The analytic process in psychoanalysis and psychotherapy: from the interpersonal to the intrapsychic level

The current debate over the conflicting interpersonal and intrapsychic views of the analytic process may or may not help us to distinguish between psychoanalysis and analytic psychotherapy. A comparison of psychoanalysis in the English-speaking world--especially in the United States--with French psychoanalysis reveals the features that unite and at the same time divide these different psychoanalytical tendencies, both of which are the heirs to Freud's thought, in terms, in particular, of the setting (couch and chair) and of technique (interpretation, transference analysis and technical neutrality). Whereas all psychoanalytic work belongs within the framework of an interpersonal relationship, that relationship becomes meaningful only when linked to the intrapsychic dimension, which alone can open the way to the unconscious and to infantile sexuality.     

The goal as process: music and the search for the Self

This paper explores and compares the processes of music and analysis from the author's experience as a musician, piano teacher and analyst. It explains how the use of music improvisation in analysis (with simple percussion instruments) can powerfully enhance the dialogue between the unconscious and conscious psyche, as well as deepen the relationship between analyst and analysand. This is connected theoretically to Jung's active imagination and Winnicott's concept of play within the analytic encounter. Finally, the question is raised whether analytic trainings could do more to expose trainees to the possibility of using music within the analytic encounter. This touches on the more basic and controversial issue (which often separates analytical psychology and psychoanalysis) of whether expressive therapy should be used in analysis at all.     

The analyst's countertransference to the psychoanalytic process1

There is countertransference, not just to individual patients, but to the process of psychoanalysis itself. The analytic process is a contentious topic. Disagreements about its nature can arise from taking it as a unitary concept that should have a single defi nition whereas, in fact, there are several strands to its meaning. The need for the analyst's free associative listening, as a counterpart to the patient's free associations, implies resistance to the analytic process in the analyst as well as the patient. The author gives examples of the self‐analysis that this necessitates. The most important happenings in both the analyst's and the patient's internal worlds lie at the boundary between conscious and unconscious, and the nature of an analyst's interventions depends on how fully what happens at that boundary is articulated in the analyst's consciousness. The therapeutic quality of an analyst's engagement with a patient depends on the freeing and enlivening quality, for the analyst, of the analyst's engagement with his or her countertransference to the analytic process.     

On “That Is Not Psychoanalysis”: Ethics as the Main Tool for Psychoanalytic Knowledge and Discussion

“That is not (or that is) psychoanalysis” is a statement that, more often than not, can only remind us that psychoanalysis is divided into many schools and that discussion among them is difficult if not impossible. This will always be the case as long as analysts hold to their respective ontological definitions as if these were impervious to the laws and, most important, to the Ethics of translation. In psychoanalysis our Ethics and our Epistemology are two sides of the same coin, inseparable from our know-how. Our ethical stance is what allows (or impedes) central psychoanalytic facts to be brought into daylight. This principle applies both in the analytic room and in the room where analysts from different schools try to hold a productive discussion. In both instances “translation” is necessarily incomplete; it is therefore recommended to start by looking for the missing part.     

Vicissitudes of ideas of cure in analysands and their analysts: a longitudinal interview study

This longitudinal prospective study focuses on analysands' and analysts' implicit ideas of how psychoanalysis might help analysands' psychological problems. Seven analysands and their analysts were periodically interviewed. Single ideas of cure from 75 interviews were inductively categorized. Nine distinct types of cures emerged, representing the wished-for goals of psychoanalysis, as well as the actions to achieve the wished-for changes. Each category might comprise more or less utopian ideas of wished-for cure as well as ideas of an attainable, more limited cure, or combinations of these. The utopian ideas of wished-for cures persisted throughout the psychoanalytic process for more than half the analysands and analysts. The abandonment of these ideas was related to the experienced outcome of psychoanalysis. The relation between the theories of one analysand and her analyst is explored in depth in a case study with special emphasis on the analytic process. The study suggests that the psychoanalytic process might profit from the analyst's observance of such incongruities and an openness to work through them.     

Comments on the Ikonen and Rechardt papers on the death drive and the origin of shame

In this paper, psychoanalysis is viewed as a method in opposition to the reigning spirit of our age with its demands for fast and measurable results. The concept ?the psychoanalytic room” is introduced in order to grasp the uniqueness of psychoanalysis and how it distinguishes itself from what is ordinarily held to be included under the category of work. The psychoanalytic room is explored in both a concrete and metaphoric sense and is discussed in relation to the concept of time, reality, Ogden's concept of the analytic third, and, inspired by Winnicott, children's play. The playroom of the child and its similarity with the analytic room is illustrated by the book ?Benny's Bathtub” by the Danish author Flemming Kvist Møller.     

On teaching psychoanalysis

Teaching psychoanalysis is no less an art than is the practice of psychoanalysis. As is true of the analytic experience, teaching psychoanalysis involves an effort to create clearances in which fresh forms of thinking and dreaming may emerge, with regard to both psychoanalytic theory and clinical practice. Drawing on his experience of leading two ongoing psychoanalytic seminars, each in its 25th year, the author offers observations concerning (1) teaching analytic texts by reading them aloud, line by line, in the seminar setting, with a focus on how the writer is thinking/writing and on how the reader is altered by the experience of reading; (2) treating clinical case presentations as experiences in collective dreaming in which the seminar members make use of their own waking dreaming to assist the presenter in dreaming aspects of his experience with the patient that the analytic pair has not previously been able to dream; (3) reading poetry and fi ction as a way of enhancing the capacity of the seminar members to be aware of and alive to the effects created by the patient's and the analyst's use of language; and (4) learning to overcome what one thought one knew about conducting analytic work, i.e. learning to forget what one has learned.     

The edge of chaos: A nonlinear view of psychoanalytic technique

The field of nonlinear dynamics (or chaos theory) provides ways to expand concepts of psychoanalytic process that have implications for the technique of psychoanalysis. This paper describes how concepts of “the edge of chaos,” emergence, attractors, and coupled oscillators can help shape analytic technique resulting in an approach to doing analysis which is at the same time freer and more firmly based in an enlarged understanding of the ways in which psychoanalysis works than some current recommendation about technique. Illustrations from a lengthy analysis of an analysand with obsessive‐compulsive disorder show this approach in action.     

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.     

Relational-oriented character analysis

Referring to the diversity of psychoanalysis of today, a position called relational-oriented character analysis is discussed. It is stated that relation and character as concepts refer to different and partly contradictory points of view in psychoanalysis, the first one emphasising mobile, dynamic aspects of personality, the second underlining stable, structural aspects. The principle aim of the article is to argue how the two perspectives can be theoretically combined in an overriding object-relational (two-person) conception and to discuss some implications for analytic technique. Finally, convergences and differences with other positions or schools in contemporary psychoanalysis are suggested.     

Pichon Rivière's psychoanalytic contributions: Some comparisons with object relations and modern developments in psychoanalysis

Enrique Pichon Rivière's work, fundamental to Latin American and European psychoanalytic development, is largely unknown in English‐language psychoanalysis. Pichon's central contribution, the link (el vinculo), describes relational bonds in all dimensions. People are born into, live in, and relate through links. Psychic structure is built of links that then influence external interaction. Links, expressed in mind, body and external action, continuously join internal and external worlds. Links have two axes: vertical axis links connect generations through unconscious transgenerational transmission; horizontal axis links connect persons to life partners, family, community and society. For Pichon, treatment constitutes a spiral process through which interpretation disrupts existent structures, promoting new emergent organizations at successively deeper levels. Psychic and link structures evolve over time unless repetitive cycles stunt growth. For Pichon, transference is constituted in the here‐and‐now‐with‐me because of the analytic link. Pichon also undertook family and group psychoanalysis where individuals become spokespersons for unconscious links and family secrets. He developed operative groups that apply psychoanalysis to both analytic and non‐analytic tasks. After describing Pichon's major contributions, the paper compares Pichon Rivière's ideas with those of Klein, Fairbairn, Bion, Winnicott and Bowlby, and contemporary writers including Ogden, Kaës, and Ferro whose works echo Pichon Rivière's thought.     

Editorial

Abstract

This paper will examine the current crisis in psychoanalysis in terms of the profession's decline, the apparent lack of patients, the ongoing debate over what constitutes psychoanalysis versus other therapies, and the lack of clinical focus in those debates. The concept of analytic contact will be introduced, and clinical material is used to showcase this concept as a bridge from the circular political debates to a more meaningful examination of what is psychoanalytic. In addition, case material will explore how patients tend to fight off the establishment of analytic contact in favor of safer, less threatening modes of relating. The author suggests that most patients fight off analytic contact and try to shift the treatment into something less analytic. It is up to the analyst to detect this, interpret it, and notice any countertransference collusion that may occur. Although the state of psychoanalysis as a profession is less than stellar in the eyes of the public, and the profession is apt to sabotage itself with endless debates about what constitutes true analytic work, the end is not necessary near. This paper proposes analytic contact to be the more useful focus of research and productive area of clinical exploration. If the decline of our field is to turn around, it will be on the clinical battlefront, not in terms of the theorizing among disagreeing groups of territorial analysts afraid of losing their political high-ground. The concept of analytic contact assumes that a deep exploration of intrapsychic phenomena, conflicts, and defenses, all within the realm of the transference, is the best clinical method of helping the mentally troubled individual. This genuine chance of change is best administered by a trained psychoanalyst. This simple idea is something the profession has contaminated with its often pointless arguments over frequency, analyzability, couch, and so forth. The clinical material will show that what happens in the room between analyst and patient is what best defines the true psychoanalytic treatment.     

The patient's part in analytic process: the influence of the analyst's expectations.

The psychoanalyst's expectations of the patient are complex and crucial to the work of analysis. These expectations, operating at a level generally outside the consciousness of patient and analyst, are part of the "microstructure" of analysis, the interactional give-and-take that brings about change. The view taken here is that analytic process is necessarily interactive, as well as intrapsychic. In addition to transference-countertransference motivations, both parties to an analysis operate in a social context that prescribes a range of desired and undesired behavior. The analyst brings to the interaction professional analytic attitudes about how to listen and act, and a set of expectations of the patient. These attitudes and expectations modulate subjective reactions to the patient's transferentially driven actions, and influence the expression of countertransference. The mutative process of psychoanalysis involves the action of these attitudes and expectations on the patient, both in ways specific to individuals and in more general ways. Such expectations lie behind analytic tactics and, though not often written of, are part of the oral tradition of psychoanalysis. Here the expected patient role is described in terms of five bipolar continua: (1) reporting and editing; (2) transferring and containing; (3) thinking about oneself and thinking about the analyst; (4) regressing and listening/self-observing; (5) initiating trial action and mediating among inner states. The activity and thinking of the dyad move constantly along these continua. A clinical example from the beginning of an hour illustrates how these expectancies emerge in analytic work.     

On Learning to Inquire: Revisiting the Detailed Inquiry

This paper describes the author's experience of initial disorientation when encountering for the first time in supervision an interpersonal analytic approach with an emphasis on active questioning of the patient through the use of a detailed inquiry. This initial disorientation is linked to a predominant trend in psychoanalysis that generally opposes the use of questions as a significant means of analytic interaction. In contrast, Interpersonal approaches that make free use of inquiry are discussed in light of the author's clinical experience that learning to inquire contributed to a more finely tuned awareness of the analytic process.     

The analyst's anxieties in the first interview: Barriers against analytic presence

To answer the questions: why don't more people enter analysis and how do we get more people to do so? Attention is drawn to anxieties in the analyst that become obstacles to the initiation of analysis. The main focus of the paper is how to understand why analysts, irrespective of patient characteristics, seem to have resistances against embarking on analysis. Being a meeting between strangers the consultation activates strong emotional reactions in both parties. One way of coping is defensively to diagnose, assess and exclude instead of being present as an analyst. The analytic frame of a consultation is ambiguous, and a secure analytic function is needed in order to meet the openness and unpredictability of this frame. A fragile psychoanalytic identity is seen as central to analysts' failure to create an analytic practice; it takes years to develop and maintain a robust analytic function, and analytic work continues to cause disturbing emotional reactions in the analyst. Analysts' vulnerable identity is also linked to the history of psychoanalysis that has fostered an ideal of analytic practice that is omnipotent and impossible to reach. Therefore it is no wonder that attempts to reach a convinced recommendation of analysis can become diverted in the process of consultation. Confronting these inner impediments in order to strengthen the analytic identity is suggested as a better way to get more analytic patients than to keep looking for so‐called analysability in patients.     

Chestnut Lodge and the psychoanalytic approach to psychosis

The study of psychosis has a long history in psychoanalysis, as does the debate over the suitability of psychoanalysis for treating schizophrenia. For decades, Chestnut Lodge was not only a hospital but also a clinical research and educational institution. A unique patient-staff ratio--about twenty analytic therapists for a hundred patients--made possible prolonged and intense clinical work with schizophrenic and other severely disturbed patients. Interstaff discussions were encouraged and facilitated. This quasi-academic approach to in-depth individual case studies led to clinical findings and theoretical formulations that had a significant impact on developments in psychoanalysis, both here and abroad. Many of these findings and theoretical formulations are relevant to current studies and treatments of psychotic and nonpsychotic patients.     

Seeking an Analytic Identity

Abstract

Rothstein has stimulated all analysts to rethink how we can better commit ourselves to our analytic work. In this paper I focus on factors in analysts' personalities and experiences in their training and practice that contribute to or distract from establishing an analytic identity.

First, I explore analysts' background and motivation. In admissions to psychoanalytic institutes we look for candidates who can see psychoanalysis as an intellectual puzzle to be solved and an emotional involvement to be experienced. We look for earlv conflicts that the candidate can sublimate in the service of analytic functioning. We assume that the capacity to sublimate is only partial and that analysts in their development continue to recognize conflicts in transference—countertransference reactions.

Second, I give some examples of experiences from analysts' training that stimulate the formation of their analytic identities. These include transient identifications and counter-identifications with the training analyst, supervisor, seminar leader, and favorite analytic authors.

Third, I discuss more external factors that influence the development of analytic identity. These include the climate in training and continuing education at the institute. How much does the institute support its members in immersion in psychoanalysis? Economic factors continue to he an important factor in determining individual choice in this immersion.

Finally, I review studies on the effectiveness of psychoanalysis. Dedicated analysts with considerable experience believe that analysis works despite some limitations. Part of high motivation to continue analytic work includes understanding how analytic results differ from the simpler solutions achieved by nonanalytic therapies.     

Clinical issues in analyses over the telephone and the internet

There is professional consensus that teleanalysis, the practice of psychoanalysis conducted remotely using the telephone and the Internet, is increasing in response to more mobility in the population. But there is controversy as to whether the use of technology leads to a dilution of analysis or to adaptive innovation that is clinically effective and true to the tenets of psychoanalysis. The author reviews the psychoanalytic literature and shows the development of analytic thinking about this technology-assisted practice of psychoanalysis. She summarizes analysts' perceptions and experiences of the advantages and disadvantages, and considers the indications and contra-indications. She focuses on the clinical concerns that arise in terms of the frame, resistance, and the development of analytic process through the unconscious communication of internal objects, unconscious fantasy, transference and countertransference. She gives vignettes from the analysis of a man with trauma-related depression to address the concerns raised and to support her argument that analysis using the telephone and the Internet is a viable, clinically effective alternative to traditional analysis where necessary.