External and internal reality: The impact of the current socio‐economic crisis on the analytic dyad

This paper addresses the impact of the current economic crisis on the psychic functioning of the patient and the analyst, their relationship and collaboration. This intrusion of ‘external reality’ is multidimensional, and thus with multiple meanings. The critical role of the economic factor brings various dimensions of money into play, such as self‐preservation, power as well as aspects of psychosexual development. In addition, the crisis involves symbolic loss of basic ideals such as honesty and social responsibility. Patient and analyst are affected in similar and different ways in their respective roles as well as according to the specific intrapsychic functioning of each. Moreover, unique characteristics of the crisis often create a crisis in the analysis. In order to avoid deformation of the analytic relationship, the analytic dyad must examine and work through the multiple meanings of the crisis as well as the meaning of the impact of the crisis on the analytic relationship for both patient and analyst. This complex transference‐ countertransference interplay poses specific challenges to the analyst. After discussion of these issues, clinical material is presented that demonstrates how they appear in analytic practice today.     

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.     

Residues in the analyst of the patient's symbiotic connection at a somatic level: unrepresented states in the patient and analyst

This paper discusses the residues of a somatic countertransference that revealed its meaning several years after apparently successful analytic work had ended. Psychoanalytic and Jungian analytic ideas on primitive communication, dissociation and enactment are explored in the working through of a shared respiratory symptom between patient and analyst. Growth in the analyst was necessary so that the patient's communication at a somatic level could be understood. Bleger's concept that both the patient's and analyst's body are part of the setting was central in the working through.     

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.     

The role of the analyst in the analytic cure during times of chronic crises

The role of the analyst in psychoanalytic treatment during periods of chronic crises is illustrated with material from two case studies. The first clinical vignette shows an analyst able to stay with fears evoked in the patient by the traumatic external reality, even as the analyst tried to explore with the patient an inner universe that handled this reality in unique ways. The second case study focuses on how the analyst's countertransference during this period of chronic crises, which she was experiencing along with the patient, made it difficult for her to contain the patient's fears and anxieties, because of the threat to her own existence, as well as to her identity as an analyst. In this second case the analyst, out of denial of the external situation, focused blindly on the patient's internal reality in order to counteract her own sense of passivity and helplessness in the confrontation with death and destruction. She clung to "classical" analysis by trying to analyze the patient's defenses, work them through, etc., thus making so-called analytic interpretations rather than staying with the patient's fear, as well as her own, and helping the patient more directly. A turning point came with the birth of the analyst's granddaughter; fear for the new arrival's safety made the analyst sharply aware that it is impossible to ignore external reality, that it must be given a place both in everyday life and in analysis. This awareness enabled the analyst to contain the patients' fears, which helped him feel more supported and facilitated change.     

The patient's part in analytic process: the influence of the analyst's expectations.

The psychoanalyst's expectations of the patient are complex and crucial to the work of analysis. These expectations, operating at a level generally outside the consciousness of patient and analyst, are part of the "microstructure" of analysis, the interactional give-and-take that brings about change. The view taken here is that analytic process is necessarily interactive, as well as intrapsychic. In addition to transference-countertransference motivations, both parties to an analysis operate in a social context that prescribes a range of desired and undesired behavior. The analyst brings to the interaction professional analytic attitudes about how to listen and act, and a set of expectations of the patient. These attitudes and expectations modulate subjective reactions to the patient's transferentially driven actions, and influence the expression of countertransference. The mutative process of psychoanalysis involves the action of these attitudes and expectations on the patient, both in ways specific to individuals and in more general ways. Such expectations lie behind analytic tactics and, though not often written of, are part of the oral tradition of psychoanalysis. Here the expected patient role is described in terms of five bipolar continua: (1) reporting and editing; (2) transferring and containing; (3) thinking about oneself and thinking about the analyst; (4) regressing and listening/self-observing; (5) initiating trial action and mediating among inner states. The activity and thinking of the dyad move constantly along these continua. A clinical example from the beginning of an hour illustrates how these expectancies emerge in analytic work.     

The translational metaphor in psychoanalysis

The translational metaphor in psychoanalysis refers to the traditional method of interpreting or restating the meaning of verbal and behavioral acts of a patient in other, presumably more accurate terms that specify the forces and conflicts underlying symptoms. The analyst translates the clinical phenomenology to explain its true meaning and origin. This model of analytic process has been challenged from different vantage points by authors presenting alternative conceptions of therapeutic action. Although the temptation to find and make interpretations of clinical material is difficult to resist, behaving in this way places the analyst in the position of a teacher or diagnostician, seeking a specific etiology, which has not proven fruitful. Despite its historical appeal, I argue that the translational model is a misleading and anachronistic version of what actually occurs in psychoanalysis. I emphasize instead the capacity of analysis to promote the emergence of new forms of representation, or figuration, from the unconscious, using the work of Lacan, Laplanche, and Modell to exemplify this reformulation, and provide clinical illustrations of how it looks in practice.     

The stranger1

This work concerns a nine‐year analytical experience with a patient who presented as a main feature an apparent inability to experience and express feelings. Right from the beginning the author was confronted with the question of the viability of analytical work, considering transference or emotional involvement in the absence of perceptible establishment of an affective link on the part of the patient. The patient never missed a session, was usually very punctual and presented very rich material, but the accounts of his life, everything he was saying, hearing and observing was manifestly deprived of any emotional meaning for the patient and consequently deprived of sense for the analyst. If, at the beginning, the question was how to communicate with the patient, after some time it became a problem of how to enable the patient to communicate with himself. Confi rming an observation by Bion that the patient is the best colleague the analyst can have, the way forward was indicated by the patient himself. This article is a theoretical exercise based on this clinical experience, using concepts developed by Bion, Ferro and Winnicott.     

The Role of Psychoanalysis in the Conflict of Interpretations

This paper describes how the temporary illness of the analyst affects the analytic work when it breaks the habitual analytic setting and exposes the analyst to countertransference reactions. The illness stimulates different meanings and reactions in the analysand. The paper describes how the fostering of the habitual analytic work helps the analysand to make use of the event, i.e., to integrate it into the transference. In the light of the patient cases, it would seem that corporeality is the key: the crucial question is what it means not only to the analyst him/herself but also to the analysand, that the analyst's body remains unchanged, secure, living and stable and does not require any particular attention.     

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.     

From countertransference to "passion"

Bion's ideas may be extended to describe an emotional phenomenology of the analyst's subjectivity and a methodology which helps differentiate countertransference enactments from fuller emotional participation. Bion called the process of integrating and utilizing one's most basic and important emotions to make meaning, "passion." The analyst's primal feelings--of love, hate, and curiosity--serve as a central organizer of meaning in the analytic interaction. These feelings involve pain, and to the extent the analyst unconsciously decides to evade or foreclose the evolution of the feelings, such that they remain unintegrated in the thinking process, the analyst is liable to become mired in repetitive transference-countertransference experiences without establishing fresh meaning. A case example illustrates the relevance of "passion" to contemporary relational theory and practice.     

The perversion of language in the analyst's activity: Navigating the rhythms of embodiment and symbolization

Abstract

In this short text, the problem of how “the talking cure” itself can become a perverse relation is considered and illustrated with a brief clinical vignette. Contributions coming from the work of Stern in infant research and Lacan in post-Freudian thought illuminate the potential for experience to be split off through the use of language itself. These perspectives are brought to bear on thinking about representation, splitting, and perversion as a basis for considering a clinical instance in which patient and analyst enact a perverse relation constituted by the way in which the patient uses the analyst's language to construct a sado-masochistic perversion of the treatment process. Within the clinical episode, Stein's reformulation of perversion, informed by Ogden's observations and expanding Stoller's earlier contribution, provides a basis for considering how the analyst was able to use attention to the body-based countertransferential experience to repair a sense of “erasure” that was being accomplished for both analyst and analysand through the enactment.     

Synchronicity as A Basis of Analytic Attitude

My aim is to describe Jung's approach to the experience of the chaotic, which could equally be termed the irrational, the non-ego, the unordered or prima materia , and to extract from this a clinical approach to the analytic patient which, in Jung's own writings, is often more implicit than explicit. My interest in this enquiry arises from the clinical experience of the unconscious in the form of transference/ countertransference, involving relentless pressure on both analyst and analysand to attempt to impute meaning and order. I examine Jung's work 'Synchronicity: an acausal connecting principle' and extrapolate from it what I think to be its unique contribution to hermeneutics - the ontologically-based concept of a psychoid understanding of meaning and pattern. In the second part of the paper, I discuss the application to analytic work of Jung's hermeneutic approach. I look at how analysts relate to meaning in terms of their relationship to theory. I illustrate this by comparing two short psychoanalytic papers on aggression, an instinct which is often seen as engendering splitting and which tends therefore to promote the dissociations which Jung was trying to address in 'Synchronicity'. I then illustrate with clinical material how Jungian analysts might relate to meaning in their approach to the patient. Together, these form the basis of what is commonly called 'analytic attitude', which I see as the basis for a distinctively Jungian identity for analytic practice.     

Incognito or not? the patient's subjective experience of the analyst's private life

This paper examines the meaning for the patient of the analyst's personal life and personality which are ostensibly banished from the consulting room. The therapist has a not‐always‐so‐secret “secret life”; that the patient is supposed to “not know”; about. Yet, more or less unconscious perceptions, impressions, and fantasies about extratherapeutic aspects of the analyst are omnipresent and significantly color the psychoanalytic enterprise.

Moreover the analyst as a person generally plays a critical and underacknowledged role in the patient's experience of the endeavor. Constructing multiple overlapping images of the analyst and of the analytic relationship, the patient discovers himself or herself in the matrix of these relationships with various images of the analytic other. The analysand is motivated to make sense of the analyst as wholly as possible, the better to place into context the analyst's interventions. The patient's resulting view of the analyst's subjective experience acts as a lens that filters and subtly alters the meaning of the analyst's communications.

I illustrate these points by relating my work with a patient whose dreams uncannily picked up on a (consciously) unknown aspect of my private life—my having a handicapped son. The treatment thereafter centered on the patient's identification with my child (as someone “disabled") and on the meaning of her having dreamt something so personal about her therapist.     

The role of audition in early psychic development, with special reference to the use of the pull-toy in the separation-individuation phase

The role of audition as an important perceptual modality in early psychic development has been neglected. Some reasons for this neglect are suggested. In the development of psychoanalytic technique, the analyst has changed from a "tactile presence" to a "visual presence," then finally, with the analyst positioning himself behind the couch, to an "auditory presence." Several clinical examples from analytic patients as well as child development in normal and deaf children provide instances of each type of perceptual "presence." It is suggested that, in evaluating analyzability, analysis requires a specific ego ability, namely, tolerance for the analyst as an "auditory presence." It is emphasized that some patients, for reasons of development, constitution, and/or significant stress (separation), cannot work with the analyst as an "auditory presence," but regress to the analyst as a "visual" or "tactile" presence. The importance of audition in early mother/stranger differentiations, and in the peek-a-boo game, is a developmental precursor to the use of audition as a contact modality in the separation and individuation phase. Audition permits active locomotion and separation from tactile and visual contact modalities between toddler and mother, while at the same time maintaining contact via their respective "auditory presence" for each other. The utilization of the pull-toy in mastering the conflicts of the separation-individuation phase is demonstrated. The pull-toy is heir to the teddy bear and ancestor to the tricycle. Greater attentiveness to the auditory perceptual modality may help us understand developmental phenomenon, better evaluate the potential analysand, and clarify clinical problems of audition occurring in dreams and those areas of psychopathology having to do with auditory phenomena. The more refined tripartite conept of "presence" as it relates to the predominant perceptual modality--tactile, visual, auditory--is felt to be a useful conceptualization for both developmental and clinical understanding.     

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.     

Associative dreaming: reverie and active imagination

The idea of countertransference has expanded beyond its original meaning of a neurotic reaction to include all reactions of the therapist: affective, bodily, and imaginal. Additionally, Jung's fundamental insight in 'The psychology of the transference' was that a 'third thing' is created in the analysis, but he failed to demonstrate how this third is experienced and utilized in analysis. This 'analytic third', as Ogden names it, is co-created by analyst and analysand in depth work and becomes the object of analysis. Reverie, as developed by Bion and clinically utilized by Ogden, provides a means of access to the unconscious nature of this third. Reverie will be placed on a continuum of contents of mind, ranging from indirect to direct associative forms described as associative dreaming. Active imagination, as developed by Jung, provides the paradigm for a mode of interaction with these contents within the analytic encounter itself. Whether the analyst speaks from or about these contents depends on the capacity of the patient to dream. Classical amplification can be understood as an instance of speaking about inner contents. As the ego of the analyst, the conscious component, relates to unconscious contents emerging from the analytic third, micro-activations of the transcendent function constellate creating an analytic compass.     

Distinction between mental pain and psychic suffering as separate entities in the patient's experience

Abstract

Mental pain and psychic suffering are herein defined as two separate concepts in psychoanalysis. The concept of mental pain lies at the core of psychoanalysis; it was introduced by Freud and was further elaborated by a number of investigators, mostly by Bion. Mental pain refers to a pain that the patient reports as being impossible to describe in words, and lacking any associations, whereas psychic suffering can be both named and described by the patient. Mental pain is derived from non-tolerance on the part of the psychic apparatus when it is harmed by very painful emotions. In contrast to psychic suffering, mental pain resists elaboration and transformation by dream-work. How to address and transform the patient's mental pain is a major challenge facing the analyst in his clinical work because mental pain may halt or slow the progression of the analytical process. To overcome this hindrance, the work of the analyst is focused on helping patients to modify their mental pain into psychic suffering, that is, to reactivate in the patient the chain of transformations that generates thought. The analyst is also challanged with the mental pain of the patients because he has himself to tolerate the mental patient induced by counter transference. Suggestions for the analyst on how to deal with the mental pain of the patient during psychoanalytic therapy are proposed.     

Free-swinging attention

Psychoanalytic listening enlists the analyst's capacity for, and relative comfort in, rapidly shifting levels of attention and organization. Such shifts are not effortless and can be characterized as part of "free-swinging attention," a term that suggests some dimensions of the analyst's work. The need to establish meaning in the individual and immediate context parallels the task of a child in learning language, and the role of the analyst as child is an important if usually overlooked one. The author compares psychoanalytic with psychotherapeutic listening, as well as some current views on free association and evenly suspended attention.