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

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/

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/