The Middle Phase

Second Year Adult Psychoanalytic Training (APT)
2023-24, 3rd Trimester — Fridays, 3:30-5:00pm
Katherine Weissbourd, PhD


Introduction

The focus of this class will be on how psychoanalysis is practiced, and how we can make the best use of psychoanalytic theory. In an analogy to describe psychoanalytic treatment Freud famously wrote:

“He who hopes to learn the fine art of the game of chess from books will soon discover that only the opening and closing moves of the game admit of exhaustive systematic description, and that the endless variety of the moves which develop from the opening defies description; the gap left in the instructions can only be filled in by the zealous study of games fought out by master-hands.”(On Beginning the Treatment, 1913)

The middle phase of treatment allows the analyst to move between foundational approaches such as containment, interpretation, the use of language, and insight;  and the complementary approach that highlights the freeing up of unconscious process through empathy, play, spontaneity, and creativity. In our study of psychoanalytic technique we will look at some of the classic approaches to treatment: interpretation, free association, and the repetition compulsion, alongside contemporary theories of intersubjectivity and relationality. Interspersed among these theoretical classes are chapters from the book Conundrums and Predicaments in Psychoanalysis: The Clinical Moments Project (2018), edited by Richard Tuch and Lynn Kuttnauer.  We will discuss four cases from this book. In each case the treating analyst faces a challenge, and is unsure what to do. Two experienced analysts from different theoretical perspectives present their “thoughts, feelings, and behavioral inclinations” (3), and then the presenting analyst describes what they did and why. These cases offer an opportunity to compare different approaches to clinical dilemmas, sharpening our critical skills and highlighting our awareness of similarity and difference among different psychoanalytic approaches. 

Learning Objectives

At the end of this course, students will be able to:

  1. Demonstrate the connection between techniques highlighting interpretation and insight, and those which focus on empathy, relationality, and spontaneity in psychoanalytic treatment.
  2. Formulate differences and similarities among analytic models, and show how these contribute to understanding the specifics of each analytic treatment.
  3. Engage in critical reflection on alternate approaches to clinical dilemmas, seeing both the positive impact and the limitations of each.

March 8, 2024 — The possibilities and impossibilities of interpretation

[35 pages]

Poland, publishing in 2002, writes that interpretation is “an approach of open-minded curiosity… based on the certainty that unseen implications and hidden meanings lie behind manifest symptoms.” (p. 825) The analyst and patient explore this undiscovered territory together. Ogden, from an object relations perspective, highlights the emotional communication between patient and analyst. He writes, “my focus over the years has moved from what I mean to how I mean.” (p. 14) He describes the ways that clinical intuition shapes the interpretive attitude in his work. How does the analyst’s attitude of curiosity and engagement set the tone for the patient’s ability to risk deeper self-exploration and change?

Ogden, T. (2021) Chapter 3, “How I talk with my patients” in Coming to Life in the Consulting Room, Routledge, pp57-71.

Poland, W.S. (2002). The Interpretive Attitude. J. Amer. Psychoanal. Assn., 50(3):807-826.

March 15, 2024 — Free association - The spoken and the unspoken in subjectivity and intersubjectivity

[31 pages]

Anton Kris, writing in 1990, describes the value of free association, analytic neutrality, and the analysis of resistance. He highlights the role of words in the analytic process. For Kris freedom of thought is central to analytic work, and interpretation and insight are secondary. Levenkron (2009)  from a different perspective, highlights the moments of meeting between the analyst and the patient. What promotes change, she writes, is not clarity but sloppiness: “The search for fittedness is necessarily a “sloppy” business… and cannot be determined or predicted ahead of time. Indeed, in its very sloppiness lies the system’s potential for novel developments, and thus for surprise and for change”(p 184). How are free association and novelty related? How to they emerge in treatment, and how does the analyst facilitate the use of new language and experience?

Kris, A.O. (1990) The Analyst’s Stance and the Method of Free Association. Psychoanalytic Study of the Child, 45:25-41

Read pages 25-31 only.

Levenkron, H. (2009). Engaging the Implicit: Meeting Points between the Boston Change Process Study Group and Relational Psychoanalysis. Contemp. Psychoanal., 45(2):179-217.

Read pages 179-202 only.

March 22, 2024 — When and how to interpret

[25 pages]

This case explores the problem of interpretation of transference with a patient who is fragile. Adding to the complexity of the case is the role of religion in the patient’s life, a belief system that could be seen as coming into conflict with psychoanalytic theory.

Kuttnauer, L.S. (2018) Chapter 2, “Venturing onto thin ice” in Conundrums and Predicaments in Psychoanalysis (Kuttnauer, L.; Tuch, R; Eds), Routledge, pp48-72.

March 29, 2024 — Paradox and Repetition—Reframing the past traumatic event

[34 pages]

How central is repetition in psychoanalytic treatment? Drawing on Freud’s initial contributions to the repetition compulsion, Russell writes, in 1988, “It is as if things cannot be real, and the patient will not feel psychotherapy means anything, until the treatment situation becomes so much like a dangerous part of the patient’s past that there is in fact a real risk of a repeat of the past.” (p.8) How do we learn to recognize and respond to the emotional intensity of reenactments? How do we remain both engaged and reflective with the patient?

Russell, P. (1998) The Role of Paradox in the Repetition Compulsion in Trauma, Repetition, and Affect Regulation: The Work of Paul Russell. pp1-22.

Freud, S. (1914). “Remembering, Repeating and Working-Through (Further Recommendations on the Technique of Psycho-Analysis II)” in The Standard Edition of the Complete Psychological Works of Sigmund Freud, Volume XII (1911-1913): The Case of Schreber, Papers on Technique and Other Works, pp145-156.

(We will be reading excerpts.)

April 5, 2024 — Dissociation and the use of therapeutic action

[22 pages]

*The mid-term class evaluation will be conducted during this session. Please use these questions to facilitate your discussion: Midterm Evaluation Questions

Bromberg, from a relational perspective, focuses on the place of dissociation in working with past trauma. He writes in 2008 that therapy addresses, “ the growing ability to play safely with something that has so far existed only as a dissociated shadow of past trauma … the transformation in analytic treatment of unthinkable “not-me” self-states into enacted here-and-now events that, in the form of safe surprises, can be played with interpersonally, compared with the analyst’s subjective experience of the same event, and become part of the patient’s overarching configuration of “me.”

How do we move from enactment to play, as previously unknown aspects of the patient surface in treatment?

Bromberg, P.M. (2008). Shrinking the Tsunami: Affect Regulation, Dissociation, and the Shadow of the Flood. Contemp. Psychoanal., 44(3):329-350.

April 12, 2024 — Engagement and the frame

[22 pages]

The patient in this case has become angry and preoccupied when it seems that the analyst has ended a session early. How should the analyst address the multiple aspects of this enactment, making space for both empathy and interpretation?

Freedman, R. (2018) Chapter 6, “Patient as Bean Counter” in Conundrums and Predicaments in Psychoanalysis (Kuttnauer, L.; Tuch, R; Eds), Routledge, pp137-158.

April 19, 2024 — Finding the potential for change and connection through multiple theories

[31 pages]

Teicholtz argues for the use of multiple theories to provide a broad perspective and to allow the analyst to engage in a relationship with the patient that promotes growth and empathy: “the same theory not only looks different as it is practiced from one analyst to the next, but also even looks different as the same analyst practices it from patient to patient.” (49) Her case studies exemplify “…an organic system that brings together and makes sense of what have hitherto been put forth as competing viewpoints. …With empathy as a guide, the field of action and the quality of engagement are left open for the patient’s and the analyst’s coconstruction.” (70).

Teicholz, J.G. (2006) Qualities of Engagement and the Analyst’s Theory. International Journal of Psychoanalytic Self Psychology 1:47-77.

April 26, 2024 — Racial subjectivity

[21 pages]

Writing from an object relations perspective, Esprey uses examples from her own work to show the collapse of thinking and empathy within the context of racial enactments. It is important for analysts to be aware of and to address their “racial subjectivity”: “therapist and patient will inevitably enact normative unconscious processes, evidencing the link between the psychical and the social. These normative unconscious influences, it will be argued, are complicit in ambushing the clinician’s capacity to engage in the reverie that is necessary for the creation of the analytic third (Ogden, 1999) in which the clinician is able to think about and contain her own and the patient’s renderings. (22)… [T]he integrity of the therapist’s mind and her capacity to filter and manage her own subjectivity becomes potentially impeded when race enters the dyadic engagement. (25)

Esprey, Y. (2017) The Problem of Thinking in Black and White: Race in the South African Clinical Dyad. Psychoanal. Dial., 27(1):20-35.

Suchet, M. (2017) Reclaiming a Mind: Commentary on Paper by Yvette Esprey. Psychoanal. Dial., 27(1):47-51.

May 3, 2024 — Countertransference

[22 pages]

In this case the analyst had just begun to feel that the patient was experiencing some trust their work and was able to open up to her, when a comment she made caused him to become angry and critical. In response she became defensive. How should this rupture be addressed and hopefully repaired?

Orbach, S. (2018) Chapter 5, “Feeling Misunderstood Bilaterally” in Conundrums and Predicaments in Psychoanalysis (Kuttnauer, L.; Tuch, R; Eds), Routledge, pp112-133.

May 10, 2024 — The meaning and use of the body as a metaphor

[24 pages]

In this paper the author presents two cases in which the patients were tattooed during the treatment. She explores the patients’ use of their bodies to depict aspects of the relationship with the analyst. “In analytic treatment, these patients both resorted to the act of tattooing at those points at which symbolic language proved insufficient and at which the boundary between the patients and the analyst had become diffuse or the relationship was threatened by interruptions” (20) How do our bodies enter psychoanalytic treatment? When does the body provide the patient with protection from fears of disintegration and loss? How should this be addressed in our work? How are creative, playful, and artistic experiences thought about analytically?

Karacaoglan, U. (2012) Tattoo and Taboo: On the Meaning of Tattoos in the Analytic Process. International Journal of Psychoanalysis 93:5-28.

May 17, 2024 — Extra-Analytic Encounters

[19 pages]

This case presents the dilemma an analyst faces when their patient invites them to attend their art exhibit. The art has been a significant part of the treatment. Should the analyst go? How should it be discussed? What are the implications for the treatment?

Kulish, N. (2018) Chapter 8, “To Attend or Not to Attend the Exhibit” in Conundrums and Predicaments in Psychoanalysis (Kuttnauer, L.; Tuch, R; Eds), Routledge, pp180-198.