Some Miscellaneous Thoughts on the Clinical Practice of Modern Psychoanalysis

Some Miscellaneous Thoughts on the Clinical Practice of Modern Psychoanalysis

These thoughts and questions are primarily directed to modern therapists. In this context I’m assuming that modern analysts are already aware that they have their own “blind spots” and defense mechanisms - first, as people; and, second, as analysts, to protect them from “dangers” of the analytic situation.

The Omnipotent Analyst
While the curative mechanism we use is talking, language also uses and intensifies our feelings of omnipotent control. In reality language is simply an overlay on top of the organizing functions of our brain which are emotional/implicit/non-semantic memories, more primitive and present from birth. (See e.g., Fennessy, 2006).

In this respect, analysts in training sometimes succumb to the temptations of finding new outlets for their own narcissism through a mechanism that looks something like the following:

“Aha, now I am fully aware of what the pattern is… I am getting so aware (so much better)… (and then) …. Now I am much better and much more aware of everything….”

In other words, the narcissism of the analytic student does not disappear, but simply changes it's manifestation – creating in some cases omnipotent analysts who merely portray self-aware analysts. It’s a type of play-acting that many of us are all too familiar with.

This becomes a challenge for both analysts and patients when therapeutic sessions contain lots of primitive material on both sides, or when the analyst must face the challenge of feelings aroused in the statement “I’m doing nothing.”

The ultimate problem for the therapist is encapsulated in a recent comment by an esteemed mentor of mine: “It’s the resistance that burns you out, not the feelings.”

Analysts with these challenges may tend to avoid numerous feelings, including positive feelings such as love and compassion, as well as negative feelings. Using Winnicott’s term, over a period of time the “continuity of being” of the analyst may even be severely threatened.

While some of us may be under the impression that everything revolves around us, therapists don’t usually have less of the narcissistic instinct than others do, though it makes a bigger difference to us and to our patients than some realize.

We might ask, why have we chosen a “helping” profession in the first place? I think this is an important question for each of us to answer.

Some analysts maintain an attitude of helping, or wanting to help, as their main source of satisfaction or fulfillment for doing the therapeutic work. This is not necessarily an impediment to good work. Insofar as this attitude represents a feeling, or set of feelings, it should be experienced and worked through; and there may be situations where the analyst can use the feeling.

However, in a clinical sense it is important, for the patient and the analyst; that all of the narcissistic components be worked through; because of the analyst’s need to separate their impulses from what might need to happen in the room to actually help the patient.

The Importance of Emotional Education
The education of modern analysts through Transference and Resistance Workshops in each school term (previously mentioned in this forum) provides the necessary environment for training many modern therapists in working out these important issues.

The long term group environment of the “T&R Workshops” help students examine and work through their own emotions and tendencies at the same time as they observe and interact with the emotions and tendencies of other members of the group.

Students learn to experience the delicate balance of feelings that we all have throughout life. In this context, we may find that our own narcissism becomes increasing annoying to us over the years; we may also learn that many of us overevaluate our relationships in the workshop, or the other members of the group; or that our own narcissistically-based activities may carry a degree of risk (of narcissistic injury) to us due to the overvaluation of objects.

We may also learn that it’s better to go with the feelings; rather than try to force the balance and that there’s a limitation to most attitudes when we try to consciously impose them on ourselves, rather than let them develop naturally. Or, we may be aware of that constant tug-of-war between living in one’s own head and living in the world.

The workshops, when later combined with the powerful effects of our own analyses, individual and groups supervision, and case presentations, help modern analysts become far more effective with their own impulses and with others.

As with our patients, the repetition of certain statements or certain important things over a period of time helps with the learning process and our development of different perspectives. It’s a life-long process for most of us.

Talking
While we need to learn to work with our feelings, we also need to keep in mind that for many patients it’s not the similitude of feelings, but the similitude of words that makes a difference in modern analysis. This is not to infer that therapy doesn’t need to be something of a genuine relationship, at least in the sense that genuine emotions are involved. But, we must also understand that successful modern therapy depends on staying with the patient, not taking the patient where we want them to be.

We do not understand everything. Other things we know something of, but many of those are still imperfectly understood – such as whether and how might protective impulses overlap with aggressive impulses. How often do we seek to “protect” our patients – intervening as well-meaning parents may have in the past to cut off their free associations?

A little goes a long way. Many of us tend to think that our words need to “make an impression” on others. A natural human tendency is to use an abundance of words where less will do, or to repeat ourselves, or to overemphasize our points. In my experience, patients are much more sensitive to our words than we normally realize.

Opposing our native tendencies, it could be said that words tend to have more value when we use them less often (though hopefully measuring those words we do use). The fact that an intervention or clinical technique of some kind may be warranted in a particular case should not cause the therapist to leap ahead in an unrestrained manner. Are we simply suppressing our own narcissism for a time, waiting for the opportunity to display our brilliance?

While thinking of my patients, I’m sometimes reminded of an interaction I observed a while ago:

I was sitting in a waiting room when a mother came in with her young daughter; the child was about 2 years old. There was a big bucket of toys in the waiting room and some children’s books. The young girl was quite active; crawling around on the floor; grabbing toys, offering some toys to the mother and quickly moving on to the next toy. For quite some time the mother pursued the child; constantly trying to interest her daughter in a book the mother held, but to no avail. As it became increasingly important to the mother to interest the child in the book; the child remained active, but undeterred from her own tasks. At one point the mother looked at me in frustration and apologetically stated, “She doesn’t read.” I remember having strong feelings of wanting to say something to the mother, but also thinking it would be too intrusive to do so. It was most saddening to me that the mother ignored the child’s attempts at communication (with the proffered toys) as much as the child ignored the mother’s crazy attempts to force her 2 year old to read.

To help our patients we need to learn to pay attention to their efforts to communicate and recall how difficult that may be for some. Sticking closely as possible to the patient’s own words, and staying with the patient where s/he is, are most important.

According to my same mentor “patients have lives outside of their sessions with us.” We might also like to keep in mind that the successive frustrations inherent in personality growth make the ordinary living of life an exceedingly difficult task for extremely disturbed persons; their entire lives may be exercises in frustration and/or anxiety.

Just as mental/emotional difficulties are usually multi-determined and over-determined, so therapists and patients alike frequently have more than one reason for what they say or do. So often in observing individuals with difficulties we might say “They must be doing this on purpose.” To an outside observer it may look that way, or it may look like acting or melodrama; while the internal experience of the patient could be quite different.

While our words may be the same, meanings remain individual to each one of us. What makes what happens in the session real? How do we bring the reality of the patient’s life/patient’s emotions into the room? You don’t disclose everything – why should your patients? I suppose it doesn’t hurt to have as many explanations as possible available to us when we are feeling perplexed by some of our patients.

Yet, our theories and ideas can also get in the way of good treatment. So we say that to the extent that a particular view, or model, or idea helps us with a particular patient in a clinical setting it should be maintained and to the extent that it does not help us, it should be discarded or filed away for future clinical use.

And every interruption interrupts the patient’s free association. Additionally, anything the analyst says creates a counterpressure in the patient; (e.g., one may actually increase the amount of action by specifying it’s prohibition).

The frustration engendered by the analyst intervening at the patient’s point of defensive operations can also work as a re-creation of that primary frustration that started things along the continuum. If so, the analyst walks a fine line, keeping that frustration within certain limits; protecting the patient and allowing the growth process to develop further.

Of course, that’s the point. Clinically, the only value of transference is that it can develop into resistance and be resolved. Don’t foreclose opportunities for transference - whenever you speak, you do! (e.g., “Of course, we could never have sex;)” (unless your patient is psychotic).

What is the importance of the analyst as a suitable “object” for the patient? - i.e., it would do less good for a patient to lie on a couch in an empty room and talk to the walls - there is an intrinsic importance to talking to an acceptable “other.”

The acceptance of all of our feelingsOur society sometimes mirrors that “mind-body split” that takes place as part of our maturation.

I’m reminded of someone I know who has all kinds of unusual physical things going on, but he’s seen a number of doctors and had countless tests in the past few years, and they can’t seem to find much wrong with him. His wife recently commented that he was at the end of his rope and “willing to try anything.” I asked if he’d be willing to talk with someone and was quickly told, “Oh, he would never do that!”

While not usually desired in life, it can be useful for us to be aware of all of our negative (as well as positive) feelings in the countertransference. For example, even a negative feeling such as hate may be useful in the countertransference because I think 1). It is often overlooked, by analysts, patients, parents; 2). It may be found side-by-side with other undesired feelings; and 3). Known or unknown, it is (or was) a part of many relationships.

There’s usually another side of the coin when it comes to feelings; i.e., sex/aggression, frustration/love, etc.., etc… One of the many benefits of a bit of experience is that after a time modern therapists sometimes develop a type of “inner voice” with respect to their range of feelings and interventions.

Asked to describe the process: “How did you know that was the right intervention at the right time?”

The experienced therapist may answer: “I’m not sure;” and only later be able to articulate a specific reason.

Acceptance of all of our feelings results in benefits for modern therapists as well as for their patients.

References

Fennessy, J. (2006). The Mind in Modern Psychoanalysis, online at http://modernpsychoanalysis.org/Documents/MindMod_PsyA.pdf

© 2008, James G. Fennessy, M.A., J.D.
Matawan, New Jersey 07747
E-mail: njanalyst@hotmail.com
http://modernpsychoanalysis.org/

Clinical Techniques: #4 - Joining

Clinical Techniques: #4 - Joining

According to Dr. Hyman Spotnitz:

“Many communications that have a maturational effect reflect the old adage: If you can’t lick ‘em, join ‘em… The term ‘joining’ denotes the use of one or more ego-modifying techniques to help the patient move out of a repetitive pattern.”

(1985, p. 253).
This statement gives us some indication of both what “joining” is, and why we might use it; i.e., that joining avoids attacking the patient’s defensive mechanisms, while simultaneously helping the patient to engage in progressive communication with the therapist.

Dr. Benjamin D. Margolis says that:

“The ultimate purpose, in every instance, is to help the patient mobilize and liberate the negative (as well as the positive) feelings he has long kept submerged. The analyst accomplishes this by first joining the patient’s resistance and supporting and reinforcing his uncooperative attitudes.”

(1983, pp. 219-220).

Reinforcing uncooperative attitudes!?! – statements such as these give the reader some idea of how uniquely modern analysis works, as well as why it often works when other methods fail.

Dr. Spotnitz amplifies the intent even further; saying that

“The term ‘joining techniques’ is loosely applied to a number of basically similar interventions… By and large, all of these interventions communicate the same message to the patient: I am like you.” (1985, p. 263).

Thus, patients who may have spent a lifetime being criticized by well-meaning others, commonly find that modern psychoanalysis provides them with an experience where they can feel connected in a way they have rarely experienced otherwise in their lives.

A theoretical way of looking at the same thing is to say that “By functioning as an ego-syntonic object, the analyst facilitates the development of transference on a narcissistic basis as well as its eventual transformation into object transference.” (Spotnitz, 1976a, p. 142).

The various joining techniques used by modern analysts are sometimes further roughly divided into “ego-syntonic” and “ego-dystonic” joining.

One of the better known ego-dystonic joins used by Dr. Spotnitz related that when a

“… young man, trying to force the analyst to talk to him, shouted that he would 'get off the couch and bash your head in.’ The analyst responded ‘I’ll bash yours in before you can get off the couch.’”

(Spotnitz, 1985, p. 265).

Ego-dystonic joins such as this appear counterintuitive, but frequently help patient’s verbalize negative affects and feel more comfortable in the treatment relationship.

Benjamin Margolis has given us some wonderful examples of different types of ego-syntonic joining:

“P: I slept poorly last might and feel tired today.
A: You look tired.

P: I feel miserable.
A: You’re entitled to feel miserable.

P: (after a harrowing review of his life’s history) I haven’t had
much in the way of pleasure.
A: Life has been one misery after another.”

(1983, p. 214).

None of these techniques are applied in a cavalier manner. As with any of the other modern analytic techniques we have discussed, therapists would do well to keep in mind Dr. Spotnitz’s caution, (1976b, p. 146), that

“Technical proficiency is of little avail if it does not help the analyst to develop in himself the kind of feelings that will catalyze the release of his own emotional energy in language.”

Margolis echoes Spotnitz by saying:

“Joining is a powerful technique for resolving narcissistic resistance in psychoanalytic therapy. Its very power, however, calls for prudence in determining when and how to apply it… Generally speaking, technical skills such as joining come into perspective only as they further the objectives of a comprehensive therapeutic design… The joining technique, presented as it is, has no intrinsic significance.”

(1983, p. 211, emphasis original).

The significance comes from a trained therapist utilizing the technique when necessary and when this is something the patient needs. As Margolis says,

“If the analyst is in resonance with the patient, his joining and mirroring remarks, while addressed to the literal resistance message, will simultaneously engage the unconscious emotional contents sheltering behind it.”

(1983, p. 213).

Clinical techniques such as joining have greatly increased the ability of modern psychoanalysts to deal with difficulties in patients which were previously thought to be irremediable.

Though years of modern analytic training may be necessary to obtain even rudimentary proficiency in these techniques, they help modern therapists provide effective treatment to those who were formerly believed to be beyond help.

References

Margolis, B. (1983). Joining, Mirroring, Psychological Reflection: Terminology, Definitions, Theoretical Considerations. (Modern Psychoanalysis, Vol. 11, No. 1 & 2, 1983; as reprinted in Modern Psychoanalysis, Papers of Benjamin Margolis).

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

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.


© 2008, James G. Fennessy, M.A., J.D.
Matawan, New Jersey 07747
E-mail: njanalyst@hotmail.com
http://modernpsychoanalysis.org/

Beannachtaí Lá Fhéile Pádraig Daoibh!

Beannachtaí Lá Fhéile Pádraig Daoibh!

He stumbled home from Clifden Fair
With drunken song, and cheeks aglow.

Yet there was something in his air
That told of kingship long ago.
I sighed - and innly cried with grief
That one so high should fall so low.
But he plucked a flower and sniffed its scent
And waved it toward the sunset sky
Some old sweet rapture thro’ him went
And kindled in his bloodshot eye
I turned - and innly burned with joy
That one so low should rise so high.
"High & Low" by James Cousins (1873-1956).


2008, James G. Fennessy, M.A., J.D.
Matawan, New Jersey 07747
E-mail: njanalyst@hotmail.com
http://modernpsychoanalysis.org/

Clinical Techniques: #3 - Interpretation

Clinical Techniques: #3 - Interpretation

It may be useful to begin looking at this topic by briefly contrasting the modern understanding of the uses of interpretation with the classical approach. According to Dr. Hyman Spotnitz (1985, p. 166):

“Primary reliance on interpretive procedures is a distinguishing characteristic of the classical method. ‘(t)he ideal analytic technique consists in the analyst’s doing nothing other than interpreting,”… (quoting Fenichel and others)…, and the goal of the analyst is to provide insight.”

Where do verbal interpretations fit in modern psychoanalysis? While our previous writings have underscored the importance of continual silent interpretation to a successful modern analysis; we have also alluded to the potentially ego-damaging effects of interpretation on many of our most vulnerable patients.

As the title of this article suggests, modern analysts do use spoken interpretation as a clinical technique; though the expectation is that they do so in a much more careful manner than previous generations of analysts.

When may verbal interpretation be used as a technique in modern psychoanalysis?

That answer depends on the analyst’s answer to another important question - Where is the patient at?

A rule of thumb that might be applied is that “(a)n intervention is of value only when it helps the patient move out of a pattern of resistant behavior that is being engaged in ‘right now.’” (Spotnitz, 1985, p. 252, emphasis original).

Thus, verbal interpretations may be used when the patient is ready for them, and when s/he will not be damaged by their use. In the “resistance to cooperation” stage, for instance:

“When the patient is really cooperative, he solicits communications that will help him verbalize spontaneously and uncover the immediate obstacles to this. Then it is desirable for the analysts to interpret and answer questions with a view to facilitating the patient’s understanding of the analytic process.” (Spotnitz, 1985, pp. 181-82).

Spoken interpretations may even help protect the patient’s ego at times. For example, one patient, deeply engaged in self-attacking behavior; and saying “My friends tell me I should just let it go. I don’t let things go. I just keep talking about the same things over and over, but nothing ever changes;” was told “Certain things may need to be talked about over and over.”

In this case, the patient’s immediate reaction showed the effectiveness of the intervention – the patient was reassured, less self-attacking, and thanked the therapist for understanding the patient’s need to talk about some things over and over.

Dr. Spotnitz, (1985, p. 276), says that in supervision of other therapists, he has sometimes given the following advice (regarding patients jumping up from the couch):

“… the analyst may make an interpretation pointing out the significance of his own behavior, such as ‘You jumped off the couch because I stirred up too much emotion.’ Such an interpretation tends to facilitate the verbalization of hostility by the patient.”

Spotnitz points out the goals of “maturational interpretations” as follows:

"Any type of intervention that helps the patient say whatever he really feels, thinks, and remembers without causing narcissistic injury (citing Lucas) is designated as a maturational communication…. At the other end of the continuum is the interpretation that is given when requested, and when it will help the patient articulate his own thoughts and feelings… The therapeutic intent underlying the maturational interpretation is to help the patient talk progressively…" (Spotnitz, 1985, p. 253, emphasis original).

The intellectual attractions of interpretation to classical psychoanalysts may have been the cause or result of a certain amount of hubris in the profession in the past. I do not mean to suggest that modern analysts are exempt from this; or that modern analysts might not “inadvertently” use verbal interpretations inappropriately.

A case that comes to mind is one where the patient previously related a long and painful life story to the therapist. Some time later the patient and the therapist had a “falling out.” The patient experienced painful feelings as coming from the therapist, but managed to verbalize those feelings, in spite of the fact that s/he and the therapist were not getting along with each other.

The therapist’s response was to say “Kind of like… (alluding to a previous incident in the patient’s life)". Rather than investigating, the therapist effectively ignored the painful feelings of the patient in this case, even while appearing to connect to them through the interpretation that was given.

What could have been happening? There are any number of possible explanations; the therapist may have been defending against the feelings, may have been thinking s/he would “help” the patient, may have been too self-absorbed to relate to the patient at that moment, etc…, etc… What seems most clear is that this therapist was missing something from the therapist’s own unconscious.

As we’ve discussed many times before, successful treatment most often depends on analysts being closely in touch with their own thoughts, feelings and impulses. This is why modern analytic training takes so long and requires so much of it’s psychoanalytic candidates.

References

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



© 2008, James G. Fennessy, M.A., J.D.
Matawan, New Jersey 07747
E-mail: njanalyst@hotmail.com
http://modernpsychoanalysis.org/

Say Anything! - No. 1

Clinical Techniques: #2 - Commands

Clinical Techniques: #2 - Commands

Dr. Hyman Spotnitz (1985, p.255) says that “(t)he preferred intervention when the treatment gets under way is the command.” In spite of this, the use of the command as part of our clinical armamentarium could be said to be even more frequently “overlooked” than the use of our first-mentioned clinical technique, silence.

Why is this?

First, ideally modern psychoanalysis is a patient-centered, patient-driven approach to therapy. (See e.g., Fennessy, 2008). This infers that the therapist does not attempt to direct the patient in the same way as s/he might in other therapies.

Beyond that, it must be mentioned that many of the applicants for candidacy in modern analytic programs start out with personalities that aren’t easily adapted to the idea of giving patients direct orders or commands; quite the contrary. The ability to use or develop divergent clinical techniques (such as commands) may, therefore, depend on the quality of training received in the psychoanalytic institute.

Luckily for some analysts, however, in modern psychoanalysis

“… (c)ommands are not issued to secure obedience;” instead:

“(t)he therapist’s intent … is to find out whether the patient wants to obey or defy and to help him communicate why he wants to do so – in other words, to mobilize resistance and, eventually, to resolve it.” (Spotnitz, 1985, p. 255).

According to Spotnitz, commands may be as simple as ordering the patient to “(l)ie on the couch and talk,” or they may be effectively “formulated in terms of the patient’s resistive attitude…,” for example:

“The patient may say… that he is not going to talk any more. A reminder that he is supposed to talk tends to intensify the resistance of a negatively suggestible person, but if he is told, ‘You’ve talked too much. Keep quiet for the rest of the session,’ he may reply, ‘I will not’ – and continue talking.” (1985, p. 255).

Notice that when we use the term “resistance” in modern psychoanalysis we are normally referring to “anything that interferes with talking.”

Robert J. Marshall refers to commands, such as those used in the last example, as

“… prescribing the resistance in that the therapist literally orders the patient to exercise resistance. Prescribing the resistance may be best used with negatively suggestible persons. These are persons whose characterologic mode of response is ‘No.’” (1982, p. 69).

Marshall (1982, pp. 69-70) then gives the following case involving his patient, Sam, a 10-year old boy:

“He began a series of resistances after announcing that he wasn’t going to say anything more about his life. When he reiterated his unwillingness to talk, I said (in essence), ‘Sam, you’ve really told me a tremendous amount about yourself in a short period of time. I think you deserve a vacation in talking about yourself. So now tell me what kinds of things you can do in order to avoid talking about your life.’ I also indicated to him that I thought he was an ‘expert’ in thinking up ways of avoiding talk. I enjoined him to tell me any conceivable ways of avoiding talk so that I might recognize those ways with other children. He readily revealed all of his ploys… At this point I suggested to him that there probably were good reasons for his not wanting to talk, that he should really talk if he wanted to be helped, but that it was okay if he didn’t talk. Sam then ventured some complaints and feelings about his parents about which he felt guilty.”

This excellent example shows that commands may thus be used as part of joining the patient’s resistance. (“Joining” as a clinical technique will be separately discussed in a later article).

Marshall also used “requests” similar to commands to great effect with a 13-year old boy named Bill, who appeared to be the polar opposite of Sam – Bill was extremely anxious to please his therapist. Over a period of weeks, Marshall confronted Bill “…with a series of unreasonable requests such as bringing me a ham and cheese sandwich for lunch,” until Bill was finally able to object and later “became more comfortable in revealing his rage…” towards his dictatorial therapist. (1982, p. 65).

Spotnitz indicates that commands may be used to help certain patients restore control, to help teach patients to assert themselves, or for patients who cannot tolerate or respond to questions. (1985, pp. 256-57). Likewise,

“Countercommands may be issued. When ordered to do something by a patient, the therapist may say, ‘You do it.’ A patient who commands the therapist to ‘Keep quiet,’ may be told, ‘You keep quiet too.’ ‘Tell me,’ ‘Say it,’ and other brief statements in the imperative mood are often made.” (Spotnitz, 1985, pp. 256).

As with all of our modern psychoanalytic techniques, these interventions are never used haphazardly, but only as part of the treatment plan. Though the technique is simple, the implementation of it is not – it takes a skilled modern analyst to use these techniques in furtherance of “the talking cure.”

References

Fennessy, J. (2008). Narcissism and the Contact Function, in PRACTICE MATTERS, A Journal of Modern Psychoanalytic Treatment Technique (Vol. 2), Philadelphia, PSP.

Marshall, R. (1982). Resistant Interactions: Child, Family, and Psychotherapist, NY, Human Sciences Press.

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


© 2008, James G. Fennessy, M.A., J.D.
Matawan, New Jersey 07747
E-mail: njanalyst@hotmail.com
http://modernpsychoanalysis.org/