- Psychological Issues
Disruptions in psychoanalytic work go by many names depending on the theory and the alleged source of the problem. Transferences originate within the analysand and may shatter cooperativeengagement with the analyst. Problematic countertransferences are contributed by the analyst, as a reflection of projective identification orchestrated by the patient or of the analyst’s transferences. Unsettling enacted unconscious scenarios originate primarily in the analyst, analysand or both. An intersubjective perspective has each partner influencing and deflecting the other. Their individual contributions are inseparable. A point of view emphasizing discontinuity in experience substitutes dissociation for repression. The analyst represents a way of being that is foreign to the patient’s sense of self. The analyst may be invested with dissociated aspects of the analysand’s self. In either case the analysand assiduously resists joining with the analyst.
The point is that disruptions are complex events with hard to separate contributions by analyst and analysand. My impression is that most disruptions in psychoanalysis are resolved spontaneously with little or no analytic exploration. Often this process is unnoticed and unacknowledged. It occurs through subtle interactions. It hardly matters how analytical and dispassionate the analyst attempts to be.
In this paper I argue that the facilitating activity that characterizes these subtle realignments should be part of analytic technique. Being helpful and concerned is not anti-analytic. When the analyst accepts this role (at times the analyst takes the initiative) the analysand is likely to feel safer,better understood, and cared about. The result, baring paradoxical neurotic developments, will be to reenforce the analysand’s confidence that the analysis is on track. Rather than discouraging the analysand from reengaging in analytic exploration, he is more likely to undertake it.
Further, I believe the analyst’s role in resolving disruptions involves acknowledging his inevitable contribution to the analytic stalemate. Avoiding this step may lead to a collusion in which the analyst’s contribution is overlooked. A distorted picture that attributes all pathology to the analysand results. The disjunction between the two deepens. Agreement between them is likely to be based in compliance.
My view conflicts with the generally held belief that the deliberate use of influence by the analyst corrupts the analytic process (Brenner, 1982; Levenson, 1982; Gill, 1993; Mitchell, 1993, p. 207-209). I disagree withthis point of view. I believe that personal affirmation from the analyst is essentialtoanalytic engagement and change. Also, analytic detachment is an ideal that is impossible for an analyst to achieve (Spence, 1982; Strenger, 1991; Levy and Inderbitzen, 1992; Hoffman, 1996, Renik, 1996). These attempts to remain outside the action probably exert their own influence, often as subtle rejections or deprivations (Stone, 1961; Renik, 1993 and 1996).
Other authors have linked disruption and repair in psychoanalysis to analytic reevaluation and change. Each understands this sequence through his or her own theoretical lens. Disruption, for example, can be seen as an interpersonal event (Stolorow, 1995) or as reflecting a resistance deriving from intrapsychic conflict. Repair may involve the reintegration of the self (Wolf, 1993), a corrective emotional experience associated with working through an enactment (Renik, 1993), or the interpretation of an enactment (Chused, 1991). The entire sequence of disruption and repair has been described under the heading “intersubjective conjunction and disjunction” (Stolorow, 1995) as well as “concordance” and “discordance” within the analytic dyad (Greenberg, 1995). In this paper I will not examine the ideological differences in these and other interpretations of the disruption-repair sequence. Instead, I will focus on the value of the analyst’s active efforts to repair a disruption and reengage the analysand. I will also be interested in where change occurs in this sequence.
The basis for my ideas is a detailed review of segments from twelve of my own psychoanalyses. These reviews regularly revealed a link between my active effort to reengage the analysand, the maintenance of the analytic process, and change in the analysand.
My final point about the process I have described has to do with change. I believe that analytic rengagement and change are inextricable. However, it would be hard to evaluate enduring change on the basis of single sessions or even the three to six month segments I use in my review of segments. In this time frame it is possible to see improvement in the analysand’s (and the analyst’s) level of engagement in analysis, the quality of his introspection, and the analysand’s evaluation of how relevant the analytic work is to his life. While these criteria are subjective, informal, and are not a reliable measure of outcome they are suggestive of internal shifts in the direction of change. I use the word “change” throughout this paper to refer to these developments. Perhaps it would be better to use terms like “developments suggestive of change” or “incipient change.” I believe that when the analyst acts directly to resolve a rift in the analytic work, or more properly in the analytic rapport, changes of the kind I have described regularly follow.
Linking repair to the analyst’s expressed interest and concern for reviving the analysand’s involvement assumes an intrapsychic world that is at least partially accessible from the surface. Relational factors, not words alone are implicated in analytic engagement and change. According to Viderman (1991) “The internalization of the dialogue between analyst and patient…is powerfully influenced by the special quality of their relationship” (p. 486-487). He considers language as only one element of an interrelated “cognitive-affective” connection between analyst and analysand (p. 331). Levin (1991) believes that “the success of psychoanalysis hinges on the sensitivity of the participants to all nuances of communication, especially what is not verbal” (p. 146).
Self psychologists represent the extreme end of this continuum. Empathy not words tends to be seen as mediating the analytic connection. Goldberg (1988) sees language providing “orientation” through the imprecise and possibly fictionalized story the analysand and analyst develop. Lichtenberg (1989) conceptualizes a process of “symbolic reorganization” that grows out of “the ebb and flow of closeness between the analysand and analyst with respect to sharing an exploratory motive” (p. 232-233).
All relational theories have some compatibility with the position I am taking. They see change as the product of a complex set of events between two human beings. Insight is never excluded from this picture. Intersubjective and interpersonal realignments, however, are emphasized. The explanation for how the process works varies considerably among relational theories. These differences reflect the way each theory understands the structure of the mind. Some posit an internalized world populated by self and object representations and introjects (e.g., Jacobson, 1964; Kernberg, 1976). Others (e.g. Ogden, 1994; Frankel, 1995) reconceptualize these entities as self and object constellations each of which represent a separate locus of initiation. Still others (e.g., Kohut, 1977) picture a mind delineated by developmental arrests. Finally there are theories that seek to reduce or eliminate speculation about inner processes and structures. Interpersonal psychoanalysis (e.g., Levenson, 1993) and constructivism (Hoffman, 1991; Mitchell, 1993) are in this group.
The following is a short list of relational explanations for how analytic change occurs. It is organized, from least to greatest, according to how much initiative the analyst is encouraged to take in shaping the analytic process.
The positions included in categories (1) through (3) tend to argue against the analyst deliberately influencing the analysand. They describe a mostly spontaneous interactional and intersubjective engagement and change process. Some of these theorists (e.g., Strachey, 1934; Meissner, 1991) consider mutually arrived at understanding supported by interpretation a main vehicle of change. For others the analytic relationship in itself is mutative (Sullivan, 1953; Levenson, 1993).
Some theorists in categories (4) and most from (5) see it differently. When Settlage (1993) lists principles of psychoanalytic technique he includes: “actively engaging the analytic relationship,” “encouraging and acknowledging developmental initiatives,” “acknowledging and taking responsibility for disruptions of the relationship caused by failures on the part of the analyst” and “offering and demonstrating availability when such clearly is needed” (pp. 23-25). Analysts from this group do not claim to know what the analyst needs in advance of analytic exploration. They are aware of the analyst’s fallibility. The recommendation of an active analytic stance, instead, is based on the conviction that the analysand needs to feel the presence of another human being striving to be helpful.
My observations support the second view. As I see it, the analyst and analysand act reciprocally in assisting each other toward repairing a disruption. It is usually the analyst, however, who leads in the repair process.
I reviewed thirty-six, three to six month segments from twelve of my analyses. Most of these treatments were conducted according to traditional psychoanalytic principles. My goal in this review was to isolate factors associated with analytic change.
For over 10 years I have taken detailed process notes during and after analytic hours, writing down everything I notice including my own mood and responses. I only restrict note taking in the session if it interferes with my ability to pay close attention to the analysand and to my own responses. I want to minimize the distortions in recall that occur when notes are recorded after clinical events occur.
Later, I randomly select clinical sequences from each analysis and review them to identify which influences lead to change. I choose sequences by opening my notes to any point and reviewing them for a predetermined interval. One other psychoanalyst also reviews these notes. I make use of his or her impressions together with my own.
Obviously this effort does not qualify as a formal research project. I study only my own work. My analytic work, note-taking, and review are influenced by my personal biases and reactions. However, this method of note-taking and review is useful for reassessing one’s clinical work. In doing this project I was repeatedly surprised by how I could move beyond the perspective I had developed while conducting the analysis and see the analysand, myself and the analytic process differently.
I will present my impressions at greater length in the discussion section of this paper. A summary follows.
The following clinical illustration provides a dramatic example of a disruption-repair sequence. I am the target of the analysand’s transference assumption that I will cheat and humiliate him. A further rift occurs when I defensively retaliate against his attack. Repair requires that I first acknowledge my angry countertransference. Only then can the analysand begin to explore his own distorted expectations.
Mark first came to see me at age 49. He had made enough money to partly retire from his business. In spite of his financial success he felt ineffectual. He complained that people did not take him seriously.
From early childhood Mark’s father reviled him for being a weakling. His crusade was to toughen Mark up. Later, while Mark secretly wished for a relationship with his father, his effort went into resisting his father’s attempts to make him into a “real boy.” Although Mark claimed that he had contempt for this stereotype, he also felt incapable of achieving it. He believed his father considered him a failure.
Mark described his mother as “a dreamer.” She divorced his father when Mark was eleven. She then earned money as a performer. In part because of this work and in part to escape Mark’s father, she moved frequently. The moves forced Mark to depend on her for companionship. In spite of this close connection with his mother, Mark remembers both parents as entirely uninterested in his private needs and unable to carry on a “logical” conversation about any important personal issue.
In the beginning of the analysis Mark was compliant and cooperative. Over time he became more contentious, arguing that my understanding and technique were inadequate. He insisted that I be more practical and helpful with him. His stance was not absolute, however. He remained reliable about attending sessions and seemed convinced the analysis could help him.
As time passed we became used to his belief that I would be “illogical and arbitrary.” As a result of our work we could see a relationship between these assumptions and his early experiences with his father. However, he paid only minimal attention to these comparisons and very little change was evident.
The following sequence occurred over three months, three years into analysis. My policy is to reevaluate my fees every 12 to 18 months and to readjust them according to the consumer price index. I do this in order to minimize my subjective contribution to fee setting. All of my patients know about this procedure and understand that I expect to discuss any reaction they may have to a proposed fee increase.
I told Mark that it was time to raise his fee and that the change would be $5. In the next session he angrily told me that the increase I was proposing was greater than the rate of inflation and that this issue “needed to be discussed.”
I immediately felt irritated and abused. I was certain that the fee I calculated was correct. I said that I would be glad to discuss this subject.
His attack continued. I asked him why he felt I was being so unreasonable. I said reflexively that I thought he knew how careful I had been to set a reasonable initial fee and to establish procedures for fee increases. I added that I had even established a somewhat reduced fee for him as a response to his insistence that he could not afford a full analysis unless I did this. I then changed the subject and defensively attempted to “get on with the analysis.”
In retrospect my mentioning the reduced fee was retaliatory and irrelevant. It must have reflected my feeling that Mark wanted to take advantage of me. His original insistence on a lower fee undoubtedly contributed to my response and had not yet been fully explored by us. More generally, Mark was convinced that I would ultimately humiliate him and steal his last vestiges of self-respect. He retaliated through his constant demeaning criticisms of me.
My transference to Mark may also have played a part in this interaction. In ways Mark’s accusations came close to my father’s distrust of my motives during adolescence. His attacks had regularly enraged me. While this issue had been mostly settled for me in my own analysis, Mark’s extended diatribe had been wearing. At times they reevoked memories of my father’s criticisms.
During the next few sessions Mark repeatedly accused me of being “unclear in my thinking.” He said his challenge had upset and angered me. Since his claims did not make sense to me, I assumed that I was dealing with a transference distortion. I tried to explore his accusations.
This only angered Mark more. “You believe you’re right. You don’t want to be accountable for what you did. You think illogically and can’t even see it. What do we do about analyzing the analyst?”
Over the next several sessions Mark began to insist that we put events down in writing. He unilaterally wrote a description of the session when I had introduced the fee change. He attacked my “faulty methods of raising fees.” He “knew” I resented his complaints since all I wanted to do was “make a buck.” He believed I did not want to hear him. My attitude “made it impossible” to trust me. Also, he insisted, how could I understand him if I could not “even stay clear for five minutes as we discuss this fee issue?”
What exactly was happening in the analysis at this point? Was Mark’s powerful objection to my remark primarily transferential? What had I contributed to provoking this confrontation from him? What kind of transference-countertransference scenarios could we be enacting? I tried to sort through the possibilities and incorporate them in trial interpretations. But it was of no use. Mark’s rage continued unabated.
I found myself confused and at times angry. I worked to understand what was happening but my effort fell flat. At a few points I even made wild speculations. For example, I suggested that Mark’s guilt about a financial windfall with a stock might be making it harder to work with me. – Throughout this period Mark’s anger and contempt prevailed. On a few occasions I could hardly contain myself since his accusations were so strident.
In time, however, I began to have doubts about the soundness of my position. Mark’s reasoning had not changed. He seemed sure of himself. It was difficult to avoid thinking about his statements. Slowly, I questioned my perceptions. I wondered whether his claims might have some basis.
At this point, to deal with my confusion, I decided to describe my experience to him. I said I was puzzled. I recognized he was convinced I had made a mistake and was quite upset with me. I agreed to reconstruct the events involved. We could do this in writing, if he wanted that. This concession put him in a more conciliatory mood and he outlined the developments in words and writing.
I struggled to listen more closely. During the next series of sessions I heard and understood as one more time he described my inconsistency in bringing up the lowered fee when he “had only been talking about the fee change I proposed.” Since I had subliminally taken note of my irritation when I had mentioned the reduced fee, it was relatively easy – once I gained some distance – for me to remember it. I was impressed by my need to see the situation as a product of his distorted perception of me and not at all of my vindictive response to him.
I told Mark I was now able to hear him. I realized his perception was accurate. I could understand that my remarks had indeed been inconsistent. He was right. I became angry when he challenged my fee raise.
Mark immediately felt some relief. He said my inability to hear him had “made him feel crazy.” I replied that I had a similar experience when he kept refusing to listen to me while attacking me as illogical and stubborn. This had been my introduction to understanding his experience.
The events I have just related took place over three weeks. Mark’s perception of me began to shift as I acknowledged that I might have made an error. For a while he still distrusted me. Simultaneously he began to see me as reasonable. Given his experience of people it was understandable that he was distrustful of my fee increase. When I refused to hear his accusations he was especially reminded of how impossible it had been to get his father to listen to him.
Mark could then turn to the question of why this experience elicited such a negative reaction from him. His father’s attacks on Mark had reflected his father’s frustration with his own failures. Mark’s defense of himself was of no interest to him. Mark also talked about the meaning of my fee increase. Until adulthood his father used money to frustrate him by offering it and then withdrawing it capriciously. This was an opening for us to further explore how Mark originally influenced me to establish a reduced fee. Having broached these topics, Mark noted that he regularly experienced misunderstandings similar to ours with other people. In these relationships he would insist on “logical” thinking and would often anger people.
The backdrop for this sequence is Mark’s transference. Mark expected me to be arbitrary and humiliating. To protect himself he barraged me with criticism. To avoid being cheated he made sure I set a slightly reduced fee for the analysis. He experienced attempts to explore and interpret these issues as attacks and deflected them.
Mark understood my fee increase through this set of expectations. His attack provoked me. I struck back. In effect, I accused him of wanting to take advantage of me financially.
Mark caught on to my reaction immediately. He could see my statement about my originally setting a reduced fee for what it was: a reflection of my anger. I was oblivious to my counterattack. I prevented myself from noticing it by changing the subject. But Mark was not about to let me off the hook. His diatribe was unrelenting. As far as he was concerned any rapport we may have had was now destroyed.
This experience was trying for me. I had to weather Mark’s vitriolic assaults. I felt confused and misunderstood. I saw no basis for his accusation. It was only later that I began to understand.
Mark was telling me that I had been incorrect in calculating the fee increase and vindictive when he questioned it. I finally invited him to show me what he was talking about. I acknowledged that I could have been wrong. Soon I recognized that while my fee increase had been accurate, my handling of his challenge about his fee had been assaultive. I then could see that I had become the transference figure Mark reviled. In his mind I was as arbitrary and hostile as his father. He was unaware of his own transference-based provocation, but he could see my anger clearly.
At this point in our dialogue I limited my comments to my own irrational response. I apologized and explored my feeling cheated by him. Mark relaxed. I then asked about his reaction to my behavior. For the first time he could be somewhat self-reflective and begin to notice his expectation that I would abuse him.
In this sequence I was the first to acknowledge my contribution to our stalemate and to change my stance. Mark forced my attention to my countertransference. I struggled to understand it and revealed to him what I learned. Previously I had tried repeatedly to explore Mark’s hostile transference. These efforts all failed until I made it clear that I could own up to my disruptive behavior.
In my opinion two factors were responsible for the success of this analytic sequence. First, Mark observed me struggling. He could see that I was distressed and confused. There could be little doubt about whether I cared about working out our differences. Second, I was willing to ask the same hard questions of myself that I asked of him. Mark’s early experience had been with people who mainly blamed others. Discovering that I could be modest and self critical was surprising for him. These events created an atmosphere that made it safe for him to be introspective. He ran little risk of feeling used and humiliated if he was forthcoming. I was only asking him to do what I had done myself.
This understanding is consistent with the position of authors from category 5 of my list of relational explanations for analytic change. The complex mechanisms associated with explanations 1-4 are there. Externalization and reinternalization and reliving early experiences, are examples. Interpretative analytic exploration contributed, as well. Mark could better differentiate me from his internal version of his father after we worked to untangle the fee incident. But much more happened between us than is contained in these explanations. Neither Mark nor I were the same after that incident. I was humbled and reached to Mark. Mark was amazed that someone would want to understand his complaint. Change occurred as a result of our experiences together, struggling to be heard. It was based on a passionate interaction between two different people attempting to connect with and influence one another.
The critical moment in many of the clinical segments I reviewed for this project involved my recognizing and beginning to rectify my part in a disruption. In most cases the analysand behaved in ways that served his or her defensive and transferential needs. However, attempting to explore and interpret these motivations often at first furthered the analysand’s alienation. In contrast, when I could be self-critical and assume responsibility for the repair of our rift, engagement and change were often reinitiated.
The following is a summary of the disruption-repair sequence.
I regularly observed this disruption and repair pattern in the clinical segments I reviewed for this paper. The analyst draws away when there is an analytic stalemate and especially when the analyst fails to recognize his part in it. He reengages and begins to work when the analyst sees his own contribution and moves actively to reinvolve the analysand. It may be the analysand who originally points out the rift. However, usually, at some point the analyst takes over. Temporarily through action, interpretation, and self-revelation he leads in repairing the rift. He often needs to do this before the analysand can begin to be introspective. Mark could see how my countertransference played into our standoff. Reestablishing his confidence in the analytic process required that I see my part first.
Yet, however correct this description of the place of the analyst’s influence in reengaging a disaffected analyst and is, it is also too mechanical. Analysts who can look at themselves are experienced by their analysts as being personally accessible. They present themselves as fallible and unafraid of the same scrutiny they ask from the analysand. Issues of authority and superiority fall away. An atmosphere of safety and personal good will is created instead.
In my view, it is hardly surprising that human beings require this kind of reassurance before committing to a process as interpersonally precarious as analysis. The risk of being misunderstood or betrayed in such a relationship is enormous. The anticipation of relief from personal isolation and suffering brings with it terror of disappointment and victimization (Mitchell, 1993, pp. 209-214). Conversely, I believe that all people enter analysis with the hope and usually the conviction that the analyst can relieve their suffering (Mitchell, 1993, pp. 207-209; Bass, 1996; Slochower, 1996).
A key difference between my point of view and traditional psychoanalytic positions is that within limits I see this hope as reasonable. I believe that to some extent it has to actually be gratified within analysis. research in child development supports the view that affiliation is the pivotal human motivation. Other motivations are subsidiary to affiliation (Kraemer, 1992; Silverman, 1992). Analytic theories centered on this developmental research have been elaborated (Shane and Shane, 1985; Beebe, Jaffe and Lachmann, 1992; Settlage, 1992; Weiss, 1993). They advocate that the therapist take a facilitating role in analysis, actively furthering the attunement between themselves and the analysand.
Self reflection is hardly possible when the analysand’s energies are concentrated on securing himself against harm and disappointment within the analysis. In that case the analyst is an adversary. He needs to be shut out along with unacceptable segments of the analysand’s subjective life, including prohibitive ideas and degraded editions of self or other. Until the analyst’s goodwill and reliability become apparent to the analysand, the analysand cannot possibly become involved in a shared process involving self reflection. The risk is too high that it will turn into an experience of self deprecation and victimization instead.
In summary, I am proposing a model of analytic disruption and repair that has both a realistic and irrational side. However exaggerated his worries about exposure or intimacy, the analysand’s fear of the analyst harming him is in part realistic. The same is true of his need for a basic relationship of care and support from the analyst. Until freedom from these fundamental concerns are established within analysis it is unlikely that a productive analytic process can occur. The commitment will be too thin and unauthentic. The analysand’s self reflective process will be handicapped.
As I understand it, analytic change is most likely to occur in a network of safety and support like the one I describe. At points the analyst leads in its development. He facilitates the reengagement, taking his cues from the analysand but relying on his own intuition and initiative as well. Engagement and change are then interwoven. As the analysand gets to understand and trust the analyst’s motives he revises his entrenched view of himself, the analyst, and relationships. With this internal shift self reflection becomes less threatening. Paradoxically, however, by the time a coherent dialogue about the issues in analysis becomes possible much of the reengagement and even the change may already have taken place.