On the question of the patient's right to tell and the ethical reality of psychoanalysis

This paper calls into question the view that it is ethically legitimate for the patient to say whatever comes to his or her mind: that is, to adhere to the fundamental rule. While there have been some variations in the application of this rule since Freud's time, it remains for many the bedrock of clinical practice, and the patient's right to free-associate has never been questioned. Recent debates on the importance of the analyst's strict confidentiality have highlighted this right. Ethical problems raised by adherence to the fundamental rule are explored through an examination of the general ethical limitations on what one may say to another person, and the special features of the analytic relationship that seem to do away with these limitations. The fact that there are ethical questions about adherence to the fundamental rule draws attention to what the author calls the ethical reality of psychoanalysis. The recognition of this reality has implications for the understanding and handling of ethical dilemmas regarding disclosure, as well as for other ethical issues that may arise in the course of an analysis.     

Evaluating progress in training: character or competence?

Jung was mercurial in his attitudes to method and technique, leaving us a problematic legacy when it comes to evaluating the progress of trainees. Some would say that those of us involved with the assessment of candidates during their training continue to rely too heavily on intuition and subjective assessments. However good our admissions' procedures and the structures in place to review progress, the emotional and financial demands for trainees of embarking on an analytic training, the tendency for analytic institutes to remain opaque and slow to link up with the external world and the cliques within our profession make more objective assessments of progress and readiness to qualify at best haphazard and at worst inadequate. Some trainees have an immediate talent for analytic work; others develop their gifts more slowly; some never find this capacity. Working from a definition of analytic talent, the paper begins to map out a Jungian framework for assessing progress, emphasizing the significance of both character and competence and the developing relationship between them.     

Ferenczian Elasticity in the Analysis of an Adolescent

Psychoanalytic work with adolescents poses a challenge for analysts who adhere to standard analytic technique as many adolescents who need analytic intervention resist such a structured approach to analysis. The author finds that elasticity of technique is currently widely used by analysts when working with this difficult age group even though they may be unaware that this is, in fact, a Ferenczian technique. Clinical examples are presented to illustrate how frequently the technique is used in cases of resistant, troubled youth. The author outlines an approach that is sensitive to these resistances and makes compromises in technique based on the principle that engaging a troubled youth in a therapeutic venture is preferable to refusing treatment based on the patient’s not being able to adhere to standard analytic technique. In this sense, Ferenczi was an early herald of the type of contemporary analytic work that is practiced currently especially with a difficult population of patients.

     

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.     

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.     

Receptivity,or Going on (Not) Being: Commentary on Paper by Robert Grossmark

“The treatment hinged on my being able to live with him in this ongoing non-existence and know it and tolerate it, and expect no more,” writes Dr. Robert Grossmark about himself and his patient, Kyle (pp. 637–638). This is a key sentence, outlining the core of the enlightening analytic work done. I comment on the linkage between living the ongoing nonexistence and going-on-(not)-being, then reflect about the distinction between what I call the “outward” technique, which is everything Grossmark describes about treating Kyle, and the “inward” technique, which is all that occurred within him, in an inner, hidden, powerful, unconscious dialogue with the patient, and which is only hinted at. In this context, with patients like Kyle, who bring to the analyst physical sensations and actions for dreaming, the analyst's corporeality, by which I mean his experience of his body and his capacity to connect it to emotion, thereby lending it meaning, has a critical importance. I bring, in a nutshell, references to several psychoanalytic writers about the subject of corporeality in analytic treatment and use a vignette from an analysis to demonstrate the point.     

A word about words

The title of my paper comes from an essay by Václav Havel. In his essay, Havel addressed most evocatively the question of the unique power of words for thinking and to influence, for good or for harm, as well as to inform and to educate. As analysts our medium is the word. I suggest that it is of inestimable importance that we are able to listen deeply to our patients' words and to be aware of our own. The quality of our ability to think deeply and consistently about the unconscious experience of our patient is intimately related to our ability to hear what is being said. The effect of our own words upon the patient likewise cannot be overstated. I offer my reflections on words in the analytic relationship and I give some clinical examples that I hope will illustrate my thoughts as to the power and the importance of what and how we hear and of what we say.     

A case history: from traumatic repetition towards psychic representability

This paper is devoted principally to a case history concerning an analytic process extending over a period of almost ten years. The patient is B, who consulted the author after a traumatic episode. Although that was her reason for commencing treatment, a history of previous traumatogenic situations, including a rape during her adolescence, subsequently came to light. The author describes three stages of the treatment, reflected in three different settings in accordance with the work done by both patient and analyst in enabling B to own and work through her infantile and adult traumatic experiences. The process of transformation of traumatic traces lacking psychic representation, which was undertaken by both members of the analytic couple from the beginning of the treatment, was eventually approached in a particular way on the basis of their respective creative capacities, which facilitated the patient's psychic progress towards representability and the possibility of working through the experiences of the past. Much of the challenge of this case involved the analyst's capacity to maintain and at the same time consolidate her analytic posture within her internal setting, while doing her best to overcome any possible misfit (Balint, 1968) between her own technique and the specific complexities of the individual patient. The account illustrates the alternation of phases, at the beginning of the analysis, of remembering and interpretation on the one hand and of the representational void and construction on the other. In the case history proper and in her detailed summing up, the author refers to the place of the analyst during the analytic process, the involvement of her psychic functioning, and the importance of her capacity to work on and make use of her countertransference and self-analytic introspection, with a view to neutralizing any influence that aspects of her 'real person' might have had on the analytic field and on the complex processes taking place within it.     

Why being right is not enough: Predicting defensiveness in the face of group criticism

Criticism of a group can be a catalyst for reform and positive change. Despite this, group-directed criticisms can sometimes face high levels of defensiveness, and can do so even if the comments have objective merit. In this article I review research on group-directed criticism and formulate a model designed to predict when and why people will express defensiveness in the face of criticisms of their group. I argue that, when deciding how to respond to group criticism, people weigh up three independent sets of considerations: (1) attributions about the motives and agenda of the critic (“why would they say that?”), (2) questions about whether the critic had obeyed identity-related rules in the timing and delivery of their criticism (“was it appropriate for them to say that?”), and (3) questions about whether it is in the long-term interests of the individual and the group for them to express support for the criticisms (“strategically, what is the best way for me to respond?”). Practical implications of the model for promoting positive and open communication within and between groups are discussed.     

A behaviorist's response to the report of the national commission on excellence in education

The National Commission on Excellence in Education was charged with the responsibility for examining the quality of education in America. Its report, "A Nation at Risk" (1983), contained a set of alarming facts about the status of American education. These were followed by a set of five major recommendations for improving the situation. They related to (1) content, (2) standards and expectations, (3) time, (4) teaching, and (5) leadership and support. The present paper examines each of the set of recommendations from a behavior analytic perspective. It notes what the field of behavior analysis can say on the subject now; what it potentially might address and remediate at this time; what it might explore and predict; and in general what it can do to make a difference. Behavior analysis has made many important discoveries that should be communicated to educators and the public, and it has tools and concepts for further contributing toward the improvement of education.     

Freud's "analytic pact": the standard therapeutic alliance

Freud's "analytic pact," as the final therapeutic model he evolved (1937, 1940), places the fundamental rule in a two-person structural framework that operates in a continuum between the inner reality and outer reality of both patient and analyst as these come to center in the analytic situation. To Freund's basic definition of psychoanalysis as related to resistance and transference, a third component is added, the collaboration that has been a feature of the treatment since the beginning. The alliance postulated by the pact relates a helpful physician to a sufferer in a carefully regulated operational field and atmosphere suitable for a particular technique and therapeutic goal. Actually the alliance may be described from the aspect of component combinations as described in different frameworks--structural, topographic, developmental, realistic, adaptive, etc. In diverse forms of analytic or analytically oriented forms of therapy, selected aspects of the alliances receive greater prominence--but a fully informed analytic therapy retains contact with all the elements involved. Organizational aspects of the fundamental rule with respect to the flow of associations and the transient and structured interactions of patient and physician are examined with regard to their dynamic and linguistic features.     

DREAMING THE ANALYTIC SESSION: A CLINICAL ESSAY

This is a clinical paper in which the author describes analytic work in which he dreams the analytic session with three of his patients. He begins with a brief discussion of aspects of analytic theory that make up a good deal of the context for his clinical work. Central among these concepts are (1) the idea that the role of the analyst is to help the patient dream his previously “undreamt” and “interrupted” dreams; and (2) dreaming the analytic session involves engaging in the experience of dreaming the session with the patient and, at the same time, unconsciously (and at times consciously) understanding the dream. The author offers no “technique” for dreaming the analytic session. Each analyst must find his or her own way of dreaming each session with each patient. Dreaming the session is not something one works at; rather, one tries not to get in its way.     

Patient-therapist match: revelation or resistance?

Patient-therapist match is a relatively new yet frequently invoked concept within psychoanalysis. Despite Freud's appreciation of the influence of the analyst's past to his or her work within the analytic setting, psychoanalysts have historically held varied opinions about the degree to which the analyst's personality and conflicts affect the analytic process. As analysis was reconfigured as a two-person system, attention focused on the fit between patient and analyst. The literature on patient-therapist match is reviewed, and the conclusion reached that this intuitively appealing concept suffers from a lack of rigorous definition and operationalization. Many authors invoke match in ways that imply that it is real, static, external to the domain of analytic inquiry, and unaffected by analytic process. In its present form, the concept of patient-therapist match obstructs rather than facilitates analytic exploration and obscures rather than clarifies what happens between analyst and analysand in psychoanalysis. By suggesting that match exists as a reality outside the domain of transference and countertransference, analysts may overlook the importance of psychoanalytic technique in creating a sense of match. Analysts may attribute stalemated or limited analyses to a bad match, rather than tenaciously exploring the transference-countertransference configurations that remain at the heart of analytic work.     

The overstimulated state of dyslexia: perception, knowledge, and learning

Dyslexia is far more than a learning disorder; it has significant impact on personality organization. While dyslexia usually begins to manifest most clearly in early latency when the challenge of learning to read is at its height, often the dyslexic child's ego development and functioning has already been adversely affected. The literature from neuropsychology suggests that dyslexia is a subtle language-processing disorder that affects emotional, cognitive, and social development. The neuroanatomical literature also suggests a significant correlation between the neurodevelopmental basis for dyslexia, the caregiving environment, and psychological development.These two bodies of literature and analytic observations of a dyslexic patient suggest that the dyslexic individual may have a neurological deficit that increases vulnerability to overstimulation. The author hypothesizes that emotional and cognitive states result and reappear within the analytic encounter. This complicates clinical assessment and technical decisions. The author presents an analytic case and examines (1) the impact of deficit on the development of conflict; (2) the impact of the overwhelmed ego on the mastery of developmental tasks; and (3) the impact of dyslexia on dysgnosia, transference, and analytic process and technique.     

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.     

The compulsion to confess and the compulsion to judge in the analytic situation

In this paper the author shows that human beings have two quasi‐instinctual primitive tendencies – namely, the compulsion to confess and the compulsion to judge (to condemn or to absolve). These compulsions are originally unconscious and become conscious during the course of the analytic process. The compulsion to judge is a natural consequence of the compulsion to confess. These two tendencies are intensified by the analytic situation. The patient has a compulsion to confess to the analyst and to himself, and likewise the analyst has a compulsion to confess to himself and to the patient. The patient therefore has a compulsion to judge himself as good or bad and to judge the analyst as good or bad while, on the other hand, the analyst has a compulsion to judge himself as good or bad and to judge the patient as good or bad. The task of analysis is to make both patient and analyst conscious of their compulsions to confess and to judge (to condemn or to absolve). The compulsion to judge in the analyst, particularly if unconscious, may give rise to mistakes in diagnosis, technique, treatment, and the assessment of analysability. The requirement of analytic neutrality in the analyst constantly conflicts with his compulsion to judge. If we are profoundly involved in our patient's dramatic conflict, we are bound to pass a judgement (condemnation or absolution); however, when we judge, we are not neutral and therefore become incapable of intellectual consciousness of the patient's conflict. Conversely, if we do not judge, we are neutral, but are then relatively uninvolved in the patient's conflict and are hence virtually unable to achieve emotional consciousness. The author attempts to show that neutrality cannot and must not be a preconstituted attitude in the analyst, but can and must be a point of arrival following a profound, intensely felt existential experience based on an attitude of non‐condemnation and non‐absolution.     

Measuring Productivity in Primary Care Behavioral Health: A Delphi Study

High productivity by behavioral health consultants (BHC) is a defining aspect of the primary care behavioral health (PCBH) model to maximize access to care and is often measured by patient volume. Studies of productivity in health care settings suggest a single productivity target may not be optimal. We used a Delphi method to obtain expert consensus on an operational definition of high productivity by BHCs in the PCBH model. Clinicians, managers, and researchers in PCBH were recruited to participate in a multi-round survey using a modified Delphi technique and develop consensus on PCBH productivity metrics. Ten participants completed all three survey rounds and rated 28 metrics. After three rounds, two direct metrics (average number of billable BHC visits each day; number of patients seen per day) received at least 80% consensus as “Essential”, two received at least 50%, and five received less than 50%. One influencer (level of integration at the practice) received at least 80% consensus as “Very Much” influential, 19 received at least 50%, and eight items received less than 50%. Several themes arose from participant comments. PCBH productivity can be interpreted as being high volume. Numerous practice factors influence how productive a BHC may be. Future studies should determine the feasibility of our metrics in clinical practice, establish productivity expectations based on patient needs and clinic resources, and identify patient-, clinician-, or practice-level moderators of productivity.

     

Performative and enactive features of psychoanalytic witnessing: The transference as the scene of address

This paper will attempt to broaden the conception of witnessing in analytic work with traumatized patients by extending the idea to incorporate the patient’s developing and varied capacity for witnessing, as well as a witnessing that occurs within the analytic relationship itself. Actions occuring as part of traumatic repetition are understood to represent memory phenomena and are distinguised from dissociated self‐state experience. These experiences are not therapeutically intended to be symbolized, but rather lived‐through with the analyst, thus transforming the patient’s own relation to the experience. I suggest that the scene in which this living‐through takes place is the transference–countertransference matrix, and that it is the analytic encounter that allows traumatic repetition to take on the quality of a communication, an address to another, rather than remain meaningless reproduction. A clinical vignette illustrates the turning of trauma’s imperative for witnessing into an address in the analytic encounter.     

The analytic state of consciousness as a form of play and a foundational transference

The analytic state of consciousness is a particular regressive altered state in the patient characterized by an increased sensitivity and reactivity to impressions arising from both the inner world and the analyst, a heightened sense of dependence and vulnerability, a permeability of boundaries in regard to the analyst, and a shift toward functioning on the basis of omnipotent fantasy in the analytic relationship. These changes are accompanied by a feeling of realness of one's psychic reality, but without any true loss of reality testing. Based on an analysis of the structure of play, this state can itself be understood as a kind of play; it serves as a foundational transference underlying more specific transference manifestations; and it is central to the analytic process. Over time, in response to physical aspects of the analytic setting, its safety, the analyst's emotional accompaniment, and a generally restrained analytic stance (an issue I discuss in some detail), it emerges in a more developed form that promotes symbolization and ownership of aspects of self, greater emotional presence, and a deeper sense of meaning in one's experience. Additionally, the concept of the analytic state of consciousness provides a new look at the role of abstinence and frustration in analytic process.     

Engaging with Buddhism

In his new book, Jay Garfield invites philosophers of all persuasions to engage with Buddhist philosophy. In part I of this paper, I raise some questions on behalf of the philosopher working in the analytic tradition about the way in which Buddhist philosophy understands itself. I then turn, in part II, to look at what Orthodox Buddhism has to say about the self. I examine the debate between the Buddhist position discussed and endorsed by Garfield and that of a lesser-known school that he mentions only briefly, the Pudgalavāda (“Personalists”). I suggest that the views of the Pudgalavādins are strikingly similar to a position held, in the twentieth century analytic philosophy, by Peter Strawson.