Finding the neutral position: patient and analyst perspectives

In light of current debates between classical and intersubjective schools of psychoanalysis, the challenge posed by the latter to such basic concepts as the analyst's neutrality, anonymity, and abstinence is taken up. It is maintained that the term neutral position is today more germane and meaningful than the term neutrality, which frequently has been taken to prescribe the analyst's posture. It is proposed that for each patient the neutral position is uniquely sited and that it is incumbent on the analyst to find its location. The neutral position is defined within the context of the interaction between analyst and patient. The concept is therefore compatible with--indeed it is essential to--an intersubjective or relational orientation. The manifold reasons, conscious and unconscious, why the analyst is vulnerable to leaving the neutral position are considered. The patient's reaction to the analyst who has left the neutral position and the analyst's clinical use of this reaction are discussed.     

When the analyst is physically ill: Vicissitudes in the analytical relationship

Something that happened to one of the authors recently led them to refl ect upon what the analyst's falling ill may represent and the problems it may give rise to in the analytic relationship. Such an eventuality injects a massive dose of the analyst's personal reality into the analytic space, thereby allowing the patient a glimpse of images of vulnerability, frailty and loss, and mobilizing emotions, fantasies and defences in both the analyst and the patient. The authors' survey of the literature ranges between two different theoretical perspectives intrapsychic and intersubjective that, in their most radical formulations on technique, call for maintaining either the strictest neutrality and anonymity or symmetrical relationality. In both cases, that which is denied is the unconscious communication that enables the analyst, irrespective of his conscious intentions, to allow either parts of himself or inner objects of the patient to act in the relationship. In closing, the authors shall illustrate the concept discussed through three clinical vignettes.     

The holding environment and intersubjectivity

The holding environment is explored in the context of the analytic dyad, where it is seen as rooted in the patient's need to be experientially known through the intersubjective interaction. In examining previous emphasis on holding as an optimally attuned empathic environment provided by the analyst, a broadened view of what constitutes a holding environment is presented, underscoring its interactional nature. A distinction is made between empathic holding based on the patient's expressed material, and holding that is generated through the analyst's intersubjective knowledge, gained via ongoing intersubjective engagements and enactments. It is argued that the unmediated connection to the patient's internal representations resulting from these intersubjective interactions, and the ensuing verbal exploration of them, can create a profound sense of being understood and thus held. A clinical process depicting the experience of holding in an intersubjective context is presented.     

Audit of the Informed Consent Process as a Part of a Clinical Research Quality Assurance Program

Audits of the informed consent process are a key element of a clinical research quality assurance program. A systematic approach to such audits has not been described in the literature. In this paper we describe two components of the audit. The first is the audit of the informed consent document to verify adherence with federal regulations. The second component is comprised of the audit of the informed consent conference, with emphasis on a real time review of the appropriate communication of the key elements of the informed consent. Quality measures may include preparation of an informed consent history log, notes to accompany the informed consent, the use of an informed consent feedback tool, and the use of institutional surveys to assess comprehension of the informed consent process.     

Future and potentiality in the psychoanalytic process

A perspective is delineated on the dimension of the future in the psychoanalytic situation. Clinical manifestations are presented of the tension between actuality and potentiality that characterizes the treatment situation. This tension, an aspect of the intersubjective field that exists between patient and analyst, involves the analyst's hopes, expectations, anticipations, sense of purpose, and therapeutic intent, facets of the analyst's subjectivity that affect the clinical process. The question of the patient's individuality and autonomy is raised in the context of the notion of the "true self." To understand potentiality in the clinical situation, it is argued, the intersubjective emphasis on the inevitable mutual influence between analyst and patient must be complemented by a view of the self as emerging from within and gaining coherence through the unfolding of inherent dispositions and potentialities.     

The Problem of Thinking in Black and White: Race in the South African Clinical Dyad

Race, as it presents itself within the clinical dyad as an aspect of the relationship between therapist and patient, has scarcely been written about from an experience-near perspective within the South African context. This paper focuses on the difficulty of speaking and writing about race. It contends that race as a construct and as an aspect of subjectivity has the potential to interrupt the therapist’s capacity to think, in Bionian terms, and to prevent entry into the reverie that is crucial to the creation of an analytic third. Written through a relational psychoanalytic lens and drawing on the concepts of the normative unconscious and the anti-analytic third, the paper refers to clinical vignettes to illustrate the collapse in thinking and the progression to beginning to think, anew, about the race-nuanced, intersubjective space between patient and therapist.     

The patient's material as an aid to the disciplined working through of the countertransference and supervision

The author argues that the patient's largely unconscious observations of the analyst's functioning are, at times, communicated in the patient's material and that this can impart a sense of clinical relevance to the countertransference. The concept of 'understanding work' is used to provide a psychoanalytical model of this phenomenon. This is illustrated in a clinical case and it is argued that a selective consideration of the patient's material can provide a proper discipline which steers the analyst between the twin dangers of megalomania, on the one hand, and involvement in a symmetrical, self-disclosing relationship, on the other. The author then applies these ideas to supervision and uses them to distinguish psychoanalytic supervision from a practice that also derives from an intersubjective paradigm but which, to the author's mind, is not distinct enough from personal analysis.     

What comes out of the consulting-room? The reporting of clinical material

The author addresses the difficulties inherent in reporting clinical material. These fall into two main categories, the ethical problem of upholding confidentiality, and the technical problems which include the definition of analytical data, and the numerous ways in which truth can be distorted in the analytic context. It is advocated that consent be obtained from patients before publishing their material. It is also suggested that clinical reports should contain enough detail of the analytic interaction, including the analyst's thoughts and feelings, to convey the analytic process, and to enable the listener/reader to consider the evidence for himself and to draw his own conclusions. It is concluded that an analyst's anxiety about exposing a patient might obscure an anxiety about exposing himself.     

The analyst's theory: A third source of countertransference

The author asserts that the analyst's theory, personal and/or academic, is an important source of countertransference which complicates our traditional understanding of the analyst's emotional responses as being constructed from a mix of his transferences and the patient's effects on him. From this perspective, theory - because it has no intrinsic relevance to the essential phenomena of individual analytic processes - may be a confounding, as well as a necessary, factor in clinical work. Although the analyst's theory might be conceptualized as a component of his personality that shapes his emotional reactions to a patient, the author believes that there is a valuable increment of conceptual clarity and additional clinical utility to thinking about a more direct role of theory in the process of countertransference formation. He uses aspects of the clinical analysis of narcissistic resistances to illustrate how some theories might predispose an analyst to confounding unconscious enactments by generating either positive or negative countertransferences which can be used defensively by the patient and/or analyst. He also illustrates how, in some contexts, an analyst's theory might attenuate potentially informative countertransference reactions and interfere in this way with the analyst's apprehension of the patient's psychic functioning. Finally the author addresses the importance of 'fit' between an analyst's working theory and a patient's psychopathology, and considers implications of his ideas for psychoanalytic training and practice.     

And Now For Something Completely Different: Humor in Psychoanalysis Commentary on Paper by Joseph Newirth

In this commentary, I argue that if humor is to be considered in an intersubjective context, the impact of any comment or action by analyst or patient cannot be predicted with much confidence. An interaction that is experienced by both parties as humorous depends on an unconscious confluence that is largely spontaneous. Efforts to orchestrate a particular outcome to an intervention that is meant to be humorous may well reveal more than was intended, and thus have an unpredictable unconscious resonance.     

Writing about psychoanalysis: II. Analysts who write, patients who read

When we make a decision to lecture, or to write for publication, we have begun an activity that will affect every one of our patients. If they attend our lectures, or read our published works, they cannot help being influenced. Even if they do not, they will have some reaction to the focusing of our interest on particular phases of the analysis. This will be true whether or not we intend to present clinical material. These considerations inevitably affect the analyst himself, sometimes inhibiting his writing altogether, sometimes constricting its scope, or worst of all, degrading its quality. The analyst's writing is also almost certain to influence whether and with what success his patient may choose to write. Lest these considerations suggest that we avoid writing altogether, I emphasize that such a sacrifice is by no means desirable or necessary. Problems of discretion will arise, and may in some cases be virtually insoluble; but there are ways of writing that can overcome most such objections. The analyst's interest in writing should be recognized and its effects, if any, brought into the analysis; so long as the writing itself is done with due regard to the conduct of the analysis and the welfare of the patient, it need have no adverse effects on either.     

Writing About Clients: Developing Composite Case Material and Its Rationale

Ethical guidelines of the 4 major professional associations representing counselors and psychotherapists are reviewed. To help clarify thinking about writing up clinical cases, 3 kinds of cases are described. The author concludes that the current guidelines for clinician‐authors in writing about clients for publication or presentation are contradictory and conflicting. The use of composite clinical case material is discussed as having a number of advantages over disguise or consent when writing about clients. Presented are guidelines for developing composite clinical cases and an example of how to use them effectively.     

Effects of federal human subjects regulations on data obtained in environmental stressor research

A series of experiments on environmental noise was performed over a 3-year period. Those experiments in the series that incorporated federal subjects guidelines concerning informed consent failed to replicate the negative aftereffects of noise found earlier by Glass and Singer. The experiments that were performed before implementation of the federal guidelines, however, successfully replicated the Glass and Singer findings. To clarify this pattern of results, a final experiment was performed on two groups of subjects treated identically except that one group gave informed consent while the other did not. The results confirmed that the subject procedures involving informed consent as defined by the federal guidelines prevent the emergence of negative aftereffects of noise, possibly because these procedures give the subjects what amounts to control over the stressor. Similar phenomena may occur in research on other environmental stressors, such as crowding and electric shock, in which subject's perception of control is a critical variable. Possible techniques for performing future research of this type are discussed.     

Hide-and-seek or show-and-tell? Emerging issues of informed consent

This article reviews key philosophical and legal underpinnings of mental health professionals' obligation to obtain informed consent from consumers of their services. The basic components of informed consent are described, and strategies for clinically and ethically appropriate methods of obtaining informed consent are discussed. Emerging issues in informed consent involving duty to assess and protect against client dangerousness, obligations to third parties, and issues of deception are considered as well. The article proposes that part of the process of obtaining informed consent is the cultivation of a treatment environment that emphasizes beneficence and client autonomy.     

What do Patients Prefer: Informed Consent Models for Genetic Carrier Testing

The recent increased number of conditions for which patients can undergo genetic carrier testing raises the question of how best to obtain pre-test informed consent. Clinical approaches vary from a minimalist model to a model where patients are given detailed information about all conditions to be screened for. Few data exist as to patient preferences, or how information impacts decision-making. Eight high-literacy focus groups were conducted to assess the knowledge and preferences of pregnant patients and their male partners. Most groups indicated that some balance between details and brevity was optimal, recognizing that anxiety can occur when patients are provided with too much information and that the wide range of tests offered during pregnancy often led to confusion. Critical areas for the informed consent process included (1) details about the conditions and risk of being a carrier, (2) logistics of testing, (3) next steps if the test is positive, and (4) prognosis, options and resources if the child were to be affected with a disorder. It will be useful to develop model consent programs and prospectively assess their impact on informed consent and patient satisfaction, both when positive and negative results are received.     

Malpractice Arising From Negligent Psychotherapy: Ethical,Legal, and Clinical Implications of Osheroff v. Chestnut Lodge

This article reviews key philosophical and legal underpinnings of mental health professionals' obligation to obtain informed consent from consumers of their services. The basic components of informed consent are described, and strategies for clinically and ethically appropriate methods of obtaining informed consent are discussed. Emerging issues in informed consent involving duty to assess and protect against client dangerousness, obligations to third parties, and issues of deception are considered as well. The article proposes that part of the process of obtaining informed consent is the cultivation of a treatment environment that emphasizes beneficence and client autonomy.     

Unconscious fantasies, structural theory, and compromise formation

Although the existence of unconscious fantasies is an empirical assumption, in the clinical situation unconscious fantasies are treated as if they have a concrete existence. Unconscious fantasies form intermediate links in causal chains of which clinical observations constitute one end, and the components of unconscious conflicts, the other. Like all clinical material, fantasies may be affected by actual experiences; they may also be revised, layered, and can function to alter and disguise other fantasies as well as provide gratification. From a technical standpoint, it is most important to analyze their constituents and to adduce their primary purposes in the clinical situation of the moment. The nature of the evidence that identifies the presence of particular unconscious fantasies is discussed. Although a single analytic session is presented by way of illustration, I am convinced that the analyst's entire understanding of the patient inevitably channels his or her interpretive focus on the associational material of each analytic hour.     

Monsters,dreams and madness: Commentary on ‘The arms of the chimeras’

Considering Freudian and Post‐Freudian approaches to the intersubjective Beatrice Ithier puts the work of Michel de M'Uzan and Thomas Ogden in comparison. To this comparison I add a consideration of the work of Christopher Bollas. The highly creative clinical approaches these three theorists take is shown to be informed by their elaborations of the Freudian notion of unconscious communication and by new approaches to the issue of identity. Attention is paid to differentiating traumatic from fanciful chimeras; and to the experience of the analyst undergoing the sorts of transformations requisite to entering this psychic space marked by fluid exchanges of being and becoming, wherein analyst becomes patient, new subjects are created through shared dreams, and through which monsters appear.