Creating analysts, creating analytic patients

This paper applies a contemporary, 'two-track'- transformational as well as archaeological - perspective on psychoanalytic process to clinical issues in the creation of analytic patients: case finding, recommending analysis, and recommending and negotiating the intensification of frequency of sessions in analytic psychotherapy. Central importance is assigned to the role of the mind and analytic identity of the analyst, including the analyst's capacity to maintain an internal analytic frame and analyzing attitude from the very first contact with the patient and throughout the treatment, the analyst's confidence in and conviction about the usefulness of analysis for a given analytic dyad and the role of the analyst's theory, which must be broad and consistent enough to allow the analyst to feel that he or she is operating analytically when addressing non-neurotic (unrepresented and weakly represented mental states) as well as neurotic structures.     

The analyst's insights

The patient's fresh perceptions of himself come through mutative work shared with the analyst in the focused intimacy of their interaction. In finding transferential expectancies realized, the patient can experience these as yet different, providing he has the analyst's optimal participation. In this concurrence of crucial differences he can discount and discard the old perceptions that had shaped his psychic reality, and build out of them fresh insights. The analyst's regressive lapses in his best work are a liability inherent in the compromise formations comprising his work ego, built as it is out of the needs and motives of his own transferential past. The stagnation and tensions his regressive transferences contribute to the analytic work produce vivid actualization of the intrapsychic conflicts of both, now intertwined and mutually reinforcing. The analyst's self-analysis at such times can lead to resolving insights about himself that redress the impasse and restore the analytic work both must do.     

The analyst's theory: A third source of countertransference

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

A note on notes: note taking and containment

In extreme situations of massive projective identification, both the analyst and the patient may come to share a fantasy or belief that his or her own psychic reality will be annihilated if the psychic reality of the other is accepted or adopted (Britton 1998). In the example of' Dr. M and his patient, the paradoxical dilemma around note taking had highly specific transference meanings; it was not simply an instance of the generalized human response of distracted attention that Freud (1912) had spoken of, nor was it the destabilization of analytic functioning that I tried to describe in my work with Mr. L. Whether such meanings will always exist in these situations remains a matter to be determined by further clinical experience. In reopening a dialogue about note taking during sessions, I have attempted to move the discussion away from categorical injunctions about what analysis should or should not do, and instead to foster a more nuanced, dynamic, and pair-specific consideration of the analyst's functioning in the immediate context of the analytic relationship. There is, of course, a wide variety of listening styles among analysts, and each analyst's mental functioning may be affected differently by each patient whom the analyst sees. I have raised many questions in the hopes of stimulating an expanded discussion that will allow us to share our experiences and perhaps reach additional conclusions. Further consideration may lead us to decide whether note taking may have very different meanings for other analysts and analyst-patient pairs, and whether it may serve useful functions in addition to the one that I have described.     

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 EXTERNAL OBSERVER AND THE LENS OF THE PATIENT-ANALYST MATCH

A focus on the match between patient and analyst places attention on the dynamic effect of the interaction of character and conflict of both participants on the process that evolves between them. Match is neither a predictive nor static concept. Rather it refers to an unfolding transaction that itself shifts and changes during the course of analytic work. The treating analyst's perception of the effect of this match is by necessity limited by the analyst's own blind spots and other countertransference phenomena. Reporting the analyst's clinical experience to an analytically trained observer, external to the dyad, may broaden the analyst's perspective. Using the lens of the match, a colleague in the role of supervisor, consultant or peer can provide feedback from which the analyst may acquire insight. As a result of this process, the influence that the participants' similarities and differences have upon each other becomes clear to the analyst. This awareness, in turn, may lead the analyst to appreciate the effect of the analyst's stance of distance or closeness and to evaluate whether at this phase of treatment it is beneficial or detrimental to the analytic process. Clinical illustrations of the effect of the external observer's feedback in relation to the patient—analyst match are provided.     

What comes out of the consulting-room? The reporting of clinical material

The author addresses the difficulties inherent in reporting clinical material. These fall into two main categories, the ethical problem of upholding confidentiality, and the technical problems which include the definition of analytical data, and the numerous ways in which truth can be distorted in the analytic context. It is advocated that consent be obtained from patients before publishing their material. It is also suggested that clinical reports should contain enough detail of the analytic interaction, including the analyst's thoughts and feelings, to convey the analytic process, and to enable the listener/reader to consider the evidence for himself and to draw his own conclusions. It is concluded that an analyst's anxiety about exposing a patient might obscure an anxiety about exposing himself.     

Analyzing disavowed action: the fundamental resistance of analysis

Several detailed analytic hours illustrate how, with the analyst's full participation, patients use the words, setting, and activity of analysis to gratify the very wishes they are analyzing, and so disavow the work of analysis. These gratifications, which are hidden in plain sight, are themselves disavowed in the apparent pursuit of analytic understanding. In this way the patient's and the analyst's use of the analytic situation becomes the fundamental resistance to the work itself. This process shares features in common with perversion. The painful but necessary task for both analyst and patient is to analyze this process as it is occurring, moment by moment, in the real time of the hour.     

"Nothing could be further from the truth": the role of lack in the analytic process

It is an oft-noted clinical phenomenon that the analyst's mistakes are beneficial to the analytic process. Although the analyst's mistakes, misunderstandings, and faulty functioning have been described by psychoanalysts of various theoretical persuasions, no overall theory has been advanced to account for this clinical phenomenon. To address this theoretical lacuna the central Lacanian notions of lack and desire are brought to bear. In particular, lack, or nothing, is presented as an essential working condition of the analyst, one that if understood, recognized, and tolerated can positively inform the analyst's attitude. By contrast, theoretical biases that privilege presence can obscure lack as an important contributor to the analyst's attitude. A clinical case demonstrates that both analyst and patient struggle with deep anxieties generated by lack, and that both are repeatedly tempted to solve these struggles by settling for obsessional solutions.     

What the analyst does not hear

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

Some observations on the psychoanalytic process

The author's aim is to delineate the psychoanalytic process and to distinguish it from the psychoanalytic situation, the transference neurosis, "insight," and psychoanalytic technique in general. Freud's 1913 views provide the basis for a concept of the psychoanalytic process centered on the recognition and interpretation of resistances and on the patient's reactions to the analyst's interventions. This clinically observable "unit" of the process is described and compared with Bernfeld's "facts of observation." The proposition is advanced that the process does not come to an end with the termination of analysis. It continues postanalytically in the form of the patient's more objective and more effective capacity for self-observation. The paper closes with a warning about the "pitfalls of perfectibilism" and with a plea for the elevation of the not-so-good analytic hour.     

A crisis in the analyst's life: self-containment, symbolization, and the holding space

Most analysts will experience some degree of crisis in the course of their working life. This paper explores the complex interplay between the analyst's affect during a crisis in her lifeü and the affective dynamics of the patient. The central question is "who or what holds the analyst"--especially in times of crisis. Symbolization of affect, facilitated by the analyst's self-created holding environment, is seen as a vital process in order for containment to take place. In the clinical case presented, the analyst's dog was an integral part of the analyst's self-righting through this difficult period; the dog functioned as an "analytic object" within the analysis.     

Mourning analysis: the post-termination phase

One hundred twenty-one analytic candidates who had completed training analysis responded to a survey about their post-termination experience. Seventy-six percent of respondents experienced a mourning process that lasted on average between six months and a year, while 24 per cent experienced no discernible sense of painful loss. Twenty candidates were interviewed to obtain a deeper understanding of the mourning process that follows analysis. During the post-termination phase, the analysand's self-analytic capacity is tested in the struggle to contain and understand feelings about the loss of the analyst, as well as transference reactions triggered by that loss. After a "good-enough analysis," the analysand internalizes not only the analyst's functions and attitudes toward him or her, but also a sustaining, positive internal image of the analyst. Four cases illustrate unexpected difficulties that may emerge during the post-termination phase when the loss of the analyst is experienced as a repetition of earlier, traumatic losses or as a rupture of an unanalyzed, selfobject transference.     

This art of psychoanalysis

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

On the analyst's neutrality

It is by the application of the principle of neutrality, born of his respect for the essential otherness of the patient, that the analyst focuses the dyadic analytic work in the service of the patient's growing self-analytic capacity. Thus, the general principle of neutrality is distinguished from the technical tactic of abstinence, the latter being a specific function utilized to facilitate and foster analytic regression. Neutrality can be defined as it applies to the major subfunctions of the analyst's work ego. Perception of the patient's intrapsychic processes (both empathically and cognitively) requires a neutrality of appearance on the analyst's part in order to minimize the distortion of the unfolding transference neurosis. Integration and understanding of the patient's communications require mastery and neutralization of the analyst's own internal processes in order to minimize countertransferential distortions. Appropriate interpretive intervention requires neutrality of action, i.e., mastery of impulses related to power, neutralizing them into the service of the analytic work; tact is defined as a specific psychoanalytic function in this regard. Collaborative ignorance is examined as a specific instance of false neutrality. In this an analytic guise serves to mask a countertransferential conflict. Neutrality serves as an overriding technical principle, not an imperative for perfectionism . Factors intrinsic to the analytic process also influence the application of this principle.     

The week the couch arrived

Changes in the therapeutic environment can elicit intense and unpredictable responses from patients, who then react to the new elements with their own unique thoughts, fantasies, emotions and behaviours. When the change is very specific, and when it entails implications for the treatment itself, these patient responses can coalesce around more profound experiences of the transference as well as of the countertransference. The author, as a candidate or analyst-in-training, purchased an analytic couch for his office and observed the unfolding of what this new couch meant for existing treatments. Using clinical examples, he describes the three most common patient responses that occurred: rejecting, ambivalent, and embracing. The richly variant ideas and fantasies related to the analytic couch are described, and the couch's history within Freudian and Jungian contexts is reviewed. Personal determinants that could lead to the decision of whether to use a couch as part of analysis are considered from the standpoint of the analyst's preferences and own experience with the couch. The couch is discussed as a signifier of the analytic process with cultural meanings alluding not only to familiar stereotypes, but also to psychological healing and self-development.     

Raiding the inarticulate: The internal analytic setting and listening beyond countertransference

The analytic setting exists not only externally but also internally as a structure in the mind of the analyst. The internal analytic setting constitutes an area of the analyst's mind where reality is defined by unconscious symbolic meaning. Clinical examples illustrate how a secure internal setting allows flexibility in the external setting without sacrifice of its analytic quality. The internal setting can help analysts listen inwardly to themselves in a way that is free-floating with regard to their internal processes. This points beyond usual ideas of countertransference. An analytic encounter may stir up elements that belong to the analyst's psyche which, rather than impeding the analysis, can actively enrich it. Seamus Heaney's writings evoke comparisons between listening to poems and listening to patients, and a week in a patient's analysis is described in relation to these themes.     

The innocence of sexuality

The author explores aspects of sexual experiencing as they emerge in the course of development, especially as structured between parents and children. Is a certain mode of "innocent" sexual relating an important outcome of the developmental process, and does this mode have a place in the analytic process? The author suggests that the restoration of a capacity for sexual experiencing that is relatively free of convoluted developmental legacies may represent an important achievement in analytic work; and that the analyst's participation in this process, using his or her own capacity for "innocent" sexual responsiveness, may be essential to this outcome.