What happens before and after acute enactments? An exercise in clinical validation and the broadening of hypotheses

This paper seeks to validate clinical facts and theoretical hypotheses that have been discussed before and that address configurations involving chronic and acute enactments. Its validation process compares clinical material from psychoanalytic work in different psychoanalytic cultures - work from South America-Uruguay (Yardino), Europe-Spain (Sapisochin), South Africa (Ivey), Europe-UK (Bateman). It documents clinical facts described in four articles and confirms that during chronic enactments the analytic dyad gets caught up in a dual relationship that veils and congeals the triangular situation because acknowledging it would be traumatic. The lack of triangular space impedes the formation of symbols as well as dreaming and creates non-dreams-for-two. During chronic enactments analysts use their implicit alpha-function to assemble traumatic areas. These areas emerge as a mix of discharges and non-dreams that are dreamed through acute enactments. Acute enactments occur when chronic enactments dissolve and patients experience an abrupt contact with reality. The attenuated trauma is then dreamed alive. The linking of new symbols develops a network of symbolic thought and creates dreams-for-two and broadens the patient's mental universe. The validation process has deepened our vision concerning clinical facts, especially in relation to: (1) the wavering between acute and chronic enactments, (2) analysts' inhibitions and feelings of guilt, and (3) the influence of analysts' personalities on the configurations they describe. These theoretical hypotheses have been confirmed and broadened not only in relation to the vicissitudes of dream work in traumatic areas, but also in relation to defenses such as thin or thick skin, and in relation to listening in countertransferential detours.     

From psychic holes to psychic representations

Abstract

In this essay, I will explore the term “psychic hole,” and compare it to similar terms from the world of astrophysics and terms used in the psychoanalytic literature. I will then present my own conception of the “psychic hole” in cases of Holocaust survivors' offspring. I will explain how this “hole” is created, and describe a particular aspect of the “psychic hole” that is unique to Holocaust survivors' offspring, namely the enactments (termed “concretization” by Bergman) generated by the negated traumatic themes that reside in it. I will illustrate these enactments using clinical material taken from case studies of Holocaust survivors' offspring that I have previously published. The clinical vignettes reveal the transgenerational impact of the memory hole resulting from negation of survivor parents on the lives of their offspring, up to the third generation. They also show the painful journey from enactments to psychic representations, a journey which exposes the traumatic events that have been denied or repressed, and facilitates the work of mourning and the eventual achievement of a better integrated self. Finally, I will offer technical suggestions for analysts to help patients transform psychic holes into psychic representations.     

Writing about patients III: Comparisons of attitudes and practices of analysts residing outside and within the USA

When analysts write about patients, they find themselves in a position of conflict. Their first loyalty is to their patients and maintaining confidentiality. However, they are also committed to advancing scientific knowledge in the psychoanalytic field. The attitudes and practices of 36 analysts residing outside the USA, who published articles using clinical material from their patients, are reported. Their attitudes and practices are compared with those of 30 author-analysts residing within the USA, who had been previously interviewed. Among the 66 analysts, geographic region was not a basis for distinguishing differences in attitudes or practices. Slightly more than twice as many analysts use only disguised material as regularly ask permission of their patients to write about them. The decision to use only disguise is somewhat more frequent for analysts who reside outside the USA than for those living within it. Analysts around the world are increasingly concerned about the accessibility of published material. More analysts have come to believe that it is necessary to ask permission before publishing material. Some analysts also believe that the request itself, and the patients reading written material about themselves, focus issues that are central to patients' characters and confl icts that can then be explored analytically.     

The analyst's implicit alpha-function, trauma and enactment in the analysis of borderline patients

The present paper discusses situations in which patient and analyst are involved in obstructive collusions, non-dreams-for-two, shaping enactments. Specifically, it describes explosions in the analytical field, acute enactments, which the analyst assigns, at first sight, to his faulty conduct. The subsequent amplification of the analytical dyad's capacity of symbolization makes the analyst investigate his presumed fault. The present work shows how acute enactments revive traumatic situations that were concealed by previous obstructive collusions, or chronic enactments. During chronic enactments unconscious exchanges occur between the dyad, in which the analyst provides implicit alpha-function to the patient, little by little recovering the traumatized parts. When there is enough recovery, the protective collusion is undone and the trauma is revived as acute enactment. This revival will not be traumatic because there are mental resources ready at hand to symbolize it. These situations are articulated with borderline patients. The patient clings to the analyst, using him as a protective shield against reality traumas. The implicit and explicit alpha-function exerted by the analyst contributes to the processing and symbolization of this reality, recovering the injured mind and elaborating the trauma. So the patient creates a triangular space to dream and think.     

Ethics,Boundaries, and Supervision. Commentary on Trauma Triangles and Parallel Processes: Geometry and the Supervisor/Trainee/Patient Triad

The author discusses the clinical and ethical issues in enactments that are interwoven between relational therapy and supervision as described in the case illustration. The tendency to focus on enactments involving physical action risks obscuring attention to psychological boundary crossings that can be equally harmful. The current maternal tilt in psychoanalysis can unwittingly lead analysts and supervisors to avoid confrontation and analysis of hostility and aggression, thereby inhibiting the working through of intense negative transference and countertransference. The similarities and differences between supervision and treatment are discussed in terms of maintaining responsible boundaries.     

The wish to regress in patient and analyst

The analyst's wish to regress is used as a paradigm of the "forbidden" topic of what analysts want from their analysands. The aim is to expand the subjective domain of analysts' awareness so that they can analyze better by grasping more of their temptations with patients before enactment can occur. Clinical examples illustrate how the author temporarily joined patients in wish-fulfilling mutual regression. Analytic process is disrupted when the analyst wishes to relinquish the more differentiated role of the containing and interpreting analyst in favor of more childlike relatedness both with the patient and with the analyst's internal objects. The author, expecting a more typical counter-transference, had not anticipated that he might temporarily join these nonpsychotic patients in mutual regression. It is suggested that in the face of analytic impasse analysts should consider whether they might temporarily have joined the patient in mutually regressive wishes that have taken them away from more responsible analytic functioning.     

A renaissance for Freud's Papers on Technique

The analyst depicted in Freud's Papers on Technique (1911-1915) struggles to split the patient's stubborn desire by reframing it as memory. In contrast, after the structural theory was adopted, analysts could picture themselves as liberating rather than struggling with patients, since their design was to show that the patient's fears are unrealistic. But North American analysts have come to doubt their ability to rule on what is and isn't realistic. They thus find themselves again struggling with stubborn desires, not just easing fears. Their solution has been to emphasize--and thus detach from--enactments. These analysts would seem to be even more in need of the old ideals of procedure than were "classical" analysts, who thought they could use "reality" as a standard.     

Thoughts on medication and psychoanalysis: a lay analyst's view

The issues involved in split analytic treatments-where a second person manages the patient's medication-are discussed from the point of view of a developmentalist and lay analyst. Case material is presented to illustrate the interplay of medication with other elements of the psychoanalytic situation. Medication and its effects, it is argued, should be accorded no special status apart from other interventions and enactments in an analysis. Some see medication and psychoanalysis as parallel processes, two separate and unintegrated theoretical systems, and recommend shifting back and forth between models of the mind or becoming "bilingual"; against this view, it is argued that anything the analyst does will affect the patient's thoughts, fantasies, and even physiology in individual ways, and only attention to analytic material can reveal what an intervention means in a specific case. Success in split treatment depends on a collaborative therapeutic alliance among patient, analyst, and consultant. Because there is as yet no theory that bridges psychoanalysis and psychopharmacology, analysts must talk of these matters as incompletely synthesized and regard them as part of the challenges that make psychoanalysis the exciting, impossible profession it is.     

Narcissistic temptations to cross boundaries and how to manage them

The narcissism of analysts is considered here from the perspective of the narcissistic temptations of boundary crossing. The literature on boundary crossing in psychoanalysis has focused minimally on the more ordinary, nonsexual temptations analysts face with their patients. Narcissistic temptations with particularly impressive patients are explored. What analysts find impressive in their patients depends both on what patients bring and on what analysts need. This paper aims to heighten analysts' awareness of their narcissistic needs in treating patients who tempt them too much. The goal is for analysts to be able to catch and then examine their narcissistic excitement with such patients in order to avoid compromising the treatment. Danger signs and ways of managing the problems they point toward are presented.     

Meditations on Aggression,Loss, Discovery,and Influence in Psychoanalysis

Psychoanalysis requires acts of creative destruction. At the same time that analysts create new ways of being for themselves and each other, old ways are consequently destroyed. Just as parents envision futures for their children, analysts envision futures for their patients, reflecting a desire or effort to change them. Awareness of the destruction inherent in facilitating growth can enrich an analyst's work, but anxiety about being destructive, and being destroyed, can stifle it. This paper presents an analyst's reflections on creative and destructive aspects of psychoanalysis. Autobiographical and clinical data are presented to illuminate this theme.     

Enactment as understanding and as misunderstanding

The author considers the concept of enactment as a ubiquitous event that is best seen as part of a sequence in the process of understanding a patient. As such, enactments are not unusual or special save as they are often subject to disavowal or to being singled out by the analyst as especially subject to scrutiny. Once recognized, enactments need to be interpreted: not so much in terms of their unconscious origins, but more with regard to the need to include them in the analytic dialogue.     

ACUTE ENACTMENT AS A 'RESOURCE' IN DISCLOSING A COLLUSION BETWEEN THE ANALYTICAL DYAD

The author discusses various aspects of the function of enactment in analytical practice, reviewing the concept, then describing a borderline patient with whom the analytic process seemed to be developing productively. Following a change in the setting, an intense, acute enactment took place. Understanding this led to observation of an unconscious collusion, in which a symbiotic relationship had been established between the patient, the analyst and his family, as a chronic enactment. This relationship had prevented the analyst from touching on highly destructive unconscious fantasies and archaic traumatic situations. Comprehension of the enactment enabled the collusion to be dissolved. The author suggests that, besides the resistance aspect, the collusion may have been useful in strengthening the patient's mental mechanisms and trust in the analytical work, which required some time. The acute enactment arose, unveiling the collusion, when the patient and the analyst felt able to face the terrible feelings related to the triangular situation. He speculates that both enactments may occur in the analysis of these kinds of patients, as part of the 'natural history' of the analytical process, and their function is to relive archaic experiences in the analysis, also with the aim of working them through. Finally, the author proposes a classification of enactments: normal, pathological, acute and chronic.     

Why we need to write openly about our clinical cases

To learn more about what is and is not effective in the psychoanalytic situation, analysts need to develop a library of detailed analytic case material. Open case writing, by not overconstraining readers, allows them enough access to the analytic couple's affective experience to persuade them of the authenticity and validity of the analyst-author's views. They are then free to rethink the material creatively on their own, to use it as they need to, and to learn from others, in order to enhance their analytic skills. Closed case writing hinders readers' creative freedom to understand and interpret, and hence to learn. To encourage analyst-authors to share their affective experiences in the analytic situation more openly, analysts need to establish a constructively collaborative attitude toward playing with clinical material. They need to take for granted that new readers, even authors themselves newly rereading their work, will discover something new. A dialectical process can then be established in which clinical authors and readers contribute to each other in an ongoing imaginative interchange.     

Depressive rumination in an analysand after a traumatic treatment

The author attempts to understand the underpinnings of a ruminative depression that occurred in a patient after a troubled first analysis. Negative therapeutic reaction is often assumed to be the result of a patient's unconscious guilt or masochism and thus an intrapsychic phenomenon, but the author asserts that iatrogenic phenomena in the form of persistent misunderstandings and enactments that remain unanalyzed contribute to a destructive treatment experience. The analysand may relive the failed treatment again and again in his or her mind in an attempt to resolve it. The author asserts that a traumatic treatment experience can foster depressive rumination.     

Ideas of influence: the impact of the analyst's character on the analysis

The fact that analysts inevitably analyze "in character" (i.e., as themselves) has been commonly assumed but unacknowledged publicly ever since Freud's Papers on Technique (1911-1915). Analysts' implicit private beliefs about the impact of their own characters on analytic work have been addressed obliquely via theorizing about the analyst's subjectivity and the role of mutually created resistances and enactments in the transference/countertransference matrix, but these views remain largely tacit. The author suggests that the psychoanalytic concept of character has run aground as a moral issue, not a theoretical one, and that its deeper role as the vehicle for unconscious action remains indispensable in analytic work. An extended clinical example is presented to illustrate the author's preliminary ideas about the impact of her own character in this analysis.     

Psychoanalyse mit Traumatisierten

Extreme and complex traumatisation represents a severe problem in today’s world. There is a need to develop treatment approaches that are efficient for traumatised persons who often live under very difficult circumstances. There are moreover certain societal conditions that are important for the treatment and rehabilitation of the traumatised patient. The paper will discuss how psychoanalytic therapy may be helpful for severely traumatised patients and what are the mechanisms of change in the therapeutic process. A focus is on how traumatic experiences are actualised in the transference and brings the analyst in a situation where enactments inevitably occur. It will be demonstrated how these processes may lead to symbolisation of these traumatic experiences. What are the therapeutic and societal preconditions for treating traumatised patients?     

The Analyst's Secret Delinquencies

Despite a burgeoning literature on major analytic boundary violations, there has been little investigation of what might be called analytic delinquencies or misdemeanors—the small and virtually ubiquitous ways in which analysts deliberately withdraw from the therapeutic endeavor. I consider the impact of professional misdemeanors on patient and analyst and compare both with more serious analytic “crimes” and enactments. Professional delinquencies may reflect a therapeutic reenactment, an expression of the analyst's split-off or disavowed need, or an unconscious attempt to self-regulate or to negotiate space within the constraints of the treatment setting. Because the professional ideal leaves so little room for the analyst's humanity, it is often difficult for us to address and work with evidence of our own need when it clashes with what we regard as the analytic contract.     

Journeys through the valley of death: multimethod psychological assessment and personality transformation in long-term psychotherapy

The Psychodynamic Diagnostic Manual (PDM Task Force, 2006) is based on the assumption that an in-depth understanding of clients' underlying emotional, personality, and interpersonal patterns will facilitate their treatment. In this article I show how such an understanding can be achieved through multimethod psychological assessment, and how useful such information can be in long-term psychotherapy with high-achieving, successful clients who struggle with forming and maintaining intimate relationships. Such treatments are extremely difficult, because when these clients attach to their psychotherapists, many of them temporarily become more symptomatic. I illustrate these points with a detailed account of my long-term therapy with a resilient but highly traumatized young man. Repeated use of the Minnesota Multiphasic Personality Disorder-2 (MMPI-2; Butcher, Dahlstrom, Graham, Tellegen, & Kaemmer, 1989) and Rorschach with my client helped guide us in our work, and also helped create an important therapeutic "opening" into the underlying traumatic material. This and other experiences have convinced me that it is extremely useful for psychologists to have training in both assessment and psychotherapy.     

IRREDUCIBLE SUBJECTIVITY AND INTERACTIONISM: A CRITIQUE1

The authors offer a critique of the privileging of subjectivity in psychoanalysis characteristic of what Hanly has called interactionism, with specific reference to the work of Renik. First, Renik's argument for the irreducible subjectivity of the analyst is explored and critiqued from a philosophical perspective. The need for and plausibility of a subtler notion of objectivity that takes into account the limitations of human subjectivity and that analysts can meaningfully pursue is defended. Second, Renik's ‘re‐visioning’ of psychoanalysis, which follows from his notion of irreducible subjectivity, is explored and critiqued. Renik's view of enactments is contrasted with a ‘totalistic’ perspective of countertransference that allows for important, finer conceptual distinctions. Renik's conceptualisation of countertransference enactments is characterised as a ‘special case’ of countertransference as a vice. Next, Renik's view of transference is critiqued for privileging the adaptive dimensions of transference, and for potentially sidelining archaic dimensions. Finally, Renik's conclusions and ‘revisioning’ of psychoanalysis are shown to follow from his modifying or jettisoning certain features of the analytic situation and process. These features and their implications are elaborated on. The conclusion outlines the extent to which the arguments presented can be extended to other advocates of interactionism.