On psychic reality and neutrality: Empathy and the work of construction in countertransference

Abstract

The clinical challenges faced in encountering patients who do not fit the standard treatment of Oedipus conflicts clearly show the limitations of the interpretative method, thus making indispensable the study of clinical concepts and techniques as a way to broaden the psychoanalytic horizons. In order to analyse the different psychopathological problems resistant to traditional clinical approaches, it is necessary to reorganise the technique on the basis of a better understanding of the ways in which subjectivity is rooted in early psychic constitution. In this way, empathy becomes important as a clinical tool. The use of empathy must be understood as a decisive factor in handling clinical cases and situations in which the treatment encounters obstacles that restrict the power of the analyst's verbal interventions.In this case, can we say that the use of empathy interferes directly with and changes the position of the concept of psychic reality? Moreover, as we use empathy, can we also say that the concept of neutrality is transformed, without being abandoned? The intention of this paper is to discuss these questions using clinical material taken from the analysis of borderline clinical cases and situations.     

Libido und psychische Energie

The authors investigate different definitions of “psychic energy” and “libido” as well as their critique. With regard to “psychic energy” it is shown that the critique relates in particular to the perspective of Brenner and others and not to Freud's definition. They argue that Freud uses the term “psychic energy” as a synonym for “libido” and not “libido” as a synonym for “psychic energy”. It is assumed that until 1914, Freud related “libido” to manifestations of bodily sexual tensions and afterwards to manifestations of sexual energy in the psychic field. The authors reject this change for epistemological reasons as well as Freud's attempt to use dynamic, economic considerations as an explanatory device. Freud's energy concept is inconsistent with the definition of energy in natural sciences, and, whereas the meta-psychological topographical, dynamic and structural viewpoints have a solid foundation in the representational world to which the psychoanalytic process affords unique access, this is not true of the economic viewpoint. It is claimed that bodily tensions exist in the representational world only in the form of affects, so that the economic viewpoint should, in the authors' opinion, be abandoned in favour of an affective one. In the context of the endeavour to obtain pleasure and avoid unpleasure as adduced by Freud, this viewpoint concentrates on the relationships between affects and the different elements of the representational world, thereby serving as the topoi of meta-psychological investigation dimensions.     

Christer Sjödin interviews Jan Stensson

Abstract

The author examines different definitions and applications of the terms “psychic energy” and “libido.” With regard to the “psychic energy” terminology, he shows that its application and usage relate in particular to the perspective of Brenner and not to Freud's definition. He argues that Freud uses the term “psychic energy” as a synonym for “libido,” and not “libido” as a synonym for “psychic energy.” It is demonstrated that in Freud's view, up until 1914, “libido” relates to manifestations of bodily sexual tensions, and subsequently this term applies to the manifestations of sexual energy in the psychic field. The author rejects this change in terminology and also challenges Freud's attempt to use dynamic-economic considerations as an explanatory device for epistemological reasons. Freud's concept of energy is inconsistent with the meaning of energy as defined in the physical sciences, and whereas the metapsychological topographical, dynamic, and structural viewpoints have a solid foundation in the representational world to which the psychoanalytic process affords unique access, this is not true of the economic viewpoint. It is claimed that bodily tensions only exist in the representational world in the form of affects, so that, in the author's opinion, the economic viewpoint should be abandoned in favour of an affective one. In the context of the endeavour to obtain pleasure and avoid unpleasure adduced by Freud, this viewpoint focuses on the relationships between affects and the different elements of the representational world, thereby serving as the subject of metapsychological investigation.     

Structural conflict and object relations conflict.

A hierarchical model of the mind is required for a more integrated understanding of psychic conflict. At a higher developmental level, the hierarchical model includes the tripartite model, and at a lower level it includes an object-relations model. Psychic conflicts may be classified into object relations conflicts and structural conflicts. The object-relations class of psychic conflict covers the phase of psychic development prior to id-ego-superego differentiation. The earlier psychoanalytic writings tended to ascribe all kinds of symptoms, conflicts, and disorders to structural conflicts. Logical and empirical evidence against the universality of structural conflicts in various disorders and symptoms, even psychoneurotic symptoms, has been summarized and discussed.     

PARADOXES EN MIROIR ET SIGNES

The authors inquire to which degree the different levels of the bodily, psychological, and cultural alienation of mental patients reflect a psychologically and/or socially primary regression. By drawing on Arabo-islamic science and philosophy, and their own clinical practice, as well as by integrating various psychoanalytic and psychiatric theories, and psycho-physiological research, the authors develop a socio-analytic theory and methodology. By applying their approach on a psychological, intra-, inter-, and meta-cultural level the authors try to explain the psychic and socio-cultural mechanisms and paradoxes which nowadays turn many individuals into strangers to their own culture, their own body and into strangers to their own filiation and its bodily mark.     

Some notes on Freud's concept of conversion

Abstract

The author investigates conversion, the process by which psychic contents are transformed into bodily symptoms. The author concludes that this process cannot be explained by libido theory or by assuming the existence of a psychic energy. He argues that although Freud was convinced that “the leap from a mental process to a somatic innervation … can never be fully comprehensible to us,” this process is, nonetheless, comprehensible in terms of Freud's own conceptualisation. To understand this process, one must take the characteristics of the primary process to which the “replacement of external by psychical reality” belongs as radical as his thesis of a hallucinatory wish fulfilment. This thesis includes not only the hallucinatory satisfaction of instinctual wishes, but also the hallucinatory satisfaction of the desire to avoid unpleasure, which is understood as a process by which the internal conditions of this affect are displaced from the presentational world into perceptions via conversion.     

Levels of Emotional Awareness: a model for conceptualizing and measuring emotion-centered structural change

The need to establish the efficacy of psychoanalytic long-term treatments has promoted efforts to operationalize psychic structure and structural change as key elements of psychoanalytic treatments and their outcomes. Current, promising measures of structural change, however, require extensive interviews and rater training. The purpose of this paper is to present the theory and measurement of Levels of Emotional Awareness (LEA) and to illustrate its use based on clinical case vignettes. The LEA model lays out a developmental trajectory of affective processing, akin to Piaget's theory of sensory-cognitive development, from implicit to explicit processing. Unlike other current assessments of psychic structure (Scales of Psychological Capacities, Reflective Functioning, Operationalized Psychodynamic Diagnostics) requiring intensive rater and interviewer training, it is easily assessed based on a self-report performance test. The LEA model conceptualizes a basic psychological capacity, affect processing. As we will illustrate using two case vignettes, by operationalizing implicit and explicit modes of affect processing, it provides a clinical measure of emotional awareness that is highly pertinent to the ongoing psychoanalytic debate on the nature and mechanisms of structural change.     

The role of psychoanalytic assessment in the management and care of a psychotic patient

The pressure on mental health services to move patients on quickly, and the emphasis on the recovery model, can encourage a superficial assessment of the patient's difficulties. The author argues that a narrow definition of the medical model based on the presence or absence of symptoms ignores the deeper psychic structures that govern thinking and behaviour over time. A psychoanalytic assessment can offer a dynamic picture of deeper psychic structures in the patient's internal world. This is particularly important with psychotic patients who may successfully use denial and rationalization to cover up their underlying psychopathology. The developmental perspective inherent in the psychoanalytic view can also give a picture of the patient's propensity to repeat certain aspects of his/her psychopathology. In addition, a psychoanalytic approach may shine some light on the relationship between relapse and risk behaviour.     

Towards an interpersonal understanding of bodily experience

This paper attempts to understand the interpersonal nature of bodily experience. It explores the way the body symptoms we meet in the consulting room, and in everyday life, express and communicate disturbances in our relationships with others. The article seeks to understand how others that are close to us can really get under our skins. The work of the philosopher of the body, MerleauPonty, findings from contemporary developmental psychology, recent psycho-biological studies and psychoanalytic insights are all drawn upon as a way of offering an introduction to contemporary developments in thinking and research on the body.

The article explores the interdependence of body and environment. In particular, the body is always in an interpersonal context with others. Bodies are interdependent; communication is first and foremost bodily. Bodily behaviour and biological functions develop in the context of a relationship. The relationship with the other influences the formation of bodily processes and actions. Clinical examples are drawn upon to illustrate how interpersonal disturbances in development are expressed in bodily symptoms. The difference between a hysterical and psychosomatic body symptom is also briefly addressed.     

Where models intersect: a metapsychological approach

Current scientific interest in how the mind works creates a major challenge for psychoanalysis. The author proposes metapsychology as a bridging concept for an interdisciplinary dialogue. She presents a new framework on a microstructural level, within which different psychic representations are hierarchically organized. This framework permits a detailed comparison with Alexander Luria's (1973) neuropsychological model of the working brain (including recent theories of affect), and makes it possible to delineate the similarities as well as the differences between the psychoanalytic model of the mind and the neuropsychological model of the brain.     

Disability and countertransference in group psychotherapy: connecting social oppression with the clinical frame

Psychoanalysis has paid limited attention to disability, and at times the approach has lacked political awareness. Over recent decades the international disability rights movement has argued that disabled people constitute an oppressed, systemically disadvantaged minority. Lately, a critical psychoanalytic view has connected disablist discrimination to universal unconscious conflicts evoked by impairment. Corresponding evocations emerge in the therapeutic frame, producing countertransference responses to the impaired body. Drawing on psychoanalytically oriented group psychotherapy with severely physically impaired adults, countertransference phenomena were studied in developing discussion on disability-related clinical work. The complex, uncertain role of psychoanalytic practice in combating oppression was also examined. Key issues include challenges to the traditional frame, the crossing of psychic boundaries, anxieties relating to not knowing, and the role of unconscious factors in marginalizing disabled experience.     

Psychoanalysis: the transformation of the subject by the spoken word

Psychoanalysis recruits the power of the spoken word to modify the subject's relationship with his or her own unconscious psychic processes. It helps the analysand to reclaim for his or her words the psychic integrity that was lost or never achieved due to the power of defensive dissociation and repression. The psychoanalytic dialogue and the working through mediated by it lead to the elaboration of self-narratives and interpretive understandings, which contribute to the transformation of the subject's self-experience. Such transformation is conditioned by earlier integration of experiences of satisfaction in the context of bodily dialogues and speech with primary objects.     

Blurring Boundaries or Why Do We Refer to Sexual Misconduct With Patients as “Boundary Violation”

I argue for the notion that we reserve the term boundary for the psychic realm because the psychic boundaries of psychoanalysis are so fundamentally complex, dense, and intrinsically confusing that bringing in the realm of behavioral ethical violations is actually unnecessarily vague and mystifying. The notion of a psychological boundary as a term in psychoanalytic work is a fragile, metaphoric construction that allows us to explore fantasy, affect, symbols, and elements of shared and unique realities. Psychoanalysis hinges on a social compact by patients and analysts to open up otherwise forbidden territory offered through this metaphoric construction. Rather than conflate forensic vocabulary (“violation”) with a central psychic concept for conducting psychoanalytic work (“boundary”), I suggest that we refer to ethical misconduct in more straightforward conventional terms such as misconduct (behavioral referents) or with specific psychological understandings of the many determinants of this behavior that we have available to us as psychoanalysts.     

Working with countertransference

The transference-countertransference relationship is only one of five modalities of relationship that research has identified as potentially present in the therapeutic encounter. This paper gives the background and definition to one aspect of this - the countertransference - and traces the development of the concept from Freud's first use of the term in 1910 to the contemporary view that it is a useful tool of psychotherapy. The first part explains its connection with the Kleinian concept of projective identification and discusses its elaboration by the object relations school. There is general acceptance nowadays that the countertransference contains a great deal of information about the client's psychological world. It is therefore important to understand this process and the authors have identified three main dimensions to countertransference. These are its vector (or direction and force), its variance (the quality it represents), and its valence (its effect on the client). The second part of the article illustrates, through the use of example and metaphor, how these three dimensions are defined and can be recognized. Common themes and paradigms of countertransference are identified and discussed along with some ways in which experience has shown how these might be contained and worked with constructively. Finally, a clinical vignette is presented in which some of the dimensions of countertransference are identified and used to understand the client's psychic world and foster therapeutic change.     

Psychoanalysis and cancer. A case report and a hypothesis

The psychoanalytic treatment of a 39 year old female cancer patient demonstrates a close connection between psychic factors (cumulative separation trauma, conflict-laden relationship to the mother, oedipal conflicts etc.) and the onset and course of the cancer. After eight years of analytic therapy the cancer symptoms disappeared. The authors formulate the hypothesis that cancer may occur on a primarily somatic or psychic basis.     

To Know Another Inside and Out: Linking Psychic and Somatic Experience in Eating Disorders

ABSTRACT

This article explores the role of the body in the psychoanalytic treatment of eating disorders from a relational and developmental perspective. Many who struggle with eating disorders and related issues have had early experiences that adversely affected the development of flexible, adaptive self-regulation, including the ability to experience affects as psychic states that can be safely shared in the context of a relationship. Because of their difficulty symbolizing and expressing feelings, patients with eating disorders often experience affects as somatic problems, for which they seek somatic solutions. Tuning in to patients’ bodily experience can open up pathways for accessing and, eventually, verbalizing and reflecting on internal states in the therapeutic relationship. As shown through a detailed case illustration, the therapist can discover and engage aspects of the intersubjective matrix that may not meet the eye by attending to his or her own bodily experiences and associations in and out of sessions.     

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.     

The construction, reconstruction, and deconstruction of memory in the light of social cognition.

Psychic trauma results when the ego is overwhelmed by intolerable affect. Some childhood experiences are directly traumatic, requiring no intervening interpretive process to render them traumatic. Troublesome affect that falls short of being truly traumatic, in the strict sense of the term, may nevertheless exert a psychopathogenic effect on the child's psychic development. Whether a child is troubled by an experience depends on what that experience meant to the child. Accordingly, the psychopathogenic effects of childhood experience are a function of the child's general level of cognitive sophistication and specific ability to appreciate the subtle nuances of social interactions. If a child's cognitive capabilities are not up to the task of providing the necessary explanations for a given social interaction, the child is left to fall back on fantasy to fill in the gaps. The field of "social cognition" proves particularly helpful in understanding what a child is capable of gleaning from an experience. Research in this area helps psychoanalysts understand how experience becomes constructed and reconstructed in the form of memories. Social cognition also helps psychoanalysts understand when and how a lived experience ends up being psychopathogenic or, alternatively, ceases any longer to exert an ongoing psychopathogenic effect on an individual's psyche. A review of social cognition research leads to a reconsideration of such psychoanalytic concepts as repression, dissociation, reconstruction, and resistance. It also directs attention to the concept of developmental (as opposed to psychoanalytic) reconstruction and deconstruction.     

Negativism and countertransference

The purpose of this work is to explore the phenomenon of negativism and the analyst's response to it during the course of analytic work with a patient in whom negativism is a central behavioral pattern. Melville's short story, "Bartleby the Scrivener," describing in telling detail the response of a sympathetic lawyer to profound and pervasive negativism in his legal scribe, is discussed as a literary analogy to the analyst-analysand dyad. Aspects of the concept of negativism within psychoanalysis are discussed. The potential usefulness of understanding certain unexpected countertransference responses to pervasive negativism is explored, as this is a relatively neglected area of psychoanalytic technique. A case is presented describing the analysis of a patient whose character, like Bartleby's, is a mixture of profound negativism along with schizoid, obsessional, and masochistic elements.