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The How-To Book for Students of Psychoanalysis and Psychotherapy

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This is a book that grew out of the many practical "how-to" questions that the author's psychotherapy students have asked him over the years. It is neither an evidence-based compendium nor an attempt to summarize general practice or the viewpoints of others, but rather a handbook of practical answers to many of the questions that may puzzle students of psychotherapy and psychoanalysis. Some of the short chapters include:How to choose a personal psychoanalystHow to do an initial interviewHow to listen to a patientHow to recognize and understand self-states, multiple identities, true and false selves, etc.How to tell what the transference isHow to deal with the sadomasochistic transferenceHow to understand the need for recognitionHow to think about analytic processHow to practice holistic healingHow to refer a patient for medicationHow to get paid for your workHow to manage vacations, weekends, illnesses, no-shows and other disturbances of continuityWhile trying to give simple answers to sometimes very difficult questions, it is written at a level of sophistication that may make it of interest even to experienced practitioners.

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19 Chapters

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Chapter One: How to choose a psychoanalytic theory

ePub

When I began in this field we all studied Freudian theory because at that time anything else was considered “not psychoanalytic”. It was a difficult theory and I studied it assiduously with, among others, David Rapaport, who seemed to believe that you couldn’t be a Freudian unless you learned chapter seven of The Interpretation of Dreams by heart.

Nowadays there is a smorgasbord of theories available and beginners often are inducted into one or the other almost by chance, depending on whom they happen upon as a supervisor or analyst. Fortunately, more and more institutes are offering courses in orientations other than their own, so that students are often faced with a panoply of rich and varied viewpoints that can at times seem quite confusing.

It took me a while to realize that major psychoanalytic theories have generally been constituted around the personal character structure, culture, and world-view of their originators, an unsurprising conclusion. If that is the case, it would seem reasonable that you might choose a theory as you choose a friend, that is, primarily because of personal compatibility. In this sense you can become a personal friend of some of the greatest minds in our field such as Freud, Ferenczi, Klein, Winnicott, and so on.

 

Chapter Two: How to do an initial interview

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In an initial interview the patient is seeking relief from some kind of suffering. He wants to find out what the matter is and what can be done about it. He is hoping to find that you are the person who can help him.

In an initial interview you are trying to figure out whether you can help this person, whether you want him as a patient and, if the answer to the first two questions is positive, how you can get him to come back.

You should always have in mind a bottom fee below which you cannot afford to work. If the patient cannot reasonably meet this fee or if you do not want to work with him, then you should make a careful referral (see 14, How to Make a Careful Referral). Although everyone reacts poorly to being rejected, you should make a real effort to help the patient allow you to make the referral, because it will generally be to his own great advantage as well as to yours.

Try to be totally natural with the patient as if he were your friend, which he might eventually become.

Begin by asking him how you can help him or what brought him here. If he says that he was brought by a taxi, he is demonstrating a thought disorder but this should not dishearten you.

 

Chapter Three: How to choose your personal psychoanalyst

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It was more than 50 years ago that as a candidate in a doctoral psychology programme I heard a student ask the director how to choose a personal analyst. I remember his reply: “Take the analyst to a stable and see how the horses react to him.” This was impractical advice even at that time, and more so now that there are no longer any stables in Manhattan. But the import was clear: training qualifications, reputation, and the number of books written were less important than some affective personal quality to which horses were more sensitive because their minds were presumably not distracted by cognitive considerations.

You should of course consider length of training and other qualifications, books and articles written, courses taught, etc. since these may sometimes indicate a depth of commitment, but do not be overly impressed by the accoutrements of reputation, since some highly reputed analysts, just as some highly acclaimed physicians, may be total duds.

Other things being equal, you should prefer an analyst who has practised a substantial number of hours per week, is readily available, and does not spend most of his time primarily involved with non-clinical work or travelling around the country. If you needed surgery you would choose a surgeon who has done the most operations. That being said, we have all learned much from people who were not full-time clinicians; you want a flexible analyst who is capable of learning from experience, and not one who just keeps repeating the same mistakes year after year.

 

Chapter Four: How to listen to a patient

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When I was in training in the Fifties and early Sixties, we were taught to listen primarily for the unconscious meaning of what the patient was saying. Our ultimate goal was to convert the unconscious or primary process meanings back into conscious or rational thought. It was as if we were translating a foreign language, the language of dreams, back into everyday English. Some of us got to be quite good at this simultaneous translation, but it was never entirely clear whether it was the lifting of repressions that helped the patient, the fact that we were paying such close attention to them, or something else.

Of course this was a distortion of the kind of listening that Freud had sometimes recommended, which was listening without a defined goal, with free floating attention. That is still quite difficult to do, as getting paid to be purposeless requires an uncommon faith in the analytic process. It is still a lot easier for us to assume the role of translator, advisor, benign adversary, older sibling, eager relater, or whatever, especially since that often seems to be exactly what the patient would like us to do.

 

Chapter Five: How to frame and change perspectives

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Recently I was walking in High Line Park, newly built on an elevated rail track that runs over a part of the meat packing district in lower Manhattan. Suddenly I came upon a little amphitheatre in the air, two stories above the ground, with a huge picture window where the stage should be, looking down on Tenth Avenue. Now Tenth Avenue is a nondescript street, with few stores, few pedestrians, and uninteresting vehicular traffic. But framed in this huge window and from this aerial perspective, it took on an interest and meaning such that several dozen people were crammed into the amphitheatre, just staring out of the window at something that ordinarily would never have drawn their attention. My first thought was how wonderful it must be to be a creative architect!

But then I realized that analysts are in fact architects of the mind and that we are constantly engaged in framing, re-framing, and changing perspectives on our own and our patients’ vision of things. For the way we see things, frame them, and give them perspective is essential to giving them meaning, and meaning is what makes life feel worth living.

 

Chapter Six: How to recognize and understand self-states, alternate states, true and false selves, multiple identities, etc.

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I think that the term self-state was popularized by Kohut (1971, 1977) and later used by the relational analysts, most prominently Bromberg (2009), as a way of organizing, speaking about, and structuralizing experiences concerning the self. From the Freudian perspective, “state of consciousness” is a related but more experience-distant concept, elucidated by Rapaport (1951) in his encyclopedic Organization and Pathology of Thought.

There seem to be multiple parameters to a state of consciousness, including certain patterns of affect, different kinds of body schemata, different organizations of time and of thought, and different degrees of awareness of self and other. Thus it involves self-feelings that include both mind and body; a total sense of one’s self at a given moment in time. Everyone’s sense of self or state of consciousness is changeable and changing: for example, awake or asleep, in drug states, meditative states, angry states, loving states, depressed states, exhilarated states, etc. But for some people these multiple states can all feel as if they are encompassed by or belong to the same person—one’s self—whereas for others they feel as if they belong to separate selves or people or even multiple personalities. Thus there is a continuum along which people consistently feel as if they are more or less the same person, and also a continuum along which other people will regard them as being more or less the same person—the difference between “I don’t feel like myself” and “He doesn’t seem like himself”.

 

Chapter Seven: How to manage the telephone

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Of my own three analysts, one never answered the telephone while he was with a patient (I was not even sure if there was a telephone in his office), and the two others always did. One of the answerers explained that he wanted to always be available for patients, but that he would get off the phone as quickly as possible and limit the number of calls to two per session.

Although the best analyst turned out to be one of the answerers, as a patient I was always at least slightly disturbed by this practice and have resolutely refused to answer the phone while with a patient except for emergency situations. Most of the time I even turn off the ringer, especially with certain people who are extremely sensitive to impingements, but sometimes I forget. This is part of my general policy of arranging the office, the lighting, the temperature, the pillows, etc. to suit each person’s preferences whenever possible. I look back with horror at my early years of practice when, for example, I smoked without asking permission, although that was common practice at the time.

 

Chapter Eight: How to get paid for your work

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W hen supervisees have complained about difficulty in getting paid, or when I have had such problems myself, it has almost always been a question of the therapist’s ambivalence about charging for services or lack thereof. Thus many people have difficulty charging when the patient does not show up, for whatever reason, or when the patient complains that they are not helping, or when they themselves feel that they are not helping.

One problem seems to be that it may not feel fair or appropriate to get paid for merely talking to someone, whereas it clearly feels appropriate to get paid for administering a psychotropic chemical to someone, even though it might be useless or even toxic. Now that brain studies have shown that talking therapy activates brain areas similar to psychotropic medication, we may yet come to accept that talking therapy can be as powerful a force as drug therapy for both help and harm.

It has taken me a long time to realize and then fully believe that the treatment begins when the transference is activated, sometimes even before the patient arrives at our office, and that it then continues unabated, during sessions and between sessions, on holidays and vacations, until the treatment is terminated and often for a very long time afterwards. From this point of view, I am being paid to recognize the transference and then to understand and manage it, whether or not the patient is physically present. Whether the patient or I believe that he is currently being helped or not being helped is also one part of that transference constellation.

 

Chapter Nine: How to understand and manage the transference

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Most analysts agree that understanding, managing, and interpreting the transference and countertransference is the most important but difficult part of any psychotherapy. This note cannot pretend to even introduce the subject, so a number of additional readings will be appended to it.

Although Freud “discovered” transference and at times realized its importance, it is strange how little he wrote about it, and how confusing or ambivalent some of these writings are. This trend continues to the present day, suggesting that the transference is not only very important, but also broader than originally conceived and somewhat mysterious in its workings.

Initially it was viewed as simply the displacement of feelings that pertained to an earlier object, such as the father, onto a later object, such as the analyst. It is still viewed by many in this simple, restrictive sense. But in 1914 Freud expanded this to include the notion of a transference neurosis that encompasses the entire treatment and complicates matters somewhat. In the full-blown transference neurosis (or transference psychosis, as sometimes occurs), childhood relationships are replayed with the analyst consciously in the centre, and almost everything else becomes emotionally secondary to this compelling drama. This allows for interpretations such as “What you are experiencing now is what it was like for you then” to feel utterly convincing, and it uncovers long-lost states and feelings that had been repressed by childhood amnesia. Anyone who has been either a patient or an analyst in such a situation is left with an incontrovertible faith in the analytic process.

 

Chapter Ten: How to tell what the transference is

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One way of thinking about this extremely complex subject is to imagine that all analyses have at least two transferences running at the same time: one in the foreground and one in the background (Treurniet, 1993). The one transference, sometimes called primordial, basic, narcissistic, or background transference, is a transference to the analyst as the environmental mother, that is, to the analyst as primarily a function for holding and containing rather than as a person to be related to. This is the transference that keeps the analysis ongoing, as it provides some varying degree of basic or analytic trust that allows your patient to fulfil the minimal requirements of an analysis, namely, appearing from time to time, speaking occasionally and paying his bills. This basic transference is largely preconscious or unconscious and handled through management, although it may become an object for analytic examination early on if trust is lacking, or later on as the analysis proceeds.

The other type of transference, sometimes called classic, neurotic, object-related, Oedipal, or iconic transference, is to the analyst as a partial or whole object who is being related to in some psycho-dynamic way, on both conscious and unconscious levels.

 

Chapter Eleven: How to deal with the sadomasochistic transference

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Iinclude sadomasochistic relationships in defining perversions because in my experience they always go together, and although you may not see many actual sexual perversions in your practice, I am certain that you see sadomasochistic relationships all the time. Now Freud and many early analysts did not seem to think that perversions were necessarily coupled with other pathology like disturbed object relations, but I have never seen an instance where they were not, although I am probably defining disturbed object relations much more widely than Freud did.

What Freud did get brilliantly right was the link between sadomasochism and the beating fantasy, which many people believe to be universal. The Novicks’ (1987) data suggests that beating fantasies are a developmental fact for most people, but that in certain children the beating fantasy becomes a fixed fantasy or a pathological obsession and that these are the more challenging cases.

Following Freud (1919), the conscious fantasy is: a child is being beaten, which covers the unconscious fantasy: my father is beating me. As we shall see, the beating may also become transformed into a permanent sadomasochistic way of loving. People who have beating fantasies often provoke other people in such a way as to re-enact the fantasy and thereby bring misfortune upon themselves.

 

Chapter Twelve: How to manage narcissistic disequilibrium

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It was said of Rabbi Bunim, the Chassidic sage, that he always carried two notes, one in each pocket of his trousers. One note read: “The world was made entirely for you”, while the other note said: “You are nothing but dust and ashes”. Depending on whether his self-esteem was too high or too low, he would reach into one pocket or the other and read the appropriate note to help rebalance his narcissistic equilibrium. Whether consciously or unconsciously, we are all continuously engaged in rebalancing our narcissistic equilibrium and in helping our patients rebalance theirs, even if only by our steady presence.

For those lucky enough to have internalized a steady presence in childhood, this self-esteem regulatory process is automatic and usually requires no thought. For those who have not adequately internalized this regulatory process, and that includes psychotic, bipolar, borderline, and many narcissistic patients, the treatment itself becomes the major regulating mechanism; and the frequency of sessions, their continuity, and the analyst’s homeostatic responses all contribute to the development of self and mutual regulation (cf. Bach, 1998; Beebe & Lachmann, 2005; Ellman, 2002, 2009).

 

Chapter Thirteen: How to understand the need for recognition

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A recognition scene depicts that moment at which long lost or even presumably dead characters are suddenly recognized for who they are and found to be very much present and alive. Recognition scenes abound in The Odyssey, where the old nurse Eurycleia recognizes the disguised Ulysses by his scar, in the New Testament after the Resurrection of Jesus, and in Shakespeare where, for example, Pericles recognizes his daughter who was lost as an infant. Recognition scenes can also encompass the discovery of one’s own identity or true self, or of someone else’s identity or true nature. The moment of recognition always places the event in a new and larger context, so that what formerly seemed insignificant or meaningless suddenly becomes drenched and suffused with meaning and emotion.

I recently came across a beautiful description of the awakening of a young girl who, for the first time in her life feels recognized by an adult:

         There was very little conversation in my family.

         The children shrieked and the adults went about their business just as they would have had they been alone. We ate our fill, somewhat frugally, we were not mistreated and our paupers’ rags were clean and sturdily mended so that even if we were ashamed, at least we did not suffer from the cold. But we did not speak.

 

Chapter Fourteen: How to make a careful referral

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There are many reasons you may not be able to work with a patient whom you have seen in an initial interview. You may feel unable to work at a fee that the patient can realistically afford, you may not have the hours or the time that the patient needs, or you may simply not feel able to work well with this particular kind of patient. As realistic as the reason may be and as carefully as you may explain it, most people feel hurt and rejected, even though they may have been ambivalent about coming. I have found that it often helps to make a careful referral.

I begin by explaining why I feel that this is not the best situation for them, and then offering to help them find something that will feel just right. I say that I will think about what they’ve told me and then call them within a week with the name of another therapist. It will take that long because I want to give this some thought and because I have to phone people and find someone who is right for them and who has the appropriate fee and hours available. I do not want to give them just any old name.

 

Chapter Fifteen: How to refer a patient for medication

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It is very difficult to know when to refer a patient for psychoactive medication because a good part of the data base for psycho-pharmacological research has been so distorted by the medico-pharmacological-advertising complex that reliable data is difficult to come by (see for example Marcia Angell, 2009). The best non-partisan data I have found suggests that most anti-depressants may perhaps be slightly more efficacious than placebo, but not significantly so, and that the frequent side effects, including depersonaliza-tion, render them of dubious clinical efficacy for many patients. Nevertheless, I have seen occasional patients who seem to have been helped by anti-depressants and others who feel that they have been helped, and I support this without hesitation if the patient desires them.

It should be mentioned that for many depressed patients, vigorous exercise, relaxation techniques, and supplements such as SAMe, St John’s Wort and fish oil have been shown to be as effective or more effective than many psychotropic medications (Kirsch, 2010;

 

Chapter Sixteen: How to manage vacations, weekends, illnesses, no-shows, and other disturbances of continuity

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In the old days when analysts saw patients six days a week, they often referred to the “Monday crust”, that is, the “resistances” and other disturbances that arose during the break and that “interfered” with the treatment. Although we may understand the meaning of these phenomena somewhat differently, in these days of once or twice a week therapy we are often much less sensitive to the phenomenon itself.

Thus I recently saw in consultation an analyst who had arrived a minute or two late for a session and apologized to the patient who graciously said it was nothing, but at the end of the week the patient announced that he was forced to cut back his hours for financial reasons. The analyst never made the connection between his “insignificant” tardiness and the patient’s reaction, nor did the patient.

But I believe that every break in the continuity of the treatment, no matter how small, presses a button in the unconscious that is labelled ABANDONMENT, that is, some form of emotional abandonment. According to the logic of primary process, this is true no matter whether the break is initiated by the therapist or by the patient, and no matter how realistically “insignificant” it may appear to be.

 

Chapter Seventeen: How to think about analytic process

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M any decades ago when I was teaching a course in psychology, I asked the students to pair up and then to gaze uninterruptedly into each other’s eyes for several minutes. This proved to be enormously intriguing for some students and impossibly difficult for others, and all of us were surprised at the extremes of emotion that it provoked.

I am reminded of this every time I begin seeing a new patient, for it seems that we are inherently programmed to connect to each other or to struggle against that connection, just as we have learned that an infant is programmed in many modalities to connect to its primary caretaker.

In a similar way, I feel that whenever a patient walks into our office an analytic process is potentially engaged, and that this process takes on a life and a shape of its own. And that is why whenever I do an initial interview (see 2, How to Do an Initial Interview) I am concerned to evaluate the patient’s potential for engaging this process, and also concerned that I do nothing traumatic, e.g., a quiz type “psychiatric”

 

Chapter Eighteen: How to maintain your physical health and mental equilibrium

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An informal survey of a few dozen colleagues, each of whom has been practising psychoanalysis from 30 to 60 hours a week for decades, has provided me with the following information. One of them exercises by walking up the stairs of his apartment building while talking on his cell phone; another does 90 second wall-sits while reciting Shakespeare; several walk each day or play occasional games of tennis, while most of the rest engage in some more directed physical activity like going to the gym, running, or working out at home. The women analysts seem to be more gregarious and more sensible about exercise than the men, some of whom are either maniacal or else totally neglectful. One or two do nothing that could be even faintly construed as exercise. This seems surprising in a profession where remaining seated for long hours at a stretch, often under severe emotional tension, is the rule.

The professional hazards are well known: lower back trouble and burnout are common. For the former, many analysts try to move between sessions, do exercises, wall-sits, yoga, Pilates, tai chi, and other mental and physical disciplines that aid relaxation. The right kind of personal psychoanalysis that unifies and integrates both the mental and the physical can also be quite helpful.

 

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