the parent’s future vision of the child and, by corollary, the analyst’s future vision of the patient. Using a vignette from Klein’s work with 10-year-old Richard, I show how the analyst’s image of the patient’s potential can facilitate growth and development. Melanie Klein also introduced a radical reordering of traditional psychoanalytic theory when she theorized that the mind develops and is structured as positions, not as successive phases. For Klein, the mind is organized in groupings of anxieties, defenses, and object-relations that are in a continuous state of oscillation throughout life independent of chronological age. Through a clinical vignette, I illustrate how one understands a patient differently when development is seen as occuring in momentary shifts between different levels of the personality rather than as stages over time.     

A personal commentary on J.W. Perry,M.D., and introduction to ‘Reconstitutive process in the psychopathology of the Self’

John Weir Perry’s influence on the understanding of the psychotic process through his research in San Francisco between 1950 and 1981 was groundbreaking, because it both verified and expanded upon C.G. Jung’s research at the Burghölzli Hospital in Switzerland in the early 1900’s. The author explores both the brilliance of Perry’s contribution as a psychiatrist and Jungian analyst and also shows the flawed human, who, with his rare sensitivity to the psychotic process, devoted his life work to the schizophrenic population and their often ill-fated search for meaning. She tells how his creative engagement with the analytic processes of Self discovery eventually led to analytic boundary violations, which ultimately resulted in his indefinite suspension from membership in his local Jungian community. Further, this paper describes her reflections on the innovative work that influenced both the treatment of this population, as well as educating candidates in analytical training to be receptive to and cognizant of psychotic affects and imagery. The archetypal field of the psychotic process, its influence on the development of analytical psychology relative to the psychotic process, and one man’s impact on the analytic community are considered.     

Looking back,looking forward: A reexamination of Benjamin Wolstein’s interlock and the emergence of intersubjectivity

In this paper the author takes a close look at Benjamin Wolstein’s chapter, ‘Therapy’, from his book, Countertransference, published in 1959. This chapter contains a discussion of what he refers to as the interlock between analyst and patient, or today what we might describe as transference/countertransference enactment. The author shows how Wolstein’s concept of the interlock and its relation to the analyst’s countertransference was radical and innovative for its time. Wolstein’s notion of a transference/countertransference interlock, along with the seminal contributions of Ferenczi and some of the early interpersonal theorists, anticipates the complexities of a two‐person psychology and the entanglement which can occur from the intermingling of unconscious processes of analyst and patient in the experiential field. The author highlights three main ideas. First, the author provides a brief review of enactment with an emphasis on the role of the analyst’s participation as conceptualized by the various theoretical perspectives. An historical context is given for Wolstein’s clinical theorizing. Second, the author explicates Wolstein’s concept of the interlock, with particular attention to the processes involved which account for the complexities it presents. Third, the author examines the ‘working through’ process, including the emergence of intersubjectivity in the resolution of the interlock. The author shows throughout Wolstein’s emphasis on the influence of the analyst’s personal psychology, mutuality, and intersubjectivity, all of which anticipated the gradual interpersonalization of psychoanalysis across the various schools of thought.     

On authenticity: the question of truth in construction and autobiography

Freud was occupied with the question of truth and its verification throughout his work. He looked to archaeology for an evidence model to support his ideas on reconstruction. He also referred to literature regarding truth in reconstruction, where he saw shifts between historical fact and invention, and detected such swings in his own case histories. In his late work Freud pondered over the impossibility of truth in reconstruction by juxtaposing truth with ‘probability’. Developments on the role of fantasy and myth in reconstruction and contemporary debates over objectivity have increasingly highlighted the question of ‘truth’ in psychoanalysis. I will argue that ‘authenticity’ is a helpful concept in furthering the discussion over truth in reconstruction. Authenticity denotes that which is genuine, trustworthy and emotionally accurate in a reconstruction, as observed within the immediacy of the analyst/patient interaction. As authenticity signifies genuineness in a contemporary context its origins are verifiable through the analyst’s own observations of the analytic process itself. Therefore, authenticity is about the likelihood and approximation of historical truth rather than its certainty. In that respect it links with Freud’s musings over ‘probability’. Developments on writing ‘truths’ in autobiography mirror those in reconstruction, and lend corroborative support from another source.     

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.     

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.     

On Seeing What Is Not Said: The Concrete Mode of Psychic Functioning and the Development of Symbolization

This paper examines the difficulties that arise with patients who experience a compromised capacity in working on a symbolic level when ensnared in specific transference/countertransference entanglements. In these kinds of situations, patients often operate in what is referred to as the concrete mode of psychic functioning in which there is an inability to think psychologically about their own mind, as well as the minds of others. Similarly, the analyst often has trouble thinking with the patient in processing the actions between them, unable to recruit the patient’s mind in becoming a thinking couple together. Having exhausted conventional technique and interventions in trying to observe the enactment with the patient, the author argues that the analyst’s ability to grab hold of fleeting associations and memories that have not been fully processed not only expands his own mind but also facilitates symbolic functioning in the patient’s mind. By using the imagistic and sensorial substrates of these remembrances to further symbolize personal experiences, the analyst may gain entrée into the patient’s mental life.     

Collusive induction in perverse relating: Perverse enactments and bastions as a camouflage for death anxiety

The author argues that one of the main functions of perverse relatedness is to induce the analyst into becoming the patient's unconscious accomplice in a “perverse pact” against the analytic work aimed at disavowing intolerable aspects of reality. The intense power of collusive induction in perverse relating leads the analyst to participate in transference‐countertransference enactments and to the crystallization of a silent and chronic unconscious collusion between the patient and analyst in the analytic field, stagnating the process (bastion; Baranger and Baranger). The author claims that analysis of perverse pathology should not be limited to interpretation of the patient's intrapsychic functioning but should also focus on the information obtained by the analyst through his participation in collusive enactments; the analyst should also take a “second look” at the analytic “field” to detect underlying bastions. The author reviews the main psychoanalytic contributions that have clarified the phenomenon of collusive induction in perverse relating and as an illustration, describes the analysis of a man with a perverse character; in this patient, one of the main functions of his perverse relatedness was to induce the analyst to become an accomplice in his disavowal of his terror of death. The author highlights the influence of death anxiety in the bastions that develop in the treatment of perverse patients.     

Biographical truths and their clinical consequences: Understanding ‘embodied memories’ in a third psychoanalysis with a traumatized patient recovered from severe poliomyelitis

The relationship between ‘narrative’ and ‘historical–biographical truth’ in psychoanalytic treatment has become the subject of many controversial debates in recent years. Findings of contemporary memory research have lead to great scepticism as to whether therapists are able objectively and reliably to reconstruct biographical events on the basis of their observations in the therapeutic situation. Some authors even claim that psychoanalysts should concentrate exclusively on observing the here and now of the patient′s behaviour within the transference relationship to the analyst. In this paper it will be discussed whether the baby has been thrown out with the bathwater in this debate. Centred around the insights from a third psychoanalysis with a patient who suffered from a severe case of childhood polio, the hypothesis will be discussed that working through the traumatic experience in the transference with the analyst, as well as the reconstruction of the biographical–historical reality of the trauma suffered, prove to be indispensable for a lasting structural change. Integration of the trauma into one′s own personal history and identity is and remains one of the main aims of a psychoanalytic treatment with severely traumatized patients. The reconstruction of the original trauma is indispensable in helping the patient to understand the ‘language of the body’ and to connect it with visualizations, images and verbalizations. The irreversable wounds and vulnerability of his body as the ‘signs of his specific traumatic history’ have to be recognized, emotionally accepted and understood in order to live with them and not deny them any longer. Another important aspect in psychoanalysis is to develop the capability to mentalize, in other words, to understand the intentions of central (primary) objects related to the trauma. The concept of ‘embodied memory’ might be helpful in understanding precisely in what way ‘early trauma is remembered by the body’. Observing in detail the sensory‐motor coordinations in the analytic relationship enables one to decode the inappropriate intensity of affects and fantasies which match the original traumatic interaction and are revealed as inappropriate reactions in the present, new relationship to the analyst.     

“With you I’m Born Again”: Themes and Fantasies of Birth and the Family Circumstances Surrounding Birth as These are Mutually Evoked in Patient and Analyst

Themes of birth and rebirth, being born and born-again, can be readily observed in clinical psychotherapy and psychoanalysis even as they remain undertheorized. A clinical case is presented that traces the first four years of an analysis as seen through the lens of four consecutive supervisory experiences. This paper explores the central importance of fantasies and narratives of one’s origins and birth and the observations, fantasies, and expectations generated by one’s family circumstances at the time of birth. The paper examines birth narratives, fantasies, and myths of origination by following a clinical case across four supervisions. The patient’s birth-related fantasies are shown to interact with the analyst’s concordant and complementary fantasies as the analyst interacts with a series of supervisors in the process of being born as an analyst. The analyst’s personal birth narrative is linked to his fantasies about being born professionally as an analyst, and these are shown to interact with the patient’s birth fantasies. The paper suggests the ongoing significance of unconscious fantasy within the framework of contemporary relational psychoanalysis.