Distinction between mental pain and psychic suffering as separate entities in the patient's experience

Abstract

Mental pain and psychic suffering are herein defined as two separate concepts in psychoanalysis. The concept of mental pain lies at the core of psychoanalysis; it was introduced by Freud and was further elaborated by a number of investigators, mostly by Bion. Mental pain refers to a pain that the patient reports as being impossible to describe in words, and lacking any associations, whereas psychic suffering can be both named and described by the patient. Mental pain is derived from non-tolerance on the part of the psychic apparatus when it is harmed by very painful emotions. In contrast to psychic suffering, mental pain resists elaboration and transformation by dream-work. How to address and transform the patient's mental pain is a major challenge facing the analyst in his clinical work because mental pain may halt or slow the progression of the analytical process. To overcome this hindrance, the work of the analyst is focused on helping patients to modify their mental pain into psychic suffering, that is, to reactivate in the patient the chain of transformations that generates thought. The analyst is also challanged with the mental pain of the patients because he has himself to tolerate the mental patient induced by counter transference. Suggestions for the analyst on how to deal with the mental pain of the patient during psychoanalytic therapy are proposed.     

Thinking Developmentally in Child and Adult Psychoanalysis

Psychoanalysis in theory and clinical practice is a developmental domain. Psychoanalysts think about their patients from a developmental point of view. The analytic relationship promotes development in both analyst and patient. Two concepts central to this author’s developmental point of view are epigenetics—as used in biology and philosophy—and that of the analyst as “developmental object.” Optimally, the analyst as developmental object facilitates what Rita Tähkä terms the “developmental illusion,” which intersubjectively transforms psychic structures, enabling alternatives to the repetition compulsion. Two vignettes with adult patients illustrate how empathic intimacy in psychoanalysis with an emphasis on latency and toddler phases as reconstructed in adult analysis presaged psychic growth. Transference as a vehicle for a developmental history taking is also considered.     

Critical realism: distinguishing the psychological subjectivity of the analyst from epistemological subjectivism

To clarify the concepts of critical realism, subjectivity, and subjectivism, distinctions are drawn among ontological subjectivism, moral subjectivity, psychological subjectivity, and epistemological subjectivism. Psychological subjectivity, including the ongoing affective life of the analyst, is an essential aspect of the analyst's response to the patient, and may either facilitate or distort an adequate observation of transference and countertransference dynamics and of the psychic reality of the patient. Subjectivism in current psychoanalytic literature involves an argument that there is an "irreducible" subjectivity in the analyst, who is bound to see things from an incorrigibly personal point of view, such that there is no substantial subject-object differentiation between analyst and patient. Issues of authoritarianism in the analyst, or of pathological certainty, should not be confused with the issues of epistemological objectivism. The concept of critical realism or scientific objectivism includes the essential idea that there is no pure knowledge, no complete knowledge, that often evidence is insufficient for knowledge of some aspect of nature, and that care must be to taken understand what is sufficient knowledge in a given area, in this case clinical psychoanalysis. The question is raised whether "projective identification" makes the sorting out of "what comes from whom" impossible. It is argued that when free association is sufficiently facilitated, when there are enough corrections of the distortions wrought by transference and countertransference, when defenses are analyzed, and when sufficient subject-object differentiation is recovered, the analyst can get to know enough of the patient's psychic reality for the therapeutic and scientific purposes of psychoanalysis.     

The Preservation and Transmission of Cultural Values and Ideals: Challenges Facing Immigrant Families

At this time in the history of psychoanalysis, few would question the influence of cultural factors on one’s psychic life. This influence is most obviously present in the lives of immigrant families. This article focuses on some of the issues related to the efforts immigrant parents make to transmit cultural values they had acquired in the old country while their adolescent children are exposed to a very different cultural value system in the United States. Following the theoretical discussion that cultural factors (values and ideals) have in psychic life, two clinical examples draw attention to the way cultural issues may play a role in the treatment of symptomatic adolescents in immigrant families.     

Analyst Envy in Working With an Artist: Four Scenes

The paper describes a rich analytic relationship with an artist patient in which countertransference feelings of envy surfaced. The analyst's examination of her envy led to a review and reassessment of the concept of envy in psychoanalysis. I propose here that envy is a complex affect that moves on a continuum from a fairly benign combination of admiration and desire to more malignant emotional states, described by Melanie Klein and her followers. Malignant envy may lead to anger, fury, and murderous rage. A more benign form of envy, which emerged for the analyst in the treatment, resulted in psychic support for and validation of the patient as well as a shift in personal identifications and new motivational directions for the analyst.     

The questions and curiosity of the psychoanalyst

Questions the analyst asks of the patient are a powerful but neglected aspect of the theory of psychoanalytic technique. Their importance resides in their dynamic impact on the psychic equilibrium of the patient because of their ability to destabilize existing compromise formations. A clinical vignette illustrates the view that the linguistic shift from other modes of discourse to the spoken question heralds a less visible parallel shift in the psychic equilibrium of either the psychoanalyst or patient. There is no more and no less complexity to questions than to any other communication by either analyst or patient. For that reason there can be no systematic classification of questions in the clinical psychoanalytic situation, just as there can be no definitive taxonomy of psychoanalytic discourse. It makes no sense to reduce the enormous diversity and range of all the questions the analyst asks to the simple dichotomy of good or bad for the analysis. Questions are the emblem of the analyst's mode of inquiry; they can further the development of self-observation, which is such an important concomitant, cause, and consequence of structural change.     

Faith as the Fulcrum of Psychic Change: Metaphors of Transformation in Jewish Mysticism and Psychoanalysis

This paper examines the role of faith in transformation, proposing that faith, on the part of the patient as well as the analyst, is the turning point of psychic change. It uses the metaphors of transformation of the Jewish mystical tradition as an organizing framework with which to consider the transformational experience within psychoanalytic process and the evolving view within psychoanalysis of the relationship between analyst and analysand as one of asymmetry and mutuality. It posits faith as a mutual yet asymmetrical stance within the psychoanalytic relationship of intersubjective, mutual recognition. In faith, one opens to the possibility of the transcendent Third, an experience of union with a larger whole from which one emerges with a sharper sense of one's authentic truth.     

Notes for a dialogue between psychoanalysis and neuroscience1

The author postulates that the dialogue between psychoanalysis and neuroscience is based on the assumption that both deal with virtual structures. They are two facets of the same noumenal reality, but with different phenomenal realities, and it is possible to use metapsychology as a lingua franca to develop communication between the two fi elds. In the second part of the paper, the author refl ects on the results of recent neurophysiological research which seem to offer to psychoanalysis possibilities for fi nding an anatomical‐physiological correlate of some well‐known psychic phenomena and mechanisms, such as imitation, introjection, identifi cation, empathy, identity, mother‐child communication, learning, social communication and the analyst‐patient relationship. Particular neurons, called mirror neurons, have been located in the F5 area of baboons' brains. They are also present in man's brain within Broca's area. These neurons activate our motor system during both the performance of actions and the observation of actions performed by others giving rise to an automatic response, a sort of simulation or, rather, imitation, as the process is not intentional, but automatic and unaware, that is, unconscious.     

Becoming (and Remaining) an Analyst in Latin America

The following overview of the development of psychoanalysis in Brazil and in Porto Alegre outlines the current situation and the challenges to psychoanalysis in my country. I will explain my own experiences on becoming an analyst, the main reasons for my choice, my main influences, and my evolution as a clinical psychoanalyst and as a member of psychoanalytic and psychiatric institutions. I include my main contributions to psychoanalysis and consider two broad areas of interest: psychoanalytic technique and its teaching, and the relationship of psychoanalysis and culture. As for the former, my main interests are studies on countertransference and analytic neutrality, to which I will propose a comprehensive concept. As for the latter, I discuss a culture that contrasts vividly with the one in which Freud created the discipline, psychoanalytic views on violence and perversity, psychoanalytic institutions, and the application of analytic ideas for the understanding of some artists and their work.

I will also describe some general features of my country and the development of psychoanalysis in it; report my experiences as a candidate and an analyst; and offer some information about my evolution as an analyst through papers I have written over the past 30 years.     

Invited commentary on the interview with Jan Stensson

Abstract

The potential of psychoanalysis as social criticism is explored in the context of the major social divides of gender, sexual orientation, race, social class, and ethnicity. It is argued that these divides play central roles in constructing individual psyches, and that their influence is inseparable from other social/ familial forces. Further, analyst and patient alike, inevitably enact the imperatives of class, race, gender, and sexuality in the analytic dyad. It is crucial that psychoanalytic theory be extended to account for the formative power of these cultural categories both in the construction of individual identity, and on the course of analytic work. Further, individual psychoanalysts must be aware of cultural countertransference in the analytic engagement. Finally, as a profession we have an obligation publicly to oppose the destructive imperatives of our economic, political, and social systems in the interest of individual and community psychic well-being.     

Philosophical assumptions in Freud, Jung and Bion: questions of causality

The historical development of concepts of causality in philosophy is described. Since the Enlightenment and the growth of science, exponents of the two most important concepts, determinism and teleology, have been in conflict. At the inception of psychoanalysis at the end of the nineteenth century this conflict was particularly intense. It was the cause of the first major schism in psychoanalysis between Jung and Freud. Psychoanalytic theorists have continued to disagree over this issue. Post-modernist philosophy has abolished all metaphysics and therefore called into question concepts of psychic causality. Parallel to, but uninfluenced by this development, Bion has developed a psychoanalytic conceptualization which may be seen as transcending causality. The clinical and theoretical implications of these developments are described.     

Psychic reality in the psychoanalytic process.

The case is made for regarding psychic reality as synonymous with subjective (conscious) experience, which is inherently open to, but not reducible to, unconscious determinants. Both analyst and analysand engage in the analytic relation and interaction from the perspective of their respective psychic realities. Thus, components of the analytic relation--transference/countertransference, alliance, and real relation--are forms of psychic reality. The tensions of subjectivity and objectivity are discussed in relation to the analytic situation, especially with regard to whether the patient's or the analyst's psychic reality is to be given priority or preference. The same reality, situation, or relationship can be viewed from different perspectives and subjected to varying interpretations without any one being exclusively true or false-each may be partially true and/or partially false. The patient's recounting of his history is a part of the patient's psychic reality that intersects with a necessarily divergent account constructed by the analyst. The ensuing dialogue seeks a form of real coherence that is mutually realistic and makes realistic sense for both parties. Reliance on subjective psychic reality becomes a possible, but precarious and potentially misleading, basis for analytic understanding without other observational (verbal and behavioral) or objective data.     

Being a psychoanalyst: An everyday audacity1

This paper is the work of fi ve psychoanalysts who came together as a group in order to refl ect on their work as analysts. How are we analysts to identify the unconscious resistances that may sometimes hold us back from offering psychoanalysis to some patients? Do these resistances sometimes hamper the inner freedom that we require in order to maintain a psychoanalytic focus once that process is under way? How do we manage from time to time to overcome these resistances or, better, make use of them in order to develop our understanding of the unconscious dynamics that create the link between analyst and patient? The authors discuss these issues with particular reference to clinical situations taken from classic psychoanalytic treatment cases during which the analyst had to fi nd within him‐ or herself the audacity to be a psychoanalyst. Each clinical situation is different: preliminary interviews, in the course of the actual treatment, issues that emerge in the training of candidates. One of the signifi cant features of this group lies in the fact that the participants are at different stages in their development as psychoanalysts (student, associate member, full member, training analyst). This means that their experiences complement one another and encourage a discussion of issues such as how psychoanalysis can be passed on, and the relationship between supervisor and supervisee.     

Fried and Freud on the Acropolis; on duality in the base of psychoanalytic thinking

Freud was conflicted in relation to his religious background. On the one hand, he was very clear on his adherence to a scientific Weltanschauung. On the other, he was fascinated by the Moses figure and one may see a Judaist structure in his way of thinking. The aim of this paper is to reflect on this conflict and the question of faith in psychoanalysis. After looking at object and method in religion and psychoanalysis, the authors go into the concept of ‘psychic reality’ and its change in the history of psychoanalysis. Through an analysis of Freud’s A Disturbance of Memory on the Acropolis and the function of literature, it is claimed that faith may be seen as a condition for the sense of experiential reality.     

Death Is Nothing at All: On Contemplating Non-Existence. A Relational Psychoanalytic Engagement of the Fear of Death

This paper engages the secular mind’s struggle with mortality from a relational perspective. It critically reviews the legacy of Freud’s refusal to grant mortality psychic significance and the ways in which the fear of death has consequently been understood theoretically and addressed clinically. Analytic omnipotence is foregrounded as an impediment to the kind of intersubjective engagement that minds need from other minds in grappling with the loss of the self through death. A clinical illustration is used to explore the ways in which the analyst found himself relating with a patient around her extreme fear of death, which over the course of treatment became modified into a more bearable anxiety about her own mortality. A conceptual framework is offered to account for these changes, emphasizing the analyst’s personal relationship with mortality as a crucial variable in how the fear of death is engaged psychoanalytically. The author calls for a revisionist psychoanalysis that allows for death’s centrality in both theory and practice.     

The so-called rule of abstinence revisited

The paper discusses whether the rule of abstinence is still valid in the contemporary theoretical arena of psychoanalysis. Not only is this a debate on principle. It also raises the question of how gratifying the analyst should be in the analytic encounter, still remaining within the psychoanalytic paradigm. Current criticisms of the concept of abstinence are reviewed. The author replies to the objections. He argues that the so-called rule of abstinence is not a “rule” which describes the particular behaviour of the analyst, but a general principle describing the essence of the psychoanalytic cure. In the opinion of the author, abandoning this principle may have detrimental consequences both theoretically and technically. Finally, the author discusses the emotional presence of the analyst in the analytic setting and suggests an updated version of the idea of analytic abstinence.     

The Ties That Bind

In this paper, I define a psychoanalytic object broadly, as an object that “matters” to an individual. My focus is on how someone becomes a psychoanalytic object and how our ideas about this process lead us to a particular conception of an analyst’s mutative role. Further, I examine the function of a psychoanalytic object in one’s inner world. One view of the object leads to a “dynamic” emphasis, examining the object’s role in a system of unconscious conflict and compromise, whereas a second, overlapping line of thought leads to a “structural” focus, emphasizing the object’s role in developing, stabilizing, and often maintaining compromised internal psychic capacities. These capacities are developmental achievements that form the context of conflict and compromise. Dynamic and structural emphases lead to different clinical stances. In considering the object and evolving conceptions of the object within Freudian psychoanalysis (my focus), we simultaneously review the evolution of Freudian psychoanalysis itself.     

Psychic Truth and the In-Session Work of the Analyst

I seek to address one of the issues most affected by the postmodern culture, such as the crisis of rationality and truth, and try to reformulate its place within the psychoanalytic clinic using the contributions of Freud and Ferenczi, who drew the matrix of a passionate dialogue about the truth and the analyst work that has nurtured many contemporary theoretical developments. Essentially, the major influences of postmodern thought in psychoanalysis are to emphasize the importance of the patient–analyst interaction, the role played by the analyst in the patient’s transference and the rejection of the model of the analyst as a distant observer who interprets without having anything to do with whatever happens within the mind of the patient. Consequently, because both postmodernism and psychoanalysis are concerned with human subjectivity and love for truth, although indeed understanding them from different perspectives, both schools of thought become easily interrelated. I conclude that psychoanalysis, committed as it is with the search for truth, cannot ignore the influence of postmodern thought, as well as the postmodernist movement should not disregard all theoretical consistency provided by psychoanalytic theory and metapsychology.     

Vulnerability,Resilience, and Surviving Destruction: Discussion of “The Analyst’s Experience of Trust and Mistrust”

In this response to Danielle Novack’s intellectually astute and clinically rich paper on the “analyst’s trust,” I reflect on the valuable ways in which Novack elucidates this undertheorized aspect of the analyst’s experience and reconfigures trust/mistrust as a meaningful intersubjective dimension of the therapeutic relationship. Novack shows how attending to shifts in trust/mistrust can provide valuable clues for deciphering the transference/countertransference. While I strongly agree with her construction of trust as a psychoanalytic achievement, I question the notion that the analyst’s trust is a necessary condition for her participation. Novack’s work on the analyst’s trust joins a broader contemporary conversation about potential overreaches in the relational paradigm, which I discuss. Finally, I consider the implications of Novack’s work for specifying the factors that underly resilience and engaging a conversation about surviving destruction in contemporary relational psychoanalysis.