Modern Psychoanalysis

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Monday, September 17, 2007

Priorities in Treatment

Priorities in Treatment
Modern Psychoanalysts have adopted one of their most important guidelines from the Hippocratic Oath - “First, do no harm.”

A first step to help insure that they “do no harm” is for the analyst to rely on the contact functioning of the patient’s own ego.

Do the patient’s statements or questions indicate that the patient aware of the analyst as an individual? Is the patient content to lie on the couch and talk until hell freezes over? Does the patient prefer to be silent? etc.., etc..

In any of these cases the analyst will respond (or not respond) based on what the patient’s contacts say about the individual s/he is dealing with. Rather than imposing interpretations or unsolicited ideas on vulnerable patients; modern analysts base interventions or responses, if any, on the contacts they receive from those patients.

Additionally, as long as the patient is talking and engaging in progressive communication, the analyst is usually not intervening much at all.

When resistances become operative, there a type of hierarchy involved in dealing with them. One could say that resistances are dealt with according to a system of priorities - depending upon what kind of resistance is being manifested at the time. The priorities in treatment can be conceptualized as follows:
1. Treatment Destructive Resistance – The treatment destructive resistance (or “TDR’) is first in priority and foremost in every good analyst’s mind. It refers to anything which will destroy the treatment if left unchecked. Therefore, the first question most analysts ask when confronted with new behavior or dialogue is “Is this a potential TDR?” i.e., “can this wait, or do I need to deal with this right now?”
Patient’s questions which might be totally innocent in a more social setting, such as “How is the parking near your office?”; or patient’s statements such as “I didn’t have an easy time parking here;” would each need to be carefully investigated and considered as potential treatment destructive resistances in the modern analytic setting.

When attempting to deal with a TDR, “all bets are off;” i.e., the analyst may use a variety of clinical techniques which might not otherwise be used - to try to save the treatment. The premise is that if the patient is not coming to talk s/he will not otherwise be helped.
2. Status Quo Resistance – At this stage the patient has settled in to treatment and clings to old patterns; the patient may wish to conceal any “bad feelings” and/or concentrate on proving that s/he is a good patient.
3. Resistance to Analytic Progress – In this stage, which may be difficult to distinguish from the last, patients may experience anxiety over investigating anything new or adding anything new to the treatment. Thus, the patient may have largely abandoned the idea of clinging to the old “status quo,” but may also be fearful of the new material or of “being pushed” towards new realizations.

4. Resistance to Cooperation – Here, patients may try to concentrate exclusively on themselves; to the exclusion of their analyst. In a group environment this could be called “resistance to teamwork.” At this stage, patients may be aware of their therapists as “real people,” but may not realize the importance of working together, or may not want to give their therapists the satisfaction of doing so.

5. Resistance to Termination – This stage can involve the patient’s falling back on old habits in an effort to keep the old relationship with the analyst. In this regard, some modern analysts believe that there should be a natural end to most treatments at a certain point, whereas others do not believe treatment needs to end as long as both parties want to work together. In either case, it is usually thought that the feelings surrounding the ideas of termination (i.e., separation) should be worked through.

Spotnitz, 1985, pp.175-183, Spotnitz, 1976a, pp. 86-88 and Spotnitz, 1976b, pp. 183-191.

In actual treatment, the above stages of resistance often overlap or are blurred together. Patients can display behavior reflective of several different stages in a single session or can slip back and forth between stages over a period of time.

Also, while treatment destructive resistances are generally far more common at the beginning of treatment, they can also arise when moving from one stage of resistance to another, or at any other time.

Resistances or defenses are not always obvious or easy to detect; its a good bet that many patients even do their best to conceal them. Therefore, the best modern analysts know that they need to be constantly sensitive to their own feelings as a guide to bringing their patients successfully through every stage of treatment.


References

Spotnitz, H. (1976a). Psychotherapy of Preoedipal Conditions, N.Y., Jason Aronson.

Spotnitz, H. and Meadow, P. (1976b). Treatment of the Narcissistic Neuroses, NY, Man. Center For Advanced Psychoanalytic Studies.

Spotnitz, H. (1985). Modern Psychoanalysis of the Schizophrenic Patient: Theory of the Technique, Second Edition, NY, Human Sciences Press.


© 2007, James G. Fennessy, M.A., J.D.
Matawan, New Jersey 07747
E-mail:
njanalyst@hotmail.com
http://modernpsychoanalysis.org

Psychoanalysis

8 comments:

parejanoverbal said...

Jim, in Psychotherapy of preoedipal conditions, p. 109, Spotnitz refers to the contact function as "this form of resistance" but does not go into detail. Why would he call it a form of resistance, you think?

Hugo

Jim said...

What's your idea, Hugo? Why would Spotnitz refer to asking questions as a "form of resistance?"

Jim

parejanoverbal said...

Yes, sure, Jim. I think that it is sort of obvious that if someone asks a question about what the other thinks, in a certain way, it may be that he/she is avoiding to talk about himself/herself, perhaps trying to gauge the safety of the situation for later and so on. In that sense, it can be construed as "a form of resistance". However, Spotnitz does not go into the same amount of teasing and detailing he does with other types of resistance (at least in the 3 books I have been working on) and so I wonder if he (or someone else) has ever done it and what your thoughts are about it.

Jim said...

If there is a work dealing with "the contact function as resistance" I haven't seen it yet; sounds like a nice topic, Hugo.

My preliminary thoughts are that it would be more likely to be found in certain patients rather than others - I'm unsure which, but I guess that I would expect it more in intelligent patients, or perhaps in patients that really like to relate to others as part of their "modus operandi." It deserves more thought.

I also wonder about the countertransference effects - do analysts find "this form of resistance" more difficult to recognize? I'd be interested in what your further thoughts are about it.

parejanoverbal said...

Thanks, Jim, that's helpful. I just find it intriguing that Spotnitz simply says "this type of resistance" withou going into further detail. Partially, I am inclined to go along the idea that "if you ask, you gauge" but totally agree with you that looking closely into the concept has merit. Also, what do you think..? To me, I wouldn't generalize it to the point of assuming all forms of contact be resistance. Yes, contact, no contact, and what kind of contact are absolutely important to me not just in the clinical work but in any form of relationship; however, I feel that constraining it to a form of resistance is not necessary.
To be honest with you, the idea of contact has informed the way I work in very significant ways, and I am in love with the concept. I owe that to HS.

Hugo

Jim said...

Thanks for the great ideas, Hugo.

I'm inclined to think that most modern analysts would rely on their analysis of the individual patient, as well as their countertansference, in deciding whether something is or isn't resistance. (Rather than deciding based on some categorical system).

Additionally, it may not make much clinical difference, since all resistances are not equal in modern psychoanalysis (i.e., many resistances are not addressed at all until much later in treatment).

Jim

parejanoverbal said...

Jim, although originally aimed at working with schizophrenic patients, MP indeed works with all sort of people who demand treatment, right? So, where exactly did Spotnitz branch out to "any kind of condition"?
I know he explicitly says somewhere that his goal is to create a systemic approach that adapts to any patient and, moreover, MP is particularly apt to such an open/flexible approach, but is there a specific moment in MP when he (HS) or anybody else made it explicit that "we do not just work with schizophrenic patients"?

hugo

Jim said...

Hugo, yes, MP indeed works with all sort of people. I don't know enough about the history to be able to say whether there was any specific moment which made a difference.

Jim