Flexibility of the Psychoanalytic Approach in the Treatment of a Suicidal Patient: Stubborn Silences as “Playing Dead”

The author presents the clinical case of a patient in his third analysis who seemed emotionless, did not feel alive, and complained of an uncontrollable urge to gamble, with disastrous financial results. His previous four-session-a-week “orthodox” analysis had left him prey to a sense of emptiness and to intense suicidal urges. He wanted only two weekly sessions, which became three after some analytic work. The author stresses the danger of rigidly following inflexible standards and the consequent activation of a pseudo-compliance in the analysand. A more slowly paced psychoanalysis should not be considered lower in the pecking order than “high-frequency” treatment, the author maintains: It requires great creative subjective involvement on the part of the analyst and close interaction in the context of the analytic couple. The author shows how this analysis involved a series of interactions in which the analyst was called upon to exercise a complex responsiveness, attuned in each instance to the patient's current needs. Finally he focuses on some clinical passages to show how the patient's internal theories represent a glaring assault on common sense and how death was not recognized perceptionally on a realistic level, but was instead replaced with acting out death against himself by keeping himself mentally dead and by suicidal urges.     

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.     

Fear and Shame in an Israeli Psychoanalyst and His Patient: Lessons Learned in Times of War

Living in the midst of a war presents unique challenges to ongoing psychotherapeutic treatment. This paper focuses on the ever-present threat of fracture to the analytic frame and the limited ability of the therapist to create a safe, insulated environment— a reliable container—in which to work, while coping with a violent external reality. Using an intrapsychic lens, as well as an interpersonal one, the dynamics of both the analyst's and the patient's fear and shame are brought into focus. This delicate balance is illustrated through two cases: one occurring during the First Gulf War (1991) and the second taking place during the Second Lebanon War (2006). In both cases, fear and shame cause a stalemate in the psychotherapeutic process. The analyst recalls his active duty as a soldier during the Yom Kippur War (1973). These memories and their attendant acknowledgement of fear and shame by the analyst, as well as his analysand's “supervisory” comments, gradually dissolve the knot and repair the rupture in the analytic process. The ability to fully experience fear, shame, and helplessness is at the core of psychic health, a health once destroyed by dissociation and denial of these feelings. This ability to experience fear and shame is the psyche's antidote to mental breakdown. Following discussion of the two case studies, this paper seeks to illustrate how the very structure of a society, in this case Israel, can codify societal defense mechanisms against emotions like fear and shame, exacerbating the very problems it seeks to assuage.     

Collusive induction in perverse relating: Perverse enactments and bastions as a camouflage for death anxiety

The author argues that one of the main functions of perverse relatedness is to induce the analyst into becoming the patient's unconscious accomplice in a “perverse pact” against the analytic work aimed at disavowing intolerable aspects of reality. The intense power of collusive induction in perverse relating leads the analyst to participate in transference‐countertransference enactments and to the crystallization of a silent and chronic unconscious collusion between the patient and analyst in the analytic field, stagnating the process (bastion; Baranger and Baranger). The author claims that analysis of perverse pathology should not be limited to interpretation of the patient's intrapsychic functioning but should also focus on the information obtained by the analyst through his participation in collusive enactments; the analyst should also take a “second look” at the analytic “field” to detect underlying bastions. The author reviews the main psychoanalytic contributions that have clarified the phenomenon of collusive induction in perverse relating and as an illustration, describes the analysis of a man with a perverse character; in this patient, one of the main functions of his perverse relatedness was to induce the analyst to become an accomplice in his disavowal of his terror of death. The author highlights the influence of death anxiety in the bastions that develop in the treatment of perverse patients.     

The Particularities of Form: Reply to Commentary

In this brief reply to Bollas's commentary on our paper about his work, the cycles of intersubjective dialogue endlessly sustaining should be apparent. We begin with an example of the form—content distinction and attempt to use it as a springboard for further disentangling some of the nuances of Bollas's intersubjective theorizing. Bollas's emphasis on form over content as a means of conceptualizing the analyst's contribution to the analytic process is indeed compelling. We all know from both sides of the couch the profoundly different meanings and messages that an analyst's mien invites: whether she's abrupt, verbose, meditative, tranquil. Yes, the medium is the message, and, thus, whether the analyst conveys a message through the effects of form that Bollas points out, such as “We have all the time you need for the nuances of unconscious figuring” versus “This is hot—we hafta figure it out now” surely does have an effect on the psychic material produced in the analytic process. We go on to add to Bollas's discussion of form by considering the particularities of form and how these too affect the analytic process.     

PATIENT‐ANALYST “WITHNESS”: ON ANALYTIC “PRESENCING,” PASSION,AND COMPASSION IN STATES OF BREAKDOWN,DESPAIR, AND DEADNESS

This paper focuses on the analyst's “presencing” (being there) within the patient's experiential world and within the grip of the psychoanalytic process, and the ensuing deep patient–analyst interconnectedness, as a fundamental dimension of analytic work. It engenders new possibilities for extending the reach of psychoanalytic treatment to more disturbed patients. Here patient and analyst forge an emergent new entity of interconnectedness or “withness” that goes beyond the confines of their separate subjectivities and the simple summation of the two. Using a detailed clinical illustration of a difficult analysis with a severely fetishistic‐masochistic patient, the author describes the kind of knowledge, experience, and powerful effects that come into being when the analyst interconnects psychically with the patient in living through the process, and that relate specifically to the analyst's compassion.     

Murakami,Connoisseur of Uncertainty: Commentary on Paper by Thomas Rosbrow

My discussion embroiders around Thomas Rosbrow's view of Murakami as a “trauma analyst.” I highlight the ways in which Murakami's writing reflects his keen sensitivity to existential uncertainty and how he seems to understand trauma, much as I do, as a shattering experience that destroys the certainties that organize psychological life and generates efforts at self restoration. Although I share Rosbrow's view that “After the Quake” depicts a character's awakening from the dissociative manifestations of trauma, I spell out how my perspective on this process differs from his.     

Lies and Body Cruelties in the Analytic Hour

Discussing an intensive case study of female sexual dysfunction, this paper studies mutual deregulation and disintegration as it unfolds in the transference–countertransference dyad. I propose that ethical transgressions are potentiated in analytic dyads in which the analyst's hope for either solitude or mutuality is foreclosed. This hope can be foreclosed by the particulars of the therapeutic interaction as well as by the theoretical and clinical aspects of analytic training. The deregulation that both precipitates and follows such transgression can be healed (in the analyst, in the analysis) only by the restitution of the therapist's agency, the reduction of paranoid-schizoid guilt and shame, and the location (in the analyst) of depressive, “I-Thou” remorse.     

The Wisdom of Sharing a Frame: Commentary on Papers by Anthony Bass and Ilana Laor

In this discussion I agree with Anthony Bass, who shows how the analytic frame has properties that involve both the process and the structure, and I suggest replacing the term structure with the term constraints. Bass considers analytic frames as contexts: Different frames organize different contexts of experience. He says that the frame is cocreated by patient and analyst and evolves over time. I think that Dafna's case presented by Ilana Laor is a good example of this aspect. I agree with Laor, who shows how the frame reflects the negotiation process between patient and analyst, emphasizing that this process itself is therapeutic. Following Bass I emphasize that a polarization between stability versus flexibility should be replaced by the dialectic between stability and flexibility. I conclude wondering how Bass's and Laor's “wisdom” regarding flexibility and elasticity can be passed over to younger psychoanalysts who are beginning their clinical work.     

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.     

“Crunches,” “(K)nots,” and Double Binds—When What Isn't Happening Is the Most Important Thing: Commentary on Paper by Barbara Pizer

This discussion compares Pizer's concept of “relational (k)nots” with “crunches” and double bind impasses. It argues that all of these constructs capture what happens when conventional analytic method—the exploration, elucidation, and interpretation of transference—fails to work. In this context a “last-ditch effort” emerges, a necessary crisis of treatment. The situation is a plea that something must occur “now or never” or the “charade of therapy is over.” This plea is extraordinarily challenging since it embodies contradictory elements wherein the patient's very call for involvement with the analyst is embedded in a process that obfuscates their connection. Notably this sets the stage for the “damned if one ‘gets it’ and damned if one doesn't” experience that is a part of the paradox of recognition/mis-recognition that befuddles many analyses.

Extrication from such impasses requires the analyst's recognition that she is colluding in a kind of avoidance or distraction from recognizing their disconnection. Her second act involves meta-communication about their process. That is how their “relational knot” both binds them together while negating their connection. While this observation may be necessary it is recognized as insufficient on its own. Thus her third move out of the impasse requires her to enter into a state of improvisation. That is, to use some part of herself that must surrender from the one-up one-down impasse position of “either your version of reality or mine.” Instead, she must cultivate through her action a third way in which both she and her patient can think about their impasse and do something about it, including something different from what either one might have imagined before.     

From “disciplined subjectivity” to “taming wild thoughts”: Bion's elaboration of the analysing instrument

Abstract

Freud encouraged the analyst to use his unconscious “as an instrument of the analysis,” but did not elaborate on how this should be done. This recommendation opened the door to a consideration of unconscious communication between the analyst and patient as an intersubjective exchange. Both Wilfred Bion and Erik Erikson emphasised the importance of the analyst's intuition, and the author compares and contrasts these two approaches. Erikson advocated a more cautious attitude regarding the analyst's subjectivity, while Bion promoted a broader application of the analyst's various private reactions to the analysand. A brief vignette from the analysis of a five-year-old boy is offered to illustrate the importance of the analyst's reveries, the mutual process of containment and transformation between analyst and patient, and the co-creation of an analytic narrative.     

At Death's Door: Therapists and Patients as Agents

This paper explores the interrelationship between patients' exercise of will to make advances in an analysis and their readiness to forgive their analysts for their human limitations. There is a thin line between idealization of the analyst, probably a necessary component of the process, and resentment of the analyst for his or her privileged position in the world and in the analytic situation itself. The patient's “progress” emerges as a kind of reparative gift, one that implicitly overcomes the patient's tendency to withhold such change out a sense of chronic, malignant envy. Particularly poignant in terms of its potential to elicit the patient's reparative concern is the situation in which the analyst is struggling with his or her mortality because of aging or life-threatening illness. In this essay two clinical vignettes are presented to illustrate some of the issues that this situation poses. One begins with an elderly patient appearing at the door of the analyst's (the author's) home the day of his return from the hospital after coronary bypass surgery. The other begins with an analyst who is terminally ill appearing at the door of a patient who is threatening suicide. The two stories are compared in terms of their implications for human agency, the exercise of will, and the coconstruction of meaning in the face of mortality in the analytic process.     

Phallic Integration and Male Identity Development

The analytic setting as well as the analyst's initial communications unavoidably exert influence that may be perceived by the patient as a sexually tinged intrusion, which evokes questions about what the analyst wants. Together with the asymmetry of the analytic relationship, these phenomena uncannily bring to life a repressed relationship between infant and adult in which analogous stimuli constitute enigmas for the child. The theoretical understanding of Jean Laplanche of such enigmatic transference in terms of “primal seduction” is reviewed and clinical material is provided to illustrate Laplanche's ideas. The discussion addresses “recentralized” and “decentralized” aspects of sexuality. Primal seduction is discussed as including not only intrusion, but also qualities of stimulation and trust.     

Creativity,Spontaneity, Impasse,and Leaps of Faith: Reply to Commentaries

In my reply to the commentaries, I address several points of convergence with and divergence from Drs. Danielle Knafo and Philip A. Ringstrom. I clarify my view that while shame can drive the creative process, the thrust of my paper is about ways in which shame can close down access to one's creative potential, as well as creating obstacles to vitality and intimacy in relationships. I expand on how it was indeed a visceral, embodied sense of my own shame which served as an “informant,” as Ringstrom suggests, of Julia's chronic experience of shame, opening a door to our exploration of the repetitive enactments between us. Grounding my understanding of therapeutic action and enactments in a relational perspective, I describe how I view enactments as inevitable and co-created, and reflecting on them collaboratively as a potentially useful opportunity in analytic work. I resonate with Ringstrom and Knafo's belief in the creativity inherent in the psychoanalytic process, and the importance of spontaneity and risk taking, particularly in negotiating impasses in treatment. Finally, I describe Julia's poetic reflections upon reading the paper.     

“Expanding the Frame”: Reply to Commentary

In responding to a discussion by Susi Federici-Nebbiosi of “When the Frame Doesn't Fit the Picture,” I further consider the ways in which analysts and analysands together create the best conditions for their work. I emphasize that analytic work best fulfills its potential when it grows out of a collaborative search for ways of constructing the psychoanalytic situation that are most fully and subtly responsive to the unique qualities and circumstances of each patient and analyst. Implications for psychoanalytic training of an intersubjective model of frame construction are briefly considered.     

Moments of Therapeutic Impasse: Commentary on Jody Messler Davies's “Whose Bad Objects Are We Anyway? Repetition and Our Elusive Love Affair with Evil”

Davies contributes to the development of relational theory by formulating and illustrating what occurs during especially difficult moments in an analytic exchange. In understanding enactments, Davies importantly underscores the contribution of both the analyst's and patient's “bad objects.” This author attempts to build bridges between Davies' language and concepts anchored in object relations theory and this author's language and concepts based in contemporary or relational self psychology, including the integration of cognitive psychology. In addition, this author delineates the use of the “empathic,” “othercentered,” and “analyst's self” listening/experiencing perspectives to explicate the case material and to provide alternative understandings and pathways for psychoanalytic work. The thesis set forth is that the use of different listening/experiencing perspectives expands choice for the analyst when working in difficult moments of the clinical exchange.     

Narrative Writing and Soulful Metaphors Commentary on Paper by Barbara Pizer

The author posits that Pizer's use of both narrative and lyrical style is not typical in psychoanalysis, whose scholarly tradition tends to favor a denser, more academic style of writing. The ways in which psychoanalysts read these two forms of writing are mirrors of one another. Both kinds of reading are forms of discipline; both forms of writing are necessary in psychoanalysis. The author also writes that Pizer's “nonanalytic third” does not have to be a “good” thing like a poem; it can be almost anything important to the analyst. The nonanalytic third is a soulful metaphor that can be used to create alternatives to rigid experience. Because rigidity in psychoanalytic relatedness is usually the result of problematic unconscious involvements between analyst and patient, the nonanalytic third can be significant in the negotiation of enactments.     

Affective Honesty and Compassion Come in Many Forms: Discussion of “Love (and Hate) With the Proper Stranger: Affective Honesty and Enactment,” By Holly Levenkron,L.I.C.S.W.

Holly Levenkron's work with her patient, Ali, beautifully illustrates one way that a creative analyst makes superb use of her own experience to communicate and negotiate with great affective honesty. Holly's analytic style emphasizes the effective use of a particular kind of self-disclosure and a way of thinking about intersubjectivity and enactment associated with the contemporary Relational movement. Yet, it may be Holly's personal willingness to allow the analytic relationship to profoundly destabilize and influence her that most engages Ali in their work.

An imaginary analytic scenario is described with an analyst, Dr. X, who like Holly is destabilized by Ali but whose thinking about intersubjectivity and enactment emphasizes an empathic immersion in Ali's experience of the analytic relationship. In contrast to Holly, Dr. X focuses primarily on grasping and interpreting the adaptive strivings that animate Ali's differently organized subjective world.

The underlying capacity to acknowledge and use the analyst's own version of the patient's issues may also characterize analyses such as that of the hypothetical Dr. X—in style that are more explicitly “interpretive” (less confrontative) than Holly's work. These two contrasting approaches highlight the wide range of ways to think about intersubjectivity, enactment, and affective honesty in the analytic process.