Process II: Early Analytic Process and Psychoanalytic Ethics

Third Year Adult Psychoanalytic Training (APT)
2022-23, 2nd Trimester — Fridays, 1:45-3:15pm

Table of Contents

Introduction

"The Process of Practicing Psychoanalysis" and "Ethics Related to Psychoanalysis" are not separate subjects. They are intricately connected. In this course we will continue the discussion of what psychoanalysis is (and is not), how psychoanalysis begins and how the opening phase of psychoanalysis continues to develop. While traditional courses on Ethics focus on cautioning against boundary violations and what not to do, we will look at how the origins of ethical responsibility are linked to the initial helplessness of human beings and the pull of that helplessness on the parent and on the infant. The psychoanalytic situation recreates a situation analogous to that of the mother-infant dyad, with powerful pulls on both the analyst and analysand. We will take a deep dive into how those pulls can play out in intense transference and countertransference feelings, and why we need to analyze those pulls so that we can harness their power for growth rather than recreating past traumas for analysand and analyst.

Intense feelings can feel scary for both patient and analyst…akin to being out in a stormy sea in a flimsy life raft with no clear understanding of how (or if) there will be a way to get to shore, or even what and where shore(safety) is. Being emotionally present with our patients can feel very unsettling. However, the lack of this type of authentic emotional engagement is exactly what most of our patients did not experience early in life, and from which they can now benefit in psychoanalytic treatment. We will discuss Enactments and how they can be used to form a more solid and secure connection between patient and analyst and lead to more in depth work resulting in more freedom for our patients. They also make the work more meaningful and enjoyable for us.

If you have any questions or concerns, you can email me at dmwolman@gmail.com and my mobile number is (206) 387-1908 if you need to call or text.

Learning Objectives

Our ethical responsibility is linked to understanding what our responsibility to our patients actually is in providing psychoanalytic treatment. By learning how to identify and work within and with elements of the analytic field, including the frame, enactments, and dreams, candidates will be better able to successfully use these elements to engage their patients and help facilitate their growth.
By learning to navigate various features of the analytic relationship, including differences between the members of the dyad and factors external to the relationship, candidates will be better able to respond to the dynamics enacted in these features in ways that move the treatment forward and allow patients greater freedom in their lives.
By writing about the analytic process, candidates will develop a better understanding of how to formulate and communicate what is going on in the treatment, and thus will gain confidence in their work, which will lead to better outcomes for patients.

December 2, 2022 — The Seduction of Offering Psychoanalytic Treatment

[28 pages]

During this class we will consider the intersection of ethics and psychoanalysis as it relates to the ethical seduction of the analytic situation and the importance of maintaining the frame/limits in providing the safety necessary to accomplish the tasks of psychoanalysis.

Levine, H.B. (2017). Book Review: The Ethical Seduction of the Analytic Situation: The Feminine-Maternal Origins of Responsibility for the Other by Viviane Chetrit-Vatine. Psychoanal. Quart. (86) 501-505.

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.

Wolman, Case Report (part one) In-class handout

December 9, 2022 — On Being a Student (Again!)

[55 pages]

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. During this session we will explore the impact of being a student on the analytic process and how it may contribute to ethical dilemmas. You and your patients must tolerate the “extraordinary pain and narcissistic injury of learning to do something new.” We will consider the pressures that come to bear on the student and how to navigate the desire to impress consultants and teachers with our obligations to our patients. 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.

Please come to class prepared to discuss the following:

Any thoughts or concerns you are currently having or have had in the past regarding the pressures to “perform” and how they impact your relationships with your patients.
Your thoughts and or concerns about balancing your patients’ rights to confidentiality with the obligations of being a student and to the profession of psychoanalysis.

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

Bonovitz, C.F. (2016) The Influence of Personal Analysis on the Analyst’s Clinical Style: Idealization, identification, and the Process of Individuation, Contemporary Psychoanalysis,52(2): 224-248.

Levine, H.B. (2017) Psychoanalytic Professional Ethics and Patient Confidentiality. Psychoanalytic Discourse, (4) 1-6.

January 6, 2023 — Understanding Enactments

[42 pages]

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, myself included, 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 analyst 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 13, 2023 — Enactments Continued

[46 pages]

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 20, 2023 — Countertransference

[34 pages]

The psychoanalytic relationship is a very special and complex one that involves great intimacy. These two articles do a nice job of helping us to look at the complexities of our countertransference and the importance of paying attention to when and why we might be pulling away from intimately relating to our patients.

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

Bergstein, A. (2011). The Painful Vicissitudes of the Patient’s Love: Transference-Love and the Aesthetic Conflict. Contemp. Psychoanal, 47(2): 224-244.

January 27, 2023 — Writing about Psychoanalytic Processes

[41 pages]

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. In organizing thoughts about what is going on in the analysis, we become clearer within our own minds about what is taking place. The clarity that comes with writing about a case frequently leads to opening up/movement in the analysis.

Bernstein’s article is frequently assigned, and is useful for its clarity and specificity. His 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 – with an initial section detailing the process material; a second section containing the analysts 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. As with many issues related to ethics, there is frequently not one clear cut “right” or “wrong,” but rather a call to analyze the good and/or bad that might come from particular actions and the need to reflect on why we make the choices that we do in relation to our patients.

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

On the SPSI website, under Member Area, go to the Writing Resources section and read “Guidelines for the Initial Write-up” and “6-month Reports”.

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

February 10, 2023 — Differences Between Patient and Analyst

[39 pages]

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 is the head of 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. Aisha Abbasi 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.”

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

February 17, 2023 — Ethnic Difference and Sadistic Transferences

[26 pages]

“In each analytic dyad, the analyst and the patient can differ in numerous ways. Even when they belong to similar racial, ethnic, or religious groups, significant differences can exist that sometimes never get talked about. To understand the meaning these dissimilarities have for a patient and how he or she uses them, starting with the most superficial and accessible and moving toward the deepest underpinnings, is one of the tasks of an analysis.”

Aisha Abbasi opens chapter 6 of The Rupture Of Serenity with the above commentary on differences within analytic dyads and the task of discovering the meaning of how analysands use these differences.

Please pay particular attention to the second full paragraph on page 114.

Abbasi, A. (2014). “Part IV: When Political Events Intrude Upon Clinical Space, Ch. 6: Sadistic transferences in the context of ethnic difference: before and after 9/11” in The Rupture of Serenity: External Intrusions and Psychoanalytic Technique. Karnac Press. pp111-136.

February 24, 2023 — Dreams

[48 pages]

Freud famously said that dreams were the royal road to the unconscious. He considered The Interpretation of Dreams to be his 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 52 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. 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.

Greenson, R. (1970). The exceptional position of the dream in psychoanalytic practice, Psychoanalytic Quarterly: 39:519-549.

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.

Optional Reading

Furedy, R. (2013) Summary of Dream Concepts

Furedy, R. (2013) A Guide to Working with Dreams Analytically

March 3, 2023 — What’s happening in the body? Somatic and Behavioral Disturbances: Substance Use, Eating Disorders, etc.

[34 pages]

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 has written a chapter on a successful analytic treatment of a woman with an eating disorder and epilepsy. Another SPSI faculty member, Scot Gibson, presented a case at a SPSI Scientific Session that sheds some light on working with addictions in psychoanalytic treatment.

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.

March 10, 2023 — Managing Conflicting Needs in Our Patients and Ourselves