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Resonance of Suffering

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Some sixty years after the "Controversial Discussions" in the early 40s, this passionate book resurrects their spirit on a global scale. Under Andre Green's generous, tactful yet strong leadership, a small discussion group of noteworthy analysts of the International Psychoanalytical Association, coming from all the theoretical and geographical regions in today's psychoanalytic Babel, met several times over three years in order to deal, by way of the detailed discussion of their clinical experiences, with what to many of those involved was and still is a polemical concept: that of the borderline patient. Such a concept, widely accepted in the United States, remains controversial in many parts of the psychoanalytic universe, mainly in what concerns the multifaceted relationship between psychoanalytic and psychiatric categories. To be remarked upon is the sincerity put to play by the participants in expressing their doubts, their agreements and their disagreements in the heady process of developing a grasp on the others' viewpoint. In this they set a model for future interchanges between analysts. The end result is likely to constitute a landmark in the already protracted discussion of the borderline as a diagnosis, as well as of its transference and countertransference implications. - Manuel J. Galvez

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1: Psychoanalysts doing exploratory research: the borderline patient, the borderline situation, and the question of diagnosis

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1

Elizabeth Bott Spillius

The focus of this chapter is primarily the experience of taking part in a small exploratory research group of psychoanalysts whose aim was to study countertransference in work with borderline patients. It was what is usually called an “exploratory” rather than a “scientific” research, meaning that its purpose was to develop hypotheses rather than to test them. In a sense every psychoanalytic treatment is a little piece of exploratory research, but this group research was different from that sort of solitary pursuit because it involved eight psychoanalysts belonging to at least four psychoanalytic traditions: those of France, Britain, the United States, and Argentina. There were two psychoanalysts from France, André Green and Jean-Claude Rolland; two from Britain, Gregorio Kohon and myself; two from the United States, Otto Kernberg and William Grossman, and two from Argentina, Jaime Lutenberg and Fernando Urribarri. André Green introduced and chaired the six weekend discussions, which were held from January 2000 to September 2003, and Otto Kernberg did most of the organizing and liaison with the International Psychoanalytic Association, which funded the work.

 

2: The central phobic position: with a model of the free-association method

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2

André Green

From the very beginnings of psychoanalysis, phobic neurosis was described as an irrational fear, often combined with a feeling of disgust, arising in the face of certain objects or certain situations. It combines an attitude of avoidance, a displacement on to the object or the situation which would then become phobogenic, and a projection towards the outside. Ordinarily, this combination of factors constituting the symptom only concerns the psyche in a circumscribed and limited way, to the extent that when the subject succeeds in circumventing the objects or the circumstances giving rise to the phobia, his functioning can even be compatible with normality. This well-circumscribed picture has subsequently been challenged as a result of encountering wider-ranging forms, the analysis of which was rarely based on the mechanisms of symbolization revealed by the displacement. The neurotic framework of the phobia seemed shattered, allowing much more invasive forms of anxiety to appear.

 

3: Lavoisier's law applies to mental matter

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3

Jean-Claude Rolland

It is Christmas Eve. The five-year-old boy whom the psychoanalytic tradition now knows as the “Wolf Man” is expecting his presents. On account of his current psychological constellation, no gift would be more valuable for him than one that would show his father's love. The child falls asleep and dreams: “Suddenly the window opens and, to my great terror, I see, on the big walnut tree in front of the window, several white wolves sitting. They were six or seven of them… They had big tails, like foxes, and their ears pricked up like dogs when they pay attention to something. A prey to a great terror, obviously of being eaten by the wolves, I shouted…” From this account, helped by the associations of the patient (who is now an adult) and following step by step the shifting movements, condensations, and inversions that led him to this manifest content, Freud pieces together what the dream of this celebration night must have been—the dream that was dreamed: the child, identifying with a woman (his mother), has pictured himself sexually penetrated by his father. The violent defence mechanisms arising in response to the irruption of this homosexual desire turn the acquired satisfaction into anxiety, the father, who was the single object of desire, into a horde of wolves, and the wish to be loved by him into a terror of being devoured (Freud, 1918b).

 

4: Mental void and the borderline patient

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4

Jaime M. Lutenberg

It is the intention of this chapter to expound the relationship between mental void and borderline personalities. This was the core of the paper and clinical material I submitted to our work group for discussion.

The main axis of such discussion ran through the clinical level, taking into account transference, countertransference, and framing aspects. It allowed us to theoretically specify our clinical and technical agreements and disagreements. It also helped us to see more precisely how psychoanalysis was considered and how borderline patients were treated in each of our different regions of the world.

In this chapter I am proposing a new view of the ideas contained in the paper I shared with my research group partners entitled “Mental Void and Psychic Reality”.

Given the limited space available, I have decided not to include here the pertinent clinical material and restrict my exposition to the theoretical level. I expect that the contents I include in the psycho-pathological and clinical levels will help the readers approach their own personal experience.

 

5: Transference and countertransference management with borderline patients

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5

Otto F. Kernberg

At the New Orleans IPA Congress in March, 2004, I presented a preliminary, informal report on the main conclusions of the IPA-Research-Committee-sponsored research group. Although not finalized and formally approved by our research group, this report was presented in agreement with the principal investigator and group leader, Dr André Green. This research team, organized and directed by Dr Green from 2000 to 2003, met twice a year for two or three days each in Paris and New York. Its members were Drs André Green and Jean-Claude Rolland, from Paris; Drs Jaime Lutenberg and Fernando Urribarri, from Buenos Aires, Drs Elizabeth Spillius and Gregorio Kohon, from London, and Drs William Grossman and myself, from New York. In presenting my personal conclusions and reflections on what I believe were consensus viewpoints that emerged in the course of the work of that Committee, I also offer critiques of these viewpoints and include in my formulations conclusions stemming from the recent findings of a major, randomized controlled trial studying a psychoanalytic psychotherapy for borderline patients at the Personality Disorders Institute of the Weill Cornell Medical College (Clarkin, Yeomans, & Kernberg, 1999; Clarkin, Levy, & Schiavi, 2005).

 

6: Reflections on a group investigating borderline personality

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6

William I. Grossman

The establishment of an international group of psychoanalysts to consider the nature of and psychoanalytic treatment of borderline personality disorders presents a window into the problems of clinical–conceptual research in psychoanalysis. The discussions exploring various aspects of psychoanalytic experience and problems in treating borderline patients were rich, stimulating, and illuminating for clinicians. However, in this chapter, I do not attempt to summarize the findings, agreements, and disagreements of the group members regarding what we learned about “non-neurotic” patients and their treatment. Instead, I present some reflections on the issues and problems involved in this kind of team effort. The fact that I focus on problems should not be taken as disqualifying the work that has been done but, rather, as something that has been learned through our work together. The progressive increase of mutual understanding of our points of view promised deepening of the exploration of key issues if time had permitted. It seems clear that research of this kind requires a considerably greater period of time for the realization of its potential.

 

7: The analyst's psychic work and the three concepts of countertransference: Contributions made at the final meeting of the IPA Research Group, September 2003

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7

Fernando Urribarri

“How does the contemporary analyst's mind work?” That was the key question that defined the research conducted by our group.

One of the most original and interesting features of our research was therefore the two-tier, heterogeneous, yet complementary exploration of contemporary psychoanalytic thinking. At a first level, our research explored the way of thinking of a group of psychoanalysts from different psychoanalytic orientations and cultures, both in terms of their personal opinions and, to a certain extent, as representatives of their respective currents. At a second level, the topic of “countertransference (with borderline patients)” focused on the specifics of analytic work from this side of the couch, in the analyst's mind—particularly with non-neurotic patients, who push the limits of analytic resources. At the intersection of those two levels is our goal, as set forth in the title and purpose of our research project: identifying points of consensus and disagreement among different theoretical and cultural perspectives.

 

8: Pulling it together

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8

Elizabeth Bott Spillius

At the final meeting of the IPA Research Group, André Green asked each of us what we had thought of the research as a whole.

Otto Kernberg said that he had originally wanted our group to reach a consensus but realized the rest of us did not want to do this, and so he had listed our areas of agreement and disagreement. The list was quite complicated, with 9 points of agreement and 8 of disagreement (see chapter 5; I have also included them as an Appendix).

The nine points of agreement focused mainly on the intensity of the analyst–patient relationship. Of the eight points of disagreement the most important, it seemed to me, concerned the nature of the diagnostic process. Otto works in a psychiatric institutional setting where formal procedures of structural and dynamic diagnosis precede treatment. The rest of the members of the seminar thought that they too were engaged in diagnosis, but in a different way. I believe we thought that we make some preliminary diagnosis in interviews with the patient before the treatment begins and that once it has begun, diagnosis continues on a daily basis, more or less, but without being part of a formally structured process. I think we would haveagreed, however, that our diagnoses were not as systematic as Otto's, perhaps largely because they were not conducted to determine the type of treatment. For the most part our treatments are psychoanalysis or psychoanalytic psychotherapy, whatever the diagnosis.

 

9: On the relevance of the borderline situation

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9

Jean-Claude Rolland

It seems to me unscientific to declare that the question of diagnosis is pointless and incongruous, as several of us were tempted to do during the discussion. Freud taught us to consider the establishment of a diagnosis as an essential part of psychoanalytic work, and André Green recalled that Freud had added to the existing nosological arsenal of his time by including the description of obsessional neurosis. Simply put, the diagnostic enterprise is inherent in the analytic situation and follows its course. It is included in the construction we build concerning our patients from the first interview that we have with them. These constructions are absolutely necessary for us to locate our patients’ demands metapsychologically and then in order to decide on the patients’ analysability.

But as we progress in our experience as analysts, these constructions refer less and less to considerations of structure in the noso-logical sense of the term: for example, to know whether we are in the presence of a psychosis or a neurosis, and what sort of neurosis. My diagnoses refer more and more to considerations of structure in the psychodynamic sense. We try in effect to represent what balance is achieved in this patient, between his drives and the organizationof his ego: or, further, between what one could infer of his internal experience (the nature of his anxiety, the degree of his inhibitions, the dissociation that splits him) and the means by which he can articulate all this in order to verbalize it in the precise context of free association.

 

10: Borderline traces and the question of diagnosis

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10

Gregorio Kohon

Psychoanalysis is an organized body of knowledge, acquired and developed through study and personal experience, the object of which is the psychic reality of the human subject. Psychic reality, as understood by psychoanalysis, cannot be reduced to either the mental or the physical; the psychoanalytic object is a different object of study, with its own characteristics, categories, and laws (Gomez, 2005). The psychoanalytic models and theories are based on fundamental hypotheses and basic assumptions that have been arrived at through a mixture of clinical experience and self-reflection, speculative intellectual activity and intuition, free-floating attention and deduction, and the attribution of retrospective meaning and abstract representations. Since the psychic processes under scrutiny are unconscious, there is no tangible or measurable method that would offer any kind of evidence for the accuracy of hypotheses and assumptions other than those offered by and from within the psychoanalytic method and setting. This does not make psychoanalysis necessarily inadequate or ineffective. Conversely, it challenges the very concept of science, which is forced to confront the ontological status of the psychoanalytic object of enquiry.

 

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