Subjective reality, objective reality, modes of relatedness, and therapeutic action

This paper describes a dialectic believed to be at the heart of therapeutic interaction within a relational model. The dialectic consists of the interrelationship of two modes: the dyadic and the triadic. In the dyadic mode, the analyst responds with aspects of his or her self that singularly reflect the patient's subjectivity. This mode of attunement is uniquely suited to bringing the patient's experience into a place where it can then be seen and known. In the triadic mode, realities are recognized that are important to, but still outside of, the subjectivity of the patient. The analyst invites the patient to see him- or herself not only from inside his or her own space, but also from a point outside, through the perspective of others. The analyst is charged with asymmetric but not exclusive responsibility for negotiating and sustaining a fluid and flexible relationship between these modes. Optimally, this occurs through spontaneous and authentic engagement informed by intuition, empathy, and clinical judgment. However, when this dialectic loses its robust and kinetic quality (as frequently occurs in approaches ranging from the classical to the postmodern), an impermeable dyad is formed by extruding potentially triangulating aspects of reality (and subjectivity). This can result in curiosity and the openness of uncertainty being replaced by closed-mindedness and proclamation.     

Which Horse do You Ride? Trauma from a Relational Perspective. Discussion of Prince's “The Self in Pain: The Paradox of Memory. The Paradox of Testimony”

Discussing Dr. Robert Prince's clinical case example, the author presents a relational psychoanalytic perspective on working with the traumatized patient. She considers the presentation of his work with a Holocaust survivor from a relational perspective with particular attention to the dyadic interaction, the intersubjectivity and co-creations of patient and analyst, and finally, addresses the role of the “witness” in psychoanalytic work. The idea of the witness has particular currency in contemporary psychoanalytic thinking. The author briefly examines the dimensions of the “witness” from a relational point of view. Consideration is also given to the necessary distinction between adult onset and childhood onset trauma and the repercussions of each for the analytic couple.     

Countertransference—Transference seen from the Point of View of Child Psychoanalysis

This paper explores the ‘point of interaction’, that interface where the psyches of the patient and analyst meet. The author examines what is activated in the analytic pair at the point of interaction, with a particular focus on the mental activity of the patient and analyst. This exploration of the mental activity of the patient and analyst is from a theoretical position that combines contemporary Freudian and Kleinian perspectives on the therapeutic process. The author concludes that the capacity for mutuality in both the patient and analyst rests upon a part of the mind that is connected to a certain aspect of the Oedipus complex. Finally, the point of interaction is also discussed as a place where there is a potential meeting of minds around divergent methods and applications of psychoanalytic treatment. Clinical material is presented to illustrate these points.     

Technique as a Case-Specific Problem: Reply to Commentaries

Seligman's appreciative response to the discussions of his paper is most concerned with the issues raised in Leon Kleimberg's critique of his “modifications of technique.” The dialogue between Kleimberg's and his point of view, with the latter echoed as it in Case and Dent's and Frosch's, reflects a number of key convergences and divergences between the American relational perspective and the British Independents'. Both approaches rely on a fundamentally dyadic perspective that stresses how the analyst's work is fundamentally shaped in response to the patient's internal objects. At the same time, although he is sympathetic to Kleimberg's concerns, he questions the idea of technique as a fixed set of uncontaminated practices. Instead, he endorses the North American relational idea that whatever the analyst does in the name of “technique” cannot be extricated from the transference-countertransference in which it is implicated. From this point of view, technical decisions are most likely to be experienced by the patient, and very often by the analyst, as inevitably reflecting one aspect of another of the patient's internal object world from within the phanstasmatically organized matrix of each analytic relationship. In addition, he is concerned that analysts' rigidly adhering to “technical” positions will reduce their likelihood of being effective with the widest range of patients, an increasing number of whom may not accept the traditional analytic practices. The mentalization concept, although not guiding his decisions in the case, is useful in describing many such situations.     

The problem of self-disclosure in psychoanalysis

The problem of self-disclosure is explored in relation to currently shifting paradigms of the nature of the analytic relation and analytic interaction. Relational and intersubjective perspectives emphasize the role of self-disclosure as not merely allowable, but as an essential facilitating aspect of the analytic dialogue, in keeping with the role of the analyst as a contributing partner in the process. At the opposite extreme, advocates of classical anonymity stress the importance of neutrality and abstinence. The paper seeks to chart a course between unconstrained self-disclosure and absolute anonymity, both of which foster misalliances. Self-disclosure is seen as at times contributory to the analytic process, and at times deleterious. The decision whether to self-disclose, what to disclose, and when and how, should be guided by the analyst's perspective on neutrality, conceived as a mental stance in which the analyst assesses and decides what, at any given point, seems to contribute to the analytic process and the patient's therapeutic benefit. The major risk in self-disclosure is the tendency to draw the analytic interaction into the real relation between analyst and patient, thus diminishing or distorting the therapeutic alliance, mitigating transference expression, and compromising therapeutic effectiveness.     

The reality of the other: Dreaming of the analyst1

The author discusses the obstacles to symbolization encountered when the analyst appears in the first dream of an analysis: the reality of the other is represented through the seeming recognition of the person of the analyst, who is portrayed in undisguised form. The interpretation of this first dream gives rise to reflections on the meaning of the other’s reality in analysis: precisely this realistic representation indicates that the function of the other in the construction of the psychic world has been abolished. An analogous phenomenon is observed in the countertransference, as the analyst’s mental processes are occluded by an exclusively self‐generated interpretation of the patient’s psychic world. For the analyst too, the reality of the other proves not to play a significant part in the construction of her interpretation. A ‘turning‐point’ dream after five years bears witness to the power of the transforming function performed by the other throughout the analysis, by way of the representation of characters who stand for the necessary presence of a third party in the construction of a personal psychic reality. The author examines the mutual denial of the other’s otherness, as expressed by the vicissitudes of the transference and countertransference between analyst and patient, otherness being experienced as a disturbance of self‐sufficient narcissistic functioning. The paper ends with an analysis of the transformations that took place in the analytic relationship.     

Thoughts on the limits of a mutual technique*

Ferenczi’s appreciation of the inherently mutual nature of the analytic encounter led him, and many who followed, to explore the value of mutual openness between patient and analyst. Specifically, Ferenczi saw the analyst’s openness as an antidote to his earlier defensive denial of his failings and ambivalence toward the patient, which had undermined his patient’s trust. My own view is that, while the analyst’s openness with the patient can indeed help reestablish trust and restore a productive analytic process in the short term, it also poses long-term dangers. In certain treatments it may encourage “malignant regression”, where the patient primarily seeks gratification from the analyst, resulting in an unmanageable “unending spiral of demands or needs” (Balint, 1968, p. 146). I suggest that an analyst’s “confessions”, in response to the patient’s demand for accountability, can sometimes reinforce the patient’s fantasy that healing comes from what the analyst gives or from turning the tables on his own sense of helplessness and shame by punishing or dominating the analyst. In such situations, the patient’s fantasy may dovetail with the analyst’s implicit theory that healing includes absorbing the patient’s pain and even accepting his hostility, thus confirming the patient’s fantasies, intensifying his malignant regression and dooming the treatment to failure. When malignant regression threatens, the analyst must set firmer boundaries, including limits on her openness, in order to help the patient shift his focus away from expectations of the analyst and toward greater self-reflection. This requires the analyst to resist the roles of rescuer, failure, or victim—roles rooted in the analyst’s own unconscious fantasies.     

Embodying analysis: the body and the therapeutic process

This paper considers the transfer of somatic effects from patient to analyst, which gives rise to embodied countertransference, functioning as an organ of primitive communication. By means of processes of projective identification, the analyst experiences somatic disturbances within himself or herself that are connected to the split‐off complexes of the analysand. The analysty’s own attempt at mind‐body integration ushers the patient towards a progressive understanding and acceptance of his or her inner suffering. Such experiences of psychic contagion between patient and analyst are related to Jung’s ‘psychology of the transference’ and the idea of the ‘subtle body’ as an unconscious shared area. The re‐attribution of meaning to pre‐verbal psychic experiences within the ‘embodied reverie’ of the analyst enables the analytic dyad to reach the archetypal energies and structuring power of the collective unconscious. A detailed case example is presented of how the emergence of the vitalizing connection between the psyche and the soma, severed through traumatic early relations with parents or carers, allows the instinctual impulse of the Self to manifest, thereby reactivating the process of individuation.     

Essential elements of the work of a supervisor

The supervisor’s prime task is to consider from the very beginning the analytic ability of the analyst presenting the case; this can be assessed by observing how the colleague transcribes the clinical material and describes what is meaningful in the session. It is extremely important to understand whether the patient’s suffering is neurotic, or whether he suffers from an initial psychotic disorder. In this latter case, the analyst will know that he cannot employ the same tools that he uses for the neurotic patient. It is fundamental to draw careful attention to the importance of the patient’s personal history. In the process of reconstructing the past, the patient’s difficulties are gradually understood by the analyst, the patient and the supervisor. Given that a memory may be distorted by present emotions and conflicts, the analyst must form meaningful hypotheses that, through reconstructing interaction with the original objects, help to comprehend the precarious equilibrium of the present. Over the course of supervision, I consistently emphasize the construction of the analytic relationship, which is based on the analyst’s mind and of the patient’s ability to communicate emotionally, so as to promote the analysand’s mental growth.

     

Paying Attention and Feeling Puzzled: The Analytic Mindset as an Agent of Therapeutic Change

The Relational turn has affirmed emotional interaction without losing sight of the complexities of the internal world, thus reforming psychoanalysis. This paper, however, is concerned that this well-justified enthusiasm for interaction may be distracting us from opportunities offered by analysts’ special aptitude for an open, quiet, focused mind in the midst of intense emotional and interpersonal activity. This special orientation is considered in relation to the analyst’s tolerance for ambiguity and even confusion. The effects of the analyst’s reflective concentration as a change factor in the analytic field are discussed, using nonlinear dynamic systems theories and a phenomenological perspective.     

Dyadic and triadic skills in preterm and full term infants: a longitudinal study in the first year

This longitudinal study examined dyadic and triadic skills in 26 preterm and 31 full term infants at 3, 6 and 9 months of age. In dyadic interaction, infants engaged with a stranger in face-to-face play interrupted by a still-face episode. In triadic interaction, infants interacted with the adult stranger as she coordinated gaze between the infant and object. Both groups were sensitive for non-contingency in both dyadic and triadic interactions. There were significant group and developmental differences for dyadic and triadic competencies. Compared to full term infants, preterms made less positive elicits during the still-face at 6 months and followed gaze less at 9 months of age. Six-month dyadic skills and 9-month triadic competencies were positively related in preterm and full term infants.     

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.     

Die institutionelle und die innere Familie des Analytikers

The author postulates the existence of an intense interaction between the analyst’s two families, the historical one of his infancy and the institutional one of his psychoanalytic education. In his opinion they both step into the analyst’s work with his patient on the level of his inner fantasy and to different degrees according to the various moments in the work. He points out that the common element between the infantile experience and the analytic one is the enormous opportunity for profound introjection. There are important moments that favor introjection in the young analyst’s training course which establish and constitute the cultural, theoretical and clinical foundations of his working ego and of his working self. The importance of a thoroughly analyzed separation process from the personal analyst and from the supervisors during the analysis is strongly emphasized.     

Discussion of Holly Levenkron's “Love (and Hate) With the Proper Stranger”

I agree with Holly Levenkron that the value of an intersubjective perspective is pragmatic: It directs the analyst toward more effective technique. Also, I agree with her view that a successful analytic process is a negotiation between analyst and patient. However, I question Levenkron's idea that the analyst must loosen her hold on her own subjectivity in order for the negotiation to proceed. An analyst cannot and need not diminish her subjectivity. Rather, what is required for clinical analytic work to unfold is that the analyst include the patient within the analyst's subjectivity—or, in other words, that the analyst come to love the patient.     

Enactment as Unconscious Communication

ABSTRACT

I explore the way in which unconscious primitive and nonsymbolic experience is communicated to the analyst’s unconscious through enactment. As the analyst receives the projections unconsciously, she is encouraged to enact aspects of the patient’s internal world. The analytic work then is through the understanding of these subtle and ubiquitous enactments. I value the work of understanding enactments as a rich and subtle pathway into the deepest levels of the patient’s unconscious. I explore the nature of this work and illustrate my point with clinical examples.     

Psychoanalytic Interpretation as Pharmakon: Applying Derrida’s “Plato’s Pharmacy” to Psychoanalysis

This paper presents a metaphorical heuristic to expand psychoanalysts’ views on the nature and method of interpretation from an intersubjective perspective. It uses one of Jacques Derrida’s findings in his essay “Plato’s Pharmacy,” a critique of Plato’s Phaedrus, as a model of psychoanalytic interaction. A parallel is drawn between psychoanalytic interpretation and the pharmakon—an ancient Greek term for ‘drug’ that means both remedy and poison. From this comparison, the inescapable dependence of personal meaning on contextual factors, specifically the context of the clinical intersubjective field, is shown. As a result, when an interpretation is offered, the analyst cannot truly know if the patient will receive it as remedy or poison. By keeping the context-dependent nature of personal meaning in awareness through the use of the pharmakon metaphor, analysts increase their abilities of interpretive understanding. In further discussion, the classical psychoanalytic concept of ‘negative therapeutic reaction’ is presented as an example of a decontextualized and reified psychoanalytic construct that becomes superfluous when interpretations are viewed through an intersubjective lens as pharmakon. Without the burden of expectation for being the authoritative imparter of reality and truth, the analyst may now attend to the patient in a way that is more fluid and reciprocal, where the relational field becomes what is primarily interpreted. Further, practical clinical implications of the concept of pharmakon suggest that since the analytic interpretation is subjective in every respect, effective clinical practice cannot be reduced to rigid protocols of technique.     

Here and now: My perspective1

In this paper the author describes her particular perspective in doing analytic work. She stresses working in the here and now. For example, making interpretations that grow out of what the patient says or does in the sessions, keeping the patient’s history in mind, but not letting it lead interpretations. The analysis tries to understand why something is being said now, in this way, and what impact it may have or be designed to have in the analytic relationship. The term ‘here’ refers to what is going on between patient and analyst in the room while not leaving out the patient’s immediate reality in the outside world, his everyday life. The word ‘now’ implies awareness of time that is not just of the past and future but of the patient’s situation at the moment in analysis, which is constantly shifting.The author believes that by working primarily in the present the patient will feel more anchored, both patient and analyst can observe what is going on, for example how anxiety arises or decreases, how defences are mobilised or lessen. Both analyst and patient experience movement and change rather than relying on more theoretical explanations.     

Accompaniment in Jazz and Psychoanalysis

The author explores a fundamental role of the analyst as improvisational accompanist. This role requires a dedicated attention to the shared rhythmic dimension of the interaction, a mode of psychoanalytic attention of embodied self-awareness and sensitivity–that is, embodied attunement to the pulse of the interaction. Directed action follows by providing various forms of accompaniment that depend on the nature of the patient’s needs and emotional state. By refining our accompaniment to meet clinical situations and challenges, we enlarge the range of analytic engagement. Using examples from jazz, the way the rhythm section finds the right form of accompaniment to support the soloist’s creativity and unique voice, the analyst similarly accompanies his or her patient, providing a temporal framework, a pulse that affirms emotionally shared states, recognition, differentiation, and creative expression. Various forms of analytic accompaniment include steady and present beat, an unobtrusive and loose presence, an interactive and conversational presence, or disruptive rhythms. From experiences of solid support and recognition, accompaniment can fuel the patient’s improvisations, allowing him to move away from the analyst and create a clearer differentiated voice. As the patient separates, he ventures out into new or difficult territory, the analyst’s presence is there following.     

Roles of Engagement: Commentary on Paper by Richard Almond

Richard Almond's discussion on the benefits of attending to the tension between what he refers to as analyst role and nonrole behaviors is quite stimulating and highlights important issues within the world of psychoanalysis. Although appreciating Almond's efforts to add clarity and perspective to the discourse on relational analytic activity, I point out the ways in which dichotomizing the analytic endeavor into “role” and “nonrole” behaviors can be limiting. It is proposed that prioritizing the tension between these polarities as mutative does not encourage the “spaces” between these role and nonrole behaviors to be maximally used, minimizes the interactive component, and privileges observing over experiencing. It is also contended that an affectively alive analyst, including one in the midst of enactments is acting within role. A clinical example is used to demonstrate that neither interpretation nor interaction should be privileged in terms of therapeutic action.     

Ordinary Sadism in the Consulting Room

The analyst’s retaliatory sadism can be construed as a perversion of the wish to penetrate, just as masochism can be viewed as a degradation of the desire to surrender. When a patient refuses to speak any other language but that of domination and submission, ordinary attempts for communication and recognition fail. In her attempt to reach the patient, to reinstate herself as an active agent and subject, and also to dislodge the patient from a rut of despair, passivity, or malignity, the analyst may escalate to a sadistic response, even if she suspects that this might cause the patient pain. This type of sadomasochistic enactment can gather strength when disowned self-states of analyst and analysand are activated. In this process, an analytic interpretation, seemingly legitimate, can be used as a knife, a weapon, an instrument of retaliation and sadistic control. The disastrous potential of the analyst’s sadism is easy to imagine. Through a couple of clinical vignettes I will demonstrate that even something as lamentable as the analyst’s sadistic retaliation can lead to growth as long as such sadism can enter the analytic dialogue and the patient is allowed to perceive and reflect upon the analytic misbehavior, and the analyst is willing to join the patient in the quest to understand their co-created predicament.