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/

Free Association and Resistance

Free Association and Resistance

Professor Freud (1913, p. 147) insisted that there was one “fundamental rule” the analyst needed to tell the patient “…at the very beginning:

‘Your talk with me must differ in one respect from ordinary conversation. Whereas usually you rightly try to keep the threads of your story together… here you must proceed differently… You will be tempted to say to yourself: ‘This or that has no connection here, or it is quite unimportant, or it is nonsensical, so it cannot be necessary to mention it.‘ Never give in to these objections… say whatever goes through your mind. Act as if you were sitting at the window of a railway train and describing… the changing views you see outside.’”

This fundamental rule of “saying everything” has since been referred to as “free association.” How do modern psychoanalysts implement this rule?

First, we can say that modern analysts accept that “(e)ven the analytic directive to talk must be viewed as resistance-provoking.” (Spotnitz, 1976b, p. 169).

Spotnitz (1976b, p. 159) commented that one of Freud’s first followers,

“Ferenczi had noted many devices used by patients to resist cure. He observed how difficult it was for the patient to follow the first rule of free flow of ideas until the close of the analysis, and that patients could not understand that free association did not demand complete thinking out of ideas, but complete utterance of what was actually thought.”

Dr. Spotnitz (1976a, p. 78) also recounts that attempting:

"… to overcome the resistance to free association by ‘making use of psychical compulsion’… got Freud into various difficulties. Although time-saving, his approach proved traumatizing to the patient, giving rise to feelings of disturbance, strangeness, withdrawal and the like which inhibited or even blocked communication.”

This classical approach to resistance undoubtedly also caused many patients to be labeled from the very beginning as “unanalyzable” or ‘not suitable for treatment.”

I think it could be said that most modern analysts recognize and respect the patient’s need for the “insulation” (or defenses) that result in resistances. They do not try to “smash through” the defenses and may even help reinforce some defenses until the patient is ready to give them up. This same respectful approach is taken with the question of free association.

Spotnitz (1976a, p. 141, emphasis added) indicates that cooperative behavior would be:

“…that the patient lie on the couch and talk. He is not instructed to free-associate. As the opening move in educating him to do so, he may be asked to tell his ‘ life story’ or simply to talk of his experiences; a severely disturbed individual may begin by recounting how he traveled to the office, what he ate for breakfast, and the like.”

In modern psychoanalysis, the patient’s job is to talk, while the analyst bears the responsibility of helping the patient do so.

In most cases, modern analysts rely on the contact function of the patient’s ego in deciding when and how to help in the patient’s attempts to satisfy this fundamental rule of “saying everything.” This approach helps to safeguard the patient’s developing ego from unwarranted intrusion by the analyst. (See e.g., Fennessy, 2008)

The modern psychoanalytic approach to resistance and free association has had the added benefit of expanding the number of people who may be helped by our methods to the point where “… (w)ith our increasing understanding of the psychological reversibility of the narcissistic disorders, the phrase ‘not suitable for treatment’ has been dropped from the vocabulary of the modern psychoanalyst.” (Spotnitz, 1976b, p. xi).

References

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

Freud, S. (1913). Further Recommendations in the Technique of Psychoanalysis (On Beginning the Treatment) in Freud; Therapy and Technique, (Philip Rieff, Ed., 1978), NY, Macmillan Publishing Co., Inc.

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.



© 2006, James G. Fennessy, M.A., J.D.

Matawan, New Jersey 07747
E-mail: analyst@modernpsychoanalysis.org
http://modernpsychoanalysis.org/