The role of reality testing in psychoanalysis: followup of 22 cases

As part of a prospective, longitudinal study of psychoanalytic outcome, 22 patients were evaluated for changes in their level of reality testing. These patients had been accepted for supervised psychoanalysis with candidates in training by senior analysts who had diagnosed them as neurotic. Psychological tests given prior to the beginning of analysis indicated, however, that more than one third of our sample demonstrated serious distortions in their perceptions of reality. When psychological tests administered one year after the completion of analysis were compared with these pretreatment tests, no significant improvement was found in the level of reality testing for the group as a whole. However, when excluding two patients who had suffered major traumas in the year following psychoanalysis, significant improvement in reality testing was found for the remaining 20 patients. Post-treatment interviews with the treating analysts revealed that in the course of analysis itself, approximately one third of these patients showed some disturbance in reality testing; only three of these patients showed significant improvement in the level of their reality testing during treatment. These findings suggest that while patients may not present clinically with evidence of impaired reality testing, such evidence may be available in psychological testing, and may become apparent in the course of the treatment.     

PROSPERO'S PAPER

The writer proposes that the interplay between the hermeneutics of psychoanalysis and literature can illuminate understanding of the transference and countertransference at large in an analytic treatment. Writing about the work with a young woman who had been persistently sexually abused as a child and who developed anorexia in her adolescence so severe that her life was endangered both by the illness and by attempts at suicide, the author finds his reading of Shakespeare's The Tempest a powerful informant to the work. Interpreting the object relations represented by Prospero and Miranda and the process of their integration into new mental structures lends the analytic work an additional level of understanding, in particular in relation to the oedipal bond between patient and analyst. When the analyst is confronted by the imminence of his own death towards the end of the analysis, his reading of Prospero's relinquishment of his magical powers and his release of his daughter into sexual maturity and independence helps the patient to replace her destructive inner objects with more reparative and benign ones as she develops a capacity for concern and mourning.     

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.     

Followup of psychoanalysis five to ten years after termination: I. Stability of change

Seven out of 17 patients interviewed in a long-term followup of psychoanalysis showed either improvement in psychological functioning or a retention of psychological gains they had made during the course of psychoanalysis. Six patients deteriorated in their psychological functioning, but their gains were restored with subsequent treatment. Four patients deteriorated in psychological functioning without restoration, whether or not treatment was reentered. Neither analysts' assessments at the time of termination nor patients' assessments of themselves or assessments based on psychological tests one year after termination predicted which patients would improve or retain psychological change. No causal generalizations about factors related to psychological change can be made from these data. Different factors in interaction are suggested to account for the stability and instability of psychological change.     

Emotional Detachment of Partners and the Sanctity of the Relationship with the Analyst as the Most Powerful Curative Factor

The relationship between partners and the analyst is considered the most basic means for healing in contemporary psychoanalytic theories and analyses. It also holds as one of the most fundamental phenomenon’s of psychoanalysis, so it comes as no surprise that it has always been deliberated over as an object of great interest as well as immense controversy. This same relationship, mutually co-created by the analyst and each individual and partner in analysis, represents also the core of sanctity and sacred space in contemporary psychoanalysis.     

Management of day-to-day organisational human relations: a Henri Rey perspective

Nearly all contributions to applying psychoanalytic understanding to organisational life rely either on a group relations model or observing and commenting on how people impact on each other. In this paper, I use a particular theory of human relations from post-Kleinian psychoanalysis to understand the complexity of the manager/staff relationship which is not unlike the analyst/therapist relationship with a patient.     

费尔贝恩人格客体关系理论的心理治疗观

英国精神分析学家费尔贝恩在修正与发展弗洛伊德和克莱因思想的基础之上,提出了一种纯粹的人格客体关系理论,他发展了一套修正的心理病理学思想。他认为,精神分裂是所有心理病理现象的基础;心理治疗的目标是要让病人从无意识中释放坏的客体和减少自我的分裂、达到人格的整合,而分析师与病人的关系则是心理治疗的中心。     

The Case of David: on the Couch for Sixty Minutes,Nine Years of Once-a-week Treatment

This paper illustrates a unique case of object relations psychoanalytic psychotherapy on a once-a-week treatment basis. The work of developmental mourning that would be thought to require two to five sessions a week was accomplished on a once-a-week basis. The analyst adjusted the treatment hour, in this one case, to 60 minutes, as opposed to the 45- or 50-minute hour. When treatment began, the analyst made an intuitive judgment to increase the patient's one session a week--which the patient made clear was all he was ready to do--to 60 minutes. The analyst made time in her practice for this 60-minute session and has continued with the patient using this format for 9 years of treatment. This had led up to the current stage of treatment, which has been so critical to the patient's self-integration process.     

State of the Hope: The New Bad Object in the Therapeutic Action of Psychoanalysis

Until recently, most psychoanalytic conceptualizations of the analyst as a new object have tended to equate newness with good experience and safety. Recent papers in the relational literature have explored not only the therapeutic value, but also the inevitability of the patient's experience of the analyst as bad, as well as the analyst's participation in this experience. This author examines the multifarious nature of hope, goodness, and badness in the clinical situation. The patient gets to know not only elements of his or her own self that are held by the analyst, but also ways in which the patient holds elements related to the particulars of the analyst's person in the analytic situation. Shifts in American psychoanalysis regarding conceptualizations of the analyst as a new object are examined. Limitations of a bifurcated approach to goodness and badness in clinical conceptualizations are also explored.     

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.     

On gratitude and gratification

Expressions of gratitude from the patient may be regarded by the analyst as a much-needed validation or affirmation of competence. The analyst's need for gratitude may be a relatively silent presence when things are going smoothly or when the analyst's efforts are openly appreciated by the patient. Ungrateful patients, however, are likely to force the analyst to confront his or her unconscious background wish to enact a longed-for mode of relatedness as part of the daily work of psychoanalysis. The analyst's wish for a specific form of object relationship involving a selfless, devoted helper and an appreciative patient who acknowledges having been helped may be thwarted by certain patients at every turn, knowing they are depriving the analyst of a particular form of gratification in their work. For patients of this type, failure may mean success. The implications of this particular form of clinical stalemate are outlined, and a clinical example illustrates some of the challenges encountered in psychoanalytic work with ungrateful patients.     

Objects and attitudes

The concept of an attitudinal object has long been present in psychoanalysis but almost entirely neglected. This omission is integral in the confusion and controversy about the object concept in general. It has left a theoretical gap which the so-called object relations theories have attempted to fill. This paper offers some preliminary suggestions for a psychoanalytic understanding of attitudes as a first level of inference in the study of relationships and their psychological basis.     

Psychoanalytic identity and the external world: Interaction between psychoanalysis and health service systems in Sweden

Abstract

This paper continues the exploration of the clinical phenomenon of analytic contact. The author demonstrates, through case material, the essential ingredients of psychoanalysis to be not frequency or use of the couch, but rather the moment-to-moment analysis of the patient's transference state and phantasies of what it means to establish relational contact with their objects and with themselves. The nature of the treatment can be shaped, prevented, perverted, or fostered by the patient's phantasies and unconscious conflicts into something more analytic or less analytic. Interpretation needs to include the exploration of the patient's attempts to change the treatment into something that is often a replica or a repetition of archaic object relations. The typical patient in psychoanalytic treatment is struggling with rather profound pathology and as such tends to create a significant stand-off with the analyst when analytic contact is forming. Analytic contact is often threatening to these patients in very primitive and alarming ways that must be gradually understood and interpreted if the treatment is to survive and remain a primarily analytic journey rather than be transformed into a more supportive counseling or a pathological re-enactment of conflictual phantasy states.     

In Search of the Absent Analyst: Commentary on Janine de Peyer’s “Uncanny Communication”

The subject of telepathic phenomena in psychoanalysis has been highly controversial ever since it was introduced into psychoanalysis by Freud in 1921. Following a theoretical-clinical introduction, my explanation for these profoundly mysterious phenomena combines contributory factors involving patient, archaic communication, and analyst, regarding massive primary traumatic absence that was imprinted in the patient’s nascent self and inchoate relating to others. The telepathic occurrence in treatment bursts forth as a search engine when the analyst is suddenly emotionally absent in order to seek and find the analyst and to halt the process of abandonment and collapse into the despair of the early traumatization. This is discussed here with regard to de Peyer’s clinical examples. Thus, the telepathic phenomena embody the enigmatic “impossible” extreme of patient–analyst deep-level interconnectedness and unconscious communication in the analytic process.     

Losing a father all over again: the termination of an analysis of an adolescent boy suffering from father loss

Criteria for beginning and conducting the termination phase of psychoanalysis have provoked debate and confusion from the early days of psychoanalysis. Gabbard (2009) has recently pointed to the field's tendency to cling to idealized versions of these criteria as a way to deal with disagreements. The situation becomes more complicated for child and adolescent psychoanalysts because their patients are in the midst of a developmental process at the very time they are engaged in a psychoanalytic process. The termination phase of an adolescent male suffering from father loss is presented in depth in order to provide clinical data toward further consideration of the vexing questions surrounding termination in psychoanalysis. His termination is used to examine the relative importance of losing the analyst as a transference object as against a developmental object; the meaning of action during termination; the complicating role of trauma vis-à-vis termination; and the importance of the post-termination phase of analysis. It is suggested that his termination phase demonstrates that a "good enough" termination involves the development of a self-analyzing capacity that continues to evolve and develop after termination.     

Three Phases of Treatment with Borderline and Psychotic Patients

Three distinct, yet overlapping, phases of treatment emerge when working with some borderline and psychotic patients. This are patients who test the ordinary limits of psychoanalysis, but can profit from its deep exploration. The first phase is colored by acting out, interpersonally and intrapsychically. An analytic envelope of containment is necessary to sustain the treatment. Interpretive holding and containing help the patient find a psychic receptacle capable of detoxifying violent projections. Many of these patients terminate prematurely. The second phase is centered around the patient's defensive use of the death instinct to extinguish or destroy certain parts of their mental functioning. This difficult standoff between parts of the patient's mind becomes replicated in the transference. The third phase reveals the more fundamental problem of paranoid～schizoid anxieties of loss and primitive experiences of guilt. These include fears of persecution and annihilation. Some patients abort treatment in the first or second phase and never work through the phantasies and feelings of loss. Nevertheless, much intrapsychic and interpersonal progress is possible. Given the instability and chaotic nature of these patient's object relations, the analyst must be cautiously optimistic in their work and realize the potential to help the patient even when presented with less than optimal working conditions.     

Screen memory: its importance to object relations and transference

A screen memory of an obsessive and narcissistic man, reported early in psychoanalysis, both represented and disguised the patient's oedipal conflict, incestuous wishes, and sibling rivalry. It symbolized for him his relationship with his mother and was treated by him, in a repetitive and fetishistic manner throughout treatment, as the reason for his bitterness toward life, his sense of entitlement, his narcissism, and his distrust of women. In the transference, the memory-far from being inert- constantly played an active role in his wishes and disappointments regarding the analyst, and in his fantasied oedipal triumph over him. As the analysis progressed, and after years of treatment, the encapsulated nature of this memory began to give way to the patient's growing awareness of his oedipal wishes, the full range of his feelings toward his mother, and his sense of abandonment by her. The nature of screen memory is explored, including how it relates to a patient's personality and use of the past in general, how it may figure in the development of a person's object relations, and the decisive role it may play throughout a treatment.     

Patients’ Pregnancies During Treatment: The Influence of the Analyst’s Psychology

Psychoanalytic therapists are today far more aware of countertransference effects, intersubjectivity, and mutual influence. The area that has been explored least in this two-person appreciation of psychoanalytic process is the effect of the psychodynamics of the therapist in a wide sense—that is, how the therapist brings a whole psychology, with a wide array of potential transferences, to each treatment. Triggered by the unexpected announcement of a patient’s expecting a baby, the author reviewed his practice and found that a large portion of his women patients ages 30–45 had become pregnant during therapy or psychoanalysis. The particulars were varied: how much the patient wanted a baby, whether the treatment was psychotherapy or psychoanalysis, the patients’ personality structure. Was the analyst’s psychology a common factor? The paper presents three quite different case examples and examines whether and how the author’s developmental and inner experience of women, sexuality, pregnancy could have contributed to a dyadic process that, in turn, could lead to pregnancy. If such effects happen, then it is important to look beyond and behind “anonymity” and “neutrality,” as well as momentary countertransferences, to the real-life effects that we have in our treatments.     

Psychoanalysis and negotiation

Somewhere between the image of psychoanalysis as suggestion and psychoanalysis as unearthing is that of analysis as negotiation. This is a picture of a mutual construction of reality by analyst and patient. Such an interaction allows for reciprocal input of the participants and a possible change in both. This paper sketches the role of negotiation throughout the entire process of treatment--from the initial rules, to the theory of the analyst, to the emergence of the transference, to the goal of the cure. The technique of psychoanalysis is said to lie in the process of negotiation.