Process: Continuation of Opening Phase to Early Middle Phase (with Introduction to Psychoanalytic Writing)

First Year Adult Psychoanalytic Training (APT)
2020-21, 2nd Trimester — Fridays, 3:30-5:00pm
Diane Wolman, MSW
Scot Gibson, MD


Introduction

This process class addresses the transition from starting the analysis (Opening Phase) to being solidly in the analysis (Middle Phase).  These “phases” are not sharply demarcated; rather, the terms are helpful markers for understanding the way into and through an analysis.

An analysis is a relationship, one that requires a high level of intimacy. The growth of this intimacy is one of the goals of the analysis, and this takes time and immersion (which is the main reason for the frequency of sessions in most analyses).  The analytic relationship takes place within a particular and special structure (the frame), which is carefully crafted to facilitate the necessary work.  The tension between intimacy and structure is where much of the important work of psychoanalysis happens, and it can encompass some of the most difficult areas to negotiate for both patient and analyst.

One of the major tasks in learning to be an analyst is to become comfortable within that tension.  You will become increasingly comfortable building the intimacy and also providing the structure, while holding on to the understanding of why both are important to the process.  As this understanding grows, psychoanalysis will increasingly make sense to you.  You will understand more of what is going to be created between you and the patient – at first in general terms, and increasingly in terms of what will grow between you and your specific partner in the analytic dyad.  As your ability to create the setting and provide the containment grows, you will grow increasingly confident in making a recommendation for analysis in the first place.  Your enthusiasm and hope for the analysis will be conveyed to the patient, and will itself become a part of the holding environment.

In working with patients analytically, you will rely on the frame, various theories and formulations about what is going on, as well as your affective responses to the patient. At times, when you and your patient are both having strong affective responses due to unconscious pressures, you and your patients will be involved in enactments.  Enactments, once feared as failure on the part of the analyst to deal with their countertransference, are now considered essential to the development of intimacy between analyst and analysand and to the “working-through” process that is central to psychoanalysis.

In the first part of this class, we will talk about some of the basics of what happens between analysand and analyst, in the co-created, interpersonal space that is often called the analytic field or the analytic third.  Later in the class, we will address some specific issues or dynamics that often need to be negotiated in an analytic relationship, including the use of psychotropic medications; the presence of somatic or behavioral issues such as eating disorders or addictions; or particular differences between the two members of the dyad (such as race, sex, or politics).

Another important goal of this class is to help you begin to write about your experience with psychoanalytic patients. We will use short writing exercises in class to help you into the process of writing about session material, culminating in a final session where we focus on the literature about psychoanalytic writing. At the last session, we will also ask you to submit a brief writeup of a clinical moment, which we will return to you with comment after the class ends.

December 4, 2020 — Developing an Analytic Identity

Presenter: Diane Wolman, MSW

What constitutes an analytic identity? Understanding that most of what goes wrong for people developmentally came about within the context of a relationship and it is through a relationship that healing can occur.  We are offering our patients our selves in a particularly analytic way that balances intense transference/countertransference feelings with the need for clear limits within a solid frame.

The reasons that brought you to analysis help you to understand why your patients are considering analysis and what their hopes and concerns might be.  You and your patients must tolerate the “extraordinary pain and narcissistic injury of learning to do something new.” Erlich asserts that while analysts always have to contend with the external pressures in their lives at every stage of our careers, that being an analyst in training does bring unique pressures to bear on the analytic dyad.  Shwaber beautifully explicates the reluctance we analysts can feel to take up such an important place in our analysands’ minds and why we might have a general tendency to shift away from the immediacy of the moment when we are with analysands.

As you’re reading, please think about times when you may have felt yourself pulling back from being emotionally present with a patient and why you think that you felt that way.

Erlich, J. (2003). Being a Candidate: Its Impact on Analytic Process. J. Amer. Psychoanal. Assn., 51: 177-200.

Schwaber. E.A. (1992). Countertransference: The Analyst’s Retreat from the Patient’s Vantage Point. Int. J. Psycho-Anal., 73: 349-361.

December 11, 2020 — The Analytic Field: The Relationship and the Developing the Dyad

Presenter: Scot Gibson, MD

The various elements of psychoanalytic work (the frame, the setting, the particular ways of talking, relating, and listening) come together between the patient and analyst to create what is now generally called the analytic field.  This is a new element or interpersonal relation, contributed to by conscious and unconscious elements of both members of the analytic dyad.  Ogden has a similar concept, called the analytic third, and he wrote about this co-creation in a series of seminal papers from the 1990s.  Ogden stresses that understanding of the co-created nature of the analytic third is important, because it is partly by following one’s own reverie (as the analyst) that one understands what is being communicated between the dyad.  In other words – analysis is not just about listening to the patient, it’s also about listening to what the patient’s associations draw out in the analyst’s own mind, as the two are intimately connected in the field.

Silence is often a very important part of the field, and knowing how to work with it can be challenging.  Cooper discusses how the analyst is both facilitator of the analytic process but also can become (through the transference) a feared internal object. Understanding his patient’s silence as an expression of the conflict inherent in these two important roles was useful in helping him keep the field open, and not close it down by trying to promote a premature expressiveness.

Ogden, T.H. (1994). The Analytic Third: Working with Intersubjective Clinical Facts. Int. J. Psycho-Anal., 75:3-19.

Ogden:

One thing to keep in mind is that, as human beings, we cannot really multi-task — our attention can only be in one place at a time.  Note how Odgen allows his attention to leave the patient’s associations in order to follow his own.  How does this make you feel? What about the personal nature of your own reverie, and your own need for privacy?  Also — how does this compare to other types of therapy you may have learned?

Also, note how much Ogden stays in the present moment — both in his own reverie and in the thoughts he has about and the comments he makes to his analysands.  He does think about the patient’s past and development, but he most often just comments on what he feels in happening in the room at the moment, within himself, within his patient, or between the two of them. How does this compare with your ideas about psychoanalysis?

Cooper, S. (2012). Exploring a Patient’s Shift from Relative Silence to Verbal Expressiveness: Observations on an Element of the Analyst’s Participation. Int. J. Psycho-Anal., 93(4):897-91.

Cooper:

Pay attention to how Cooper is aware of the multiple roles he is playing for the patient — for instance, he is both the (somewhat) trusted facilitator of the process but also a feared object in the transference.  What other roles does he identify?

Note also his awareness of the multiple ways communication does and does not take place — speech is not always communication, and sometimes speech can be non-discursive communication, such as when it is communicating a defense.  And silence can have multiple meanings.

Note also his skepticism and examination of his own impulses as an analyst — his acknowledgement that he is sometimes “acting out” his own anxieties or biases.  How does this, and also Ogden’s reverie, compare to or differ from the ideas from the Schwaber article from last week on staying within the patient’s vantage point?

January 8, 2021 — The Analytic Field: Enactments I

Presenter: Diane Wolman, MSW

Enactments are usually unplanned, unconsciously triggered affective communications between the analyst and patient.  They are frequently highly charged and have an element of both members of the analytic dyad feeling “out of control.”  Once feared as a sign of improper technique, they are now understood to be ubiquitous in psychoanalytic treatment and, many-including us- would argue, are central to the human connectedness necessary for analyst and analysand to forge a true therapeutic bond. Schore discusses right brain structures from the neuropsychoanalytic perspective of regulation theory and he outlines the essential role of implicit affective responses in psychotherapeutic change.  He contends that direct access to these right brain implicit processes by both patient and therapist is central to effective treatment. Ginot explains that by embodying the most intense manifestations of transference-countertransference interaction, enactments expose and repeat some of the fundamental building blocks of the patient’s earliest self and other representations while simultaneously engaging some of the analyst’s own unconscious relational schemas.

Schore, A.N. (2011). The Right Brain Implicit Self Lies at the Core of Psychoanalysis. Psychoanal. Dial., 21(1):75-100.

Ginot, E. (2007). Intersubjectivity and Neuroscience: Understanding Enactments and Their Therapeutic Significance Within Emerging Paradigms. Psychoanalytic Psychology, 24(2): 317-332.

“Prosody (Definition and elaboration)”  (Handout)

January 15, 2021 — The Analytic Field: Enactments II

Presenter: Diane Wolman, MSW

These three articles on enactments, while coming from slightly different vantage points, all deal with the importance of the affective component of “repair” as an important part of the analytic relationship. Bromberg focuses on the centrality of self-states and dissociation. He does a nice job of explaining how figuring things out together, an essential part of intersubjectivity, helps analysands’ minds to disentangle themselves from painful memories of feeling “small” and “stupid.” He includes analysts in this healing scenario when we are able to “hang in” relationally rather than feeling overcome by shame and seeing enactments as a failure of proper technique or evidence of new pathology. Chused makes the case for the centrality of the intersubjective affective relationship, pointing out that it is the patient’s transference and psychic reality that usually dominates and it is the transference-laden messenger who is usually heard and not the message. Note her discussion of non-verbal communication and the element of surprise as a pivotal aspect of some therapeutic change. Maroda focuses on self-disclosure of the analyst’s affect as an essential element of both minimizing and resolving enactments because it completes the cycle of affective communication.

Bromberg, P.M. (2010). Minding the Dissociative Gap. Contemp. Psychoanal., 46(1)19-31.

Chused, J.F. (1996). The Patient’s Perception of the Analyst’s Countertransference. Canadian J. Psychoanal., 4(2):231-253.

 Maroda, K.J. (2020). Deconstructing Enactment. Psychoanalytic Psychology 37(1): 8-17.

January 22, 2021 — The Analytic Field: Issues of Frame

The psychoanalytic frame is in large part responsible for providing the safety needed for the analytic dyad to engage in this most intimate relationship.  In today’s class we will explore the nature of that safety by considering two aspects of the frame: the fee and the use of the couch.

Myers gets to the heart of the matter when she refers to what our responsibility to our patients actually is. She reminds us that the road to health involves being willing to work with our patients around difficult intrapsychic conflicts.  She walks us through the difficulties related to discussion of the fee for both analyst and patient and how the analyst’s fear of affects can foreclose on important analytic work. She does a beautiful job of discussing how assertion of the fee is a metaphor for the assertion of subjectivity, separateness, and desire and that assertion of these important aspects of personality leads to more intimacy and growth both in the analytic relationship and for analysands in their external lives.  Ross explores the use of the couch. He discusses how the use of the couch can assist in the patient’s developing sense of separateness and autonomy. My case write-up (Wolman) is an example of how the use of the couch assisted a patient with intrusive negative obsessive thinking to be able to develop a space in which he could explore the inner workings of his mind and open up a space for us to work together.


Midterm evaluations should be conducted at the end of this class. Discussion of how remote classes are handled and suggestions on how it can be improved will of course be very welcome. An outline to start the discussion is provided in a link below.

Midterm Evaluation Discussion Questions

Myers, K. (2008). Show Me the Money: (the “Problem” of) the Therapist’s Desire, Subjectivity, and Relationship to the Fee. Contemp. Psychoanal., 44(1):118-140.

Ross, J.M. (1999) Once More Onto the Couch: Consciousness and Preconscious Defenses in Psychoanalysis. J. Amer. Psychoanal. Assn., 47:91-111.

Wolman, D. (2015). “Mike Henry” Case Write-Up on use of the couch.

January 29, 2021 — The Analytic Field: Working with Dreams

Presenter: Diane Wolman, MSW

Freud famously said that dreams were the royal road to the unconscious.  He considered The Interpretation of Dreamshis major work.  As productions of the dreamer’s mind, they offer analyst and analysand unique opportunities to better understand what might lay hidden in the  mind.  Learning to work with dreams in psychoanalytic treatments can help to open up treatments and assist the analytic dyad in getting past “stuck” places together.

The Greenson article, written 50 years ago, offers a nice history of the use of dreams in psychoanalytic treatments. It also offers beautiful examples of how different ways of working with dreams can open up or foreclose on the analytic process. Fosshage offers helpful technical principles for working with dreams. Sands, in a more recent article (2010), discusses the analytic function of dreams in activating dissociative unconscious communication, which ties in nicely with the Bromberg article we read.

Ron Furedy, a SPSI faculty member who has taught the course on Dreams to fourth year students for many years, has provided guides for how to understand dream concepts and how to work with them analytically. I have added these handouts to the Suggested Readings for Further Interest.

Given that we are offering a lot of material on Dreams, we will be better able to make recommendations for what you might want to focus on and what could be left out, for the purposes of this class, once we get to know you and what makes the most sense for you at this stage of your clinical experience and development.

Greenson, R. (1970). The exceptional position of the dream in psychoanalytic practice, Psychoanalytic Quarterly: 39:519-49.

Fosshage, J.L. (1997). The Organizing Functions Of Dream Mentation. Contemp. Psychoanal., 33:429-458.

Sands, S.H. (2010). On the Royal Road Together: The Analytic Function of Dreams in Activating Dissociative Unconscious Communication. Psychoanalytic Dialogues, 20(4)357-373.

February 5, 2021 — What’s happening in the body? Somatic and Behavioral Disturbances: Substance Use, Eating Disorders, etc.

Presenter: Scot Gibson, MD

The use and treatment of somatic-behavioral symptoms could take up a class by itself, and a fear of them has often been used by analysts as a way of refusing treatment.  However, they are symptoms like any other and do not have to be a barrier to treatment.  To the contrary, they can be a way in to understanding a patient’s basic needs and dynamics, and also how they hold their affects in their bodies.  Ron Levin, who is on SPSI Faculty, writes a chapter on a successful analytic treatment of a woman with an eating disorder.  My (Scot’s) recently delivered case presentation can also shed some light on working with addictions in psychoanalysis.

Levin, Ronald W. (1992) “Somatic Symptoms, Psychoanalytic Treatment, Emotional Growth” in Psychoanalytic Perspectives on Women, Elaine V. Siegel, ed., pp44-62.

Gibson, S.N. (2017) “Thinking Psychoanalytically about Addictions.” Unpublished.

February 19, 2021 — Psychopharmacology and Psychoanalysis

Presenter: Scot Gibson, MD

For many years, treatment with medications was eschewed by psychoanalysts. In the past 30 or so years, the pendulum has swung in the other direction, and it is now generally well-accepted that concurrent treatment with medications and psychoanalytic treatment can be very successful. Purcell cautions that we as analysts not be too cavalier toward this “new” acceptance of medication use in our patients, suggesting that it can be useful to view the introduction of medications as an enactment in the treatment so that it can be rigorously examined for transference and countertransference meanings.

Bers’ article is an examination of what it is like for a non-prescriber, candidate analyst to have a patient begin using medications during the treatment. Her case report is very thorough so if you’re short on time you may want to skim through some of the details (though the flip side of it being prolix is that it gives you a very thorough view into the analysis). Of particular note is the interactions she had with her supervisor around the medication, and the point that the meanings and dynamic implications of the medication can be well-examined even if one is not the prescriber.

Purcell, S.D. (2008). The Analyst’s Attitude toward Pharmacotherapy, JAPA, 56:913-934.

Bers, S.A. (2006). Learning about Psychoanalysis Combined with Medication: A Nonphysician’s Perspective, Journal of the American Psychoanalytic Association, 54(3):805-831.

Optional Reading

These articles by Tutter are very rich, cogent, interesting, and well-written. The first (Medication as Object) is frequently cited by other articles on this topic, with good reason. I didn’t assign them because I had other points I wanted to stress, but reading them is a pleasure and would advance your thinking on this topic.

February 26, 2021 — Differences Between Patient and Analyst

Presenter: Diane Wolman, MSW

As analysts, we have certain human characteristics in common with our patients, and we differ from each of them in that we are, in fact, separate people with unique life experiences.  In this class we will explore the ways in which certain differences between analyst and analysand inform how transference/countertransference is enhanced or at times hindered.

Dorothy Holmes  is a renowned Black psychoanalyst and scholar who was recently appointed by APsaA to head The Dorothy Holmes Commission on Racial Equality, tasked with leading APsaA in addressing racism in the Association as well as in society. In this article (a plenary address at the 2016 APsaA winter meetings) she makes a case for addressing racism in analyses. The two case examples from her paper on multicultural competence (Jewish Patient, Jewish Therapist and White Patient, Black Therapist) have rich material on how cultural factors can impact a case. AishaAbbasi is a Pakistani born Muslim woman who is a gifted and sensitive psychoanalyst and writer.  Her book, The Rupture of Serenity, is well worth the investment.  In the assigned chapter she eloquently describes how she navigates transference/countertransference with three patients for whom her ethnicity and religion in conjunction with political events become significant elements of the analytic field.

Holmes, D.E. (2016). Come Hither, American Psychoanalysis: Our Complex Multicultural America Needs What We Have to Offer. In Journal of the American Psychoanalytic Association, 64(3), pp. 569-586

Holmes, D.E. (2013) Two Clinical Cases Illustrating Multicultural Techniques and Therapists’ Reflections from her paper, “Multicultural Competence: A Practitoner-Scholar’s Reflections on its Reality and its Stubborn and Longstanding Elusiveness.”

Abassi, A. (2014). “The analyst’s infertility and subsequent pregnancy” in The Rupture of Serenity: External Intrusions and Psychoanalytic Technique, Karnac Press, pp2-22.

March 5, 2021 — External Factors Affecting the Analysis

Presenter: Scot Gibson, MD

The analytic relationship does not end at the door of the consulting room.  (Of course, in the time of COVID, that statement has to be considered much more metaphorically than previously.) The outside world intrudes.  Of course, both we and our patients live in the “outside” world, and the idea that we can separate it from the world we inhabit with them in session (as I’m doing in the sentences above) is clearly a fallacy.  But sometimes the incursions from the world “outside” the relationship are intrusive and strong, and can present as issues with which the participants or the dyad must reckon specifically.

Kulish discusses the phenomenon of the analyst needing to reckon with her own internal relationship to the patient’s objects.  These can be an overwhelming presence in an analysis – the “bad parent” or the “problematic spouse” are two common examples – and the analyst herself can sometimes feel invaded by them.  Kulish also deals with how the relative absence in the analyst’s mind of an important figure in the patient’s world was a clue that there was something in the analyst’s countertransference that needed to be considered and addressed.

One of the potential benefits of the forced transition to remote work due to COVID has been a realization that effective psychotherapeutic work can still continue with most patients over remote means.  Scharff’s 2012 article on “teleanalysis” seems a bit dated and almost quaint at times, now 8 years later.  However, it still does a nice job of raising issues around the differences between in-person work and “technology-assisted” work.

Kulish, N. (2014). The Patient’s Objects in the Analyst’s Mind. Psychoanal. Q., 83(4):843-869.

Scharff, J.S. (2012). Clinical issues in analyses over the telephone and the internet. Int Journal of Psychoanal, 93:81–95.

March 12, 2021 — Writing about the Psychoanalytic Process

Presenter: Scot Gibson, MD

The analyst Donald Meltzer wrote:

The “doing” of analytical work and the “talking” about it are very different functions of analysis. The analyst at work must be “lost” in the analytical process as the musician at his instrument, relying on the virtuosity of his mind in the depths. From this absorption he must “surface”, between patients, in repose, in conversation with colleagues and in writing. There can be little doubt that these two areas of function must interact if the individual analyst, and psycho-analysis as a whole, is to develop. Nothing could be more dangerous to this development than a split between the “doing” and the “talking”, between the practitioner and the theorist. (D. Meltzer, The Psycho-Analytical Process, Karnac 1967/2008, p. xi)

In other words, being able to communicate about the process, whether in writing or in speech, is a separate skill to be learned, and still an essential part of being a psychoanalyst.  (This is why we require case conference and case write-ups, in addition to didactics.) This “surfacing” out of the absorption of the clinical situation has important functions for the development of the capacity to think and work psychoanalytically.

The writing process mirrors the psychoanalytic process itself – the movement of unformulated, inchoate feelings and experiences into a more concrete, left-brain form.  This process is both reductive and clarifying.  Ideally, the process goes both ways, with movement from the feeling/experiencing, right-brain realm into the categorizing, linguistic left-brain and back again, with increases in understanding and focus along the way.

Bernstein’s articles (both the assigned and the one “for further interest”) are frequently assigned, and are useful for their clarity and specificity. His 2008 article presents a fairly specific method of writing about analytic content and process which (you may note) mirrors how many good psychoanalytic articles are constructed. There is an initial section detailing the process material; a second section containing the analyst’s reflections on the material, including their countertransference and “self-consultation”; and a third section which talks about how the vignette affected the analytic process and transitions into the next part of the writing.  It’s a very effective and flexible framework for approaching clinical material.

Lew Aron, a very prominent thinker and writer in the relational world, wrote this very cogent piece on the ethics of writing. This is an update of an earlier piece of his from 2000, with an eye toward the increasing availability of any published works to patients and the general public.  It’s a very nice, fairly up-to-date consideration of how to balance the need for confidentiality with the need for us as analysts to share our work and advance the field.

Bernstein, S.B. (2008). Writing about the Psychoanalytic Process. Psychoanal. Inq., 28(4):433-449.

Aron, L. (2016). Ethical Considerations in Psychoanalytic Writing Revisited. Psychoanal. Persp., 13(3):267-290.