Mechanisms of Cure

Mechanisms of Cure

Practical Use of Modern Psychoanalytic Clinical Techniques

Within our overall mission of helping to cure what ails someone; our thoughts, and subsequent clinical applications of technique in therapy sessions may be viewed from a variety of perspectives. Following our initial contact, are all our innumerable questions regarding the etiology of the patient’s ailments, how to view the case, how to view what is going on in the session, and what to do, or not do, etc… in response to the patient’s contacts with us.

This writer’s opinion is that the practical matters of treatment deserve the most attention. The concern is that we are using clinical techniques that are appropriate to the circumstances, i.e., that work! Clinical techniques have little or no value if we are simply following a formula without appreciable improvement in the lot of our patients. However, I’d like to speak here for a bit about some general guidelines for the analyst’s talking.

In particular, what functions are served by psychosis and how should we treat psychotic material during therapy sessions?

Functions of Psychosis

People are complicated… thus, while the origins of psychosis are likely multidetermined in a particular individual, psychotic operations may be recognized by their biological and psychological results. Dr. Hyman Spotnitz notes that “An excessive tie-up of neurons in fixed and pathological patterns and overactivity or underactivity of certain neuronal systems are generally associated with mental illness.” (1985, p. 96, emphasis original). Psychologically, the psychotic operation functions partly as a defense; Dr. Spotnitz says that in

   …view of the tendency of the schizophrenic patient to take flight, mentally or physically, from a frustrating object, his capacity to engage voluntarily, for therapeutic purposes, in a psychologically retrograde process is assumed to be extremely limited…the move backward in memory may give rise to severe defensive regression and tempt him into the ultimate refuge of psychosis. (1985, p. 170, citing Rothstein, A., 1982). 

Modern psychoanalysts, such as this writer, are usually interested in providing a setting where patients are able to engage in progressive verbal communications, otherwise known as “maturational communications.” While all of the patient’s communications are silently, and continuously analyzed, little or no interest may be shown by the analyst towards patient’s psychotic material. This approach avoids forcing our patients into regression.

The question arises, what about the value of insight or understanding as a clinical tool? Dr. Spotnitz provides a concise answer in the following dialogue with one of his patients (1985, p.260), from a section entitled:

The Key to Analytic Cure

       A: Suppose you convince me that you are as inadequate as you say you are, where does that lead us?

       [P: That will help you treat me.]

       A: How will it help me?

       [P: Then you will understand me.]

       A: How will my understanding help you?

       [P: It will help me get well.]

       A: Understanding alone doesn’t help anyone get well. I have demonstrated understanding and you are not getting better.

       [P: Then how am I going to be cured?]

       A: What cures you is dealing successfully with whatever interferes with your talking out your feelings, thoughts, and memories as they occur to you here.

     

How Much Talking by the Analyst?

Obviously, the answer to this question is that it depends on the circumstances! The analyst needs to insure that the patient’s frustration levels during the session are in a tolerable range. Let’s says that an exceedingly small amount of frustration may be helpful to our patients, but larger amounts are normally counterproductive. Action potential is a related concern. In this writer’s estimation, many, if not most individuals, are more susceptible to taking action, rather than talking, where intense human emotions are involved. Our natural “preference” for action (whether conscious or unconscious) is somewhat remedied by the analyst’s abilities to resolve resistances to maturation communications. Dr. Hyman Spotnitz says:

   The analyst’s participation in resolving resistance is consistently one of providing communications that will enable the patient to verbalize freely all impulses, feelings, thoughts, and memories. In the course of progressive language discharge, the interneuronic structures whose repetitive activation… has served to block maturation are gradually redirected. (1985, p.104).

Too much talking, or too little talking, by the analyst (possibly mirroring the patient’s parents), each have the potential of proving damaging to the patient. The amount of talking needed from the analyst is expressed by Dr. Spotnitz in terms of “units of communication,” and Spotnitz says that even as little as “…2 to 5 units of communication with gradual expansion in this range…” may be appropriate for patients requiring resolution of certain resistances (1985, p.110).

Patients may be greatly frustrated and distressed when they first arrive at psychotherapy. Modern psychoanalysts are particularly well-trained to work with patients as they present, and to help these patients fulfill their desires for personality maturation.

References

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

© 2016, James G. Fennessy, M.A., M.S.W., J.D.

Matawan, New Jersey 07747

E-mail: njanalyst@hotmail.com

http://modernpsychoanalysis.org

Narcissistic Transference

Narcissistic Transference

Freud (1926, pp 52-3, emphasis original) was describing the phenomenon of transference when he said:

The neurotic sets to work because he believes in the analyst, and he believes in him because he begins to entertain certain feelings towards him…. The patient repeats, in the form of falling in love with the analyst, psychical experiences which he underwent before; he has transferred to the analyst psychical attitudes which lay ready within him…

Yet classical analysts soon found that many individuals appeared to be unable to form this type of transference with their analysts. These individuals were then often deemed “unanalyzable,” because of the central role that transference plays in psychoanalysis. (See e.g., Fennessy, 2006).

How can individuals who seem to lack the capacity to develop this “object transference” be helped? Modern psychoanalysts understand that the difficulties experienced by many patients have their origins in the pre-oedipal period. Another way of expressing this is that “(t)he narcissistic patient is arrested at some point or points in approximately the first two years of life.” (Margolis, 1981, p. 149).

Modern analysts are then able to use their skills to build a transference on a narcissistic basis. In this narcissistic transference:

“(t)he patient is permitted to mold the transference object in his own image. He builds up a picture of the therapist as someone like himself – the kind of person whom he will eventually feel free to love and hate.” (Spotnitz, 1976a, p. 109).

Dr. Spotnitz answers the question:

“’Do we want a narcissistic transference to develop?’ We do because in a negative, regressed state, the patient may experience the analyst as being like him or part of him. Or the analyst may not exist for him. The syntonic feeling of oneness is a curative one, while the feeling of aloneness, the withdrawn state, is merely protective. Because traces of narcissism remain in everyone, we seek, when beginning treatment, to create an environment that will facilitate a narcissistic transference so that, first we can work through the patient’s narcissistic aggression.” (Spotnitz, 1976b, p. 58).

Margolis further says that:

“In operational terms… the oedipal patient transfers the images of distinctive objects of his oedipal period onto the analyst, whereas the preoedipal patients transfers onto the analyst the fuzzy and ambiguous images of his narcissistic period… In building the narcissistic transference and eliciting the patient’s picture of the analyst, we are actually eliciting his picture of himself.” (1979, p.140).

Therapists who have any experience with narcissism know that narcissists are often consumed with themselves and themselves alone - given the opportunity they may talk about nothing but their own self-absorptions for years on end. Therefore, it should be apparent that the narcissistic transference will not be come into being on its own – it must be developed through the skills of the therapist.

What does the narcissistic transference look like? Spotnitz (1976a, p. 109) states that:

“On the surface it looks positive. He builds up this attitude: ‘You are like me so I like you. You spend time with me and try to understand me, and I love you for it.’ Underneath the sweet crust, however, one gets transient glimpses of the opposite attitude: ‘I hate you as I hate myself. But when I feel like hating you, I try to hate myself instead.”

Developing the narcissistic transference is normally an emotionally charged process, that proceeds at the patient’s own pace. (See generally, Fennessy, 2008). The training and clinical skills of the modern analyst, including proper use of emotional reinforcement, object-oriented questions and joining techniques, make all the difference between success and failure in nurturing this relationship.

Spotnitz (1985, p. 201) describes the result when the narcissistic transference is successfully developed:

“(w)hen one focuses on the narcissistic patterns and works consistently to help the patient verbalize frustration-tension, object transference phenomena become increasingly prominent… Eventually, the patient’s transferences are aroused by his emotional perceptions of the therapist as a parental transference figure.”

In other words, personality maturation takes place. The symbiotic relationship developed between analyst and patient (See, Spotnitz, 1984, p. 135) may help the patient’s emotional perceptions along. Repeated emotional associations to the mental images of the analyst, as constructed by the patient; strengthen the object field of the mind, or form new neuronal connections.

The greater emotional maturity which results has enduring and important ramifications for the patient in therapy, and in life.

References

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

Fennessy, J. (2006). Modern Psychoanalytic Education. (Online at: http://modernpsychoanalysis.blogspot.com, June 08, 2006).

Freud, S. (1926). The Question of Lay Analysis. The Standard Edition of the Complete Psychological Works of Sigmund Freud, Volume XX (1925-1926).

Margolis, B. (1981). Narcissistic Transference: Further Considerations. (Modern Psychoanalysis, Vol. 6, No. 2, 1981).

Margolis, B. (1979). Narcissistic Transference: The Product of Overlapping Self and Object Fields. (Modern Psychoanalysis, Vol. 4, No. 2, 1979).

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. (1984). The Case of Anna O.: Aggression and the Narcissistic Countertransference. In M. Rosenbaum & M. Muroff (Eds.), Anna O.: One Hundred Years of Psychoanalysis. NY, Free Press.

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/

Building the Therapeutic Relationship

Building the Therapeutic Relationship

It as axiomatic that individuals seeking psychoanalytic treatment are not prepared to be patients simply because they show up at our offices. In fact, one of the most important tasks for the modern psychoanalyst is to teach the patient how to be a patient. Ideally, this begins to take place from the very first contact made.

Frequently, the prospective patient will make this first contact through a telephone call, or through a third person; and as Dr. Hyman Spotnitz (1985, p. 116) has noted:

Before a firm appointment is made and honored, they may oscillate for a protracted period between an intense desire to be relieved of their misery and what seems to be an unconscious need to defend themselves against the anticipated stress of the analytic situation.

Yet, this initial phase of coming together (including the first tentative contacts between analyst and patient) is not regarded as a mere preliminary, but is “governed by the general plan of treatment,” and is thought to “influence all subsequent contacts between them.” (Spotnitz, 1985, p. 113).

It should be obvious that these first contacts will often include resistances, perhaps even treatment destructive resistances, just as in the therapeutic relationship that is eventually developed. (See e.g., Fennessy, 2006).

If an initial interview does take place, the modern analyst “… needs to gather only enough information to help decide whether he could treat that individual effectively and wants to work with him.” (Spotnitz, 1985, p. 118).

In this respect, many modern analysts prefer not to review previous diagnostic records for their patients. Their thinking is that they do not want to be influenced by the diagnostic impressions of others and that they want to use their own feelings in evaluating their patients. As a rule, no pressure is placed on individuals to disclose information that they may have withheld during the interview.

One of the few questions asked during the initial interview might be “why do you want treatment?” (See e.g., Spotnitz, 1985, p. 120; Spotnitz, 1976a, p. 140). Questions such as this help the modern analyst begin to explore the patient’s attitudes and willingness to cooperate.

Practical arrangements may also be brought up in the first interview. Towards the end of the interview, questions such as “have you thought about how much you’d like to pay?” or “have you thought about how often you’d like to come?” are not uncommon.

The discussion of these and similar items may also be viewed as a part of the treatment itself; i.e., in talking about all of these practical matters “(a)rrangements and rules are flexibly formulated as dynamic tools of therapy.” (Spotnitz, 1976a, p. 141).

If an agreement can be reached, the therapeutic relationship will be based upon

… what can reasonably be expected of the patient at the emotional level at which he enters treatment. Provided that he agrees verbally to participate to that extent, the analyst assumes all responsibility for the treatment process… This changes, of course, as the patient makes progress, he becomes more and more capable of assuming an increasing degree of responsibility. Eventually he assumes full responsibility for the success or failure of the treatment. (Spotnitz, 1985, p. 122).

The therapeutic relationship in modern psychoanalysis is therefore built “from the ground up,” similarly to “the mother-child relationship.” (Spotnitz, 1985, p. 113).

This modern approach is particularly useful for those who would have been deemed “unanalyzable” by classical analysts. As Dr. Spotnitz (1985, p. 115, emphasis omitted) says:

The schizophrenic patient who can cooperate… [to a great extent]… in the early stage of treatment is rarely encountered. Nevertheless, the patient becomes capable of making that contribution if the analyst accepts the responsibility for developing an effectual alliance with him.

If the analyst accepts the responsibility and the patient begins talking, the analyst then needs to consider all those other matters in the interest of the patient, such as whether and when interventions might be necessary, whether and how a transference might develop, and what the resulting therapeutic relationship will be.

References

Fennessy, J. (2006). Free Association and Resistance. (Online at: http://modernpsychoanalysis.blogspot.com, August 03, 2006).

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.


© 2006, James G. Fennessy, M.A., J.D.
Matawan, New Jersey 07747
E-mail: njanalyst@hotmail.com
http://modernpsychoanalysis.org/