But at the Same Time and on Another Level: Clinical Applications in the Kleinian/Bionian Mode

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'This volume describes in detail my impression of specifically how to understand and to interpret in an analytic session. The reader will note that I present clinical sessions in stenographic detail and display complete sessions. It will be noted that I do not include past history but do make reference to it when it is necessary to understand the text. In the sessions of my own analysands and in those of others, I go to great lengths to detail my private observations, reveries, and countertransferences as well as my thinking about how, when, and what should be interpreted.' - From the Introduction

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1 The consultative interview: initial session

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When interviewing the prospective analysand for the first time, experience seems to suggest that it may be better for the analyst not to confuse the consultation with psychoanalysis itself. Etchegoyen (1991) believes that a marked distinction should be made between the realistic, face-to-face consultation and the future analysis so as to allow the prospective analysand to develop a semblance of the reality of the analyst’s presence—at least as much as he can glean during the consultation. Klein and her followers, including Bion, seem often to do otherwise. They consider that the analysis has already begun with the beginning of the consultative interview and, while interested in past history, do not especially ask for it but allow for it to emerge of its own accord. In other words, they follow the prospective analysand’s free associations and interpret transference from the beginning. The latter was my experience in my Kleinian (Albert Mason) and Kleinian/Bionian (Bion) analyses. Yet Mason (personal communication) has made the point that he likes to take some history of the analysand’s past so as not to be surprised by the emergence of psychosis, addictions, and other disorders of this kind.

 

2 The analysis begins: establishing the frame

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The analytic frame (setting): establishing, managing, and patrolling it

Bion established the connection between the contact-barrier1 and the analytic frame. Put succinctly, the analytic frame, which mediates the relationship between analysand and analyst, is the external counterpart to and extension of the intrapsychic contact-barrier, which, in turn, mediates the protective separation between Systems Cs. and Ucs. (Bion, 1962b, p. 17).

Following longstanding psychoanalytic tradition, I advise the analyst not only to observe the analytic frame but also to “become” the frame. One of the components of this recommendation is the following: when the analyst enters the waiting room to greet and summon the analysand, he should be courteous and return greetings but should not enter into conversation or discussion with the analysand. He should wait for the analysand to occupy the couch and begin to associate before he speaks. The analyst should also deal with an analysand’s tendency to enter the consulting room with coffee, bottle of water, and/or mobile phone (cellphone) in hand.

 

3 Recommendations on technique: Freud, Klein, Bion, Meltzer

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Freud’s (1912e) recommendations on psychoanalytic technique are as apposite today as when he first formulated them. In reading them, one sees the origin of many of Bion’s ideas on technique. I advise the reader to re-read this invaluable trove of recommendations on technique in Volume 12 of Freud’s Standard Edition (pp. 111–171). I have extracted a very brief portion of the beginning of his contribution:

Freud’s recommendations to physicians practising psycho-analysis

The first problem confronting an analyst who is treating more than one patient in the day will seem to him the hardest. It is the task of keeping in mind all the innumerable names, dates, detailed memories and pathological products which patient communicates in the course of months and years of treatment, and of not confusing them with similar material produced by other patients under treatment simultaneously or previously. . . .

The technique, . . . consists simply in not directing one’s notice to anything in particular and in maintaining the same “evenly suspended attention” (as I have called it) in the face of all that one hears. In this way we spare ourselves a strain on our attention which could not in any case be kept up for several hours daily, and we avoid a danger which is inseparable from the exercise of deliberate attention. For as soon as anyone deliberately concentrates his attention to a certain degree, he begins to select from the material before him; one point will be fixed in his mind with particular clearness and some other will be correspondingly disregarded, and in making this selection, if he follows his expectations he is in danger of never finding anything but what he already knows; and if he follows his inclinations he will certainly falsify what he may perceive. It must no be forgotten that the things one hears are for the most part things whose meaning is only recognized later on.

 

4 How to listen and what to interpret

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Monitoring the analytic text

I have learned from my own experience and from that of my colleagues and supervisees that the act of monitoring the analysand’s text has become more complicated over the years. Freud (1912b, pp. 11–12) suggested that the analyst should listen with even hovering attention to the analysand’s manifest content until he is able to discern a pattern that he feels able to interpret. Bion (1970, p. 31) suggests the same with his idea of abandoning memory, desire, understanding, and preconceptions. In fact, Bion often suggested, following a letter from Freud to Lou Andreas Salomé (1966, p. 45), that one should “cast a beam of intense darkness into the interior so that something hitherto obscured by the dazzling illumination can glitter all the more in the darkness” (personal communication,1 1974). I advise the beginning psychoanalyst and/or psychotherapist to respect this intuitive mode of listening but not to follow Freud’s and Bion’s advice strictly until they are far enough along in their training and experience. Freud’s and Bion’s advice is based on their taking for granted that the analyst/ therapist had already been schooled and drilled in the basics aspects of analytic theory. A tennis professional recently informed me that, in his opinion, to attain proficiency with my backhand stroke, I would have to hit 2,500 consecutive backhand strokes before I could “forget it and take it for granted”. The same principle applies to conducting psychoanalysis and psychotherapy: Yes, one must forget theory—but only once one has learned and mastered it! One cannot forget a theory one has not yet learned!

 

5 Termination

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Much has been written about termination, but as I believe that the jury is still out on the criteria that would justify this event, I refrain from examining the literature on the subject. I draw upon my own recent psychoanalytic experiences in terminating four analyses and from other experiences in bringing analyses to termination with supervised cases. There are many factors to be considered. I wonder, first of all, what the ratio is between the number of analysands who have gone through formal termination and those who began analyses and interrupted or terminated prematurely, and what criteria were used in the former category. I also believe that criteria may possibly be different in cases where it is psychoanalysts and psychotherapists who are in analysis. They are mandated to enter and then re-enter analysis when significant countertransference problems or blind spots develop in the treatment of their own patients.

Most of the analyses that I am familiar with that have been formally terminated showed the following characteristics:

 

6 The psychoanalytic treatment of psychotic and borderline states and other primitive mental disorders

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The analytic treatment of psychotic states has an illustrious but brief history, brief because of new understandings about schizophrenia, manic-depressive illness (currently known as “bipolar illness”), and borderline conditions, and brief also because of the rise of psychopharmacology. I should like to preface my discussion with what I believe is the key importance of differentiating clinical states from personality traits. The latter are generally untreatable by medications and are thus, in my opinion, approachable only by psychotherapy, especially psychoanalytically informed psychotherapy. The latter may also, however, be able to complement pharmacotherapy for psychotic or other primitive affect states.

The pioneers in the psychoanalytic treatment of psychotics and borderline patients include Harry Stack Sullivan, Harold Searles, Peter Giovacchini, L. Bryce Boyer, Frieda Fromm-Reichmann, Hanna Segal, Herbert Rosenfeld, Wilfred Bion, Otto Kernberg, Peter Fonagy, Mary Target, and many others. Rather than extensively reviewing the countless contributions on this subject, I merely summarize some guidelines for the treatment of these disorders.

 

7 Basic assumptions of Kleinian/Bionian technique: a recapitulation

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Before moving on to specific clinical applications, I should like to remind the reader of the basic assumptions that in my opinion inform Kleinian/Bionian technique.

A. The analytic session is to be considered as equivalent to a dream. Consequently, transference (and countertransference) is pervasive. Furthermore, individuals mentioned in the text of the session do not exist in their own right within the psychic reality of the analytic session. They are signifiers or displacements for (projective identifications of) objects of the analysand’s internal world and manifestations of the transference, including the analysand’s conscious and/or unconscious experiences of the analyst’s countertransference.

B. The analysand’s free associations, while spontaneous and consciously improvisational, are carefully crafted and “scripted” by what I believe to be a numinous Intelligence within System Pcs., an Intelligence or resident daimon, homunculus, or phantom (which I have elsewhere called the “ineffable subject of the unconscious” or the “dreamer who dreams the dream”—Grotstein, 2000). This Intelligence, which represents the unconscious itself, is incomplete. It needs the subject’s (analysand’s) consciousness (with the assistance of the analyst) as a container to complete its message and give it personal meaning—and, later, objective meaning. There also exists, I believe, another unconscious Intelligence, the “unconscious dreamer who understands the dream” or the “phenomenal dreamer of consciousness”, the one who gives its imprimatur to the dream and/or who affirms the correctness of the analyst’s interpretation.

 

8 Clinical example 1

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I have previously dealt with some of the significant extensions that Bion has added to Kleinian as well as Freudian theory and technique. In what follows, when I present my own work and those of colleagues and supervisees, the reader may see the traditional Kleinian influence but wonder where Bion—or, for that matter, the London Contemporary (post)-Kleinian influence—may be. They are there, to be sure, but I on the basis of personal experience strongly believe that analysts and psychotherapists who are not well trained and disciplined in the Kleinian → Contemporary (post-)Kleinian → Bionian oeuvre do well to master the “Kleinian basics” before immersing themselves in their later, more sophisticated techniques. (I have it in mind to follow this present work with another that will focus on these techniques.)

However, in terms of technique, Bion’s main influence on me is in his right-hemispheric listening approach: container, reverie, alphafunction, wakeful dreaming. His other influences may go unnoticed: the suspension of memory, desire, preconceptions, and understanding (categorization: “this is the kind of patient who . . . “). Ultimately, Bion is the silent analytic coach on my shoulder, ever alerting me to be available for the unexpected, to respect the mystery that is buried in the obvious aspects of the session. In other words, to be “Bionic” (he would have hated that term) is to keep him in mind while listening to the patient.—NO! Don’t look for him. Allow him to incarnate you!

 

9 Clinical example 2

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This analysis took place many years after Clinical example 1. The reader may see some changes in my technical approach. The analysis I am presenting is a good example of the negative therapeutic reaction (psychic equilibrium).

Session

ADAPTIVE CONTEXT: Monday session, one of five sessions per week.

Analysand: You know, I was kind of down most of the weekend, but not terribly so, just a little bit, and then in the evening, after we’d put all three kids to bed, I went out to the store to get some milk. As I was driving back, I realized that I was hungry and that I had been hungry all weekend. It was hard to stay on the diet. Then I had a memory of saying that I was hungry for the wrong things, or of you saying that I am hungry for the wrong things.

My private feelings: I recognized feelings of guilt and defensiveness in me while the analysand was speaking. Noting that this was the first session following a weekend break, I recognized that the patient was dramatizing how he neglected himself the way he felt I had neglected him. In other words, I thought I heard the depressive defence: he was attacking me by projecting guilt into me by his suffering neglect—not caring properly for himself in my absence. In other words, I felt that he wanted me to feel guilty and responsible for his distress. I also had the gut feeling that he was trying to pull me into believing that he was conducting the analysis on his own: first presenting typical weekend complaints and then affecting to proffer the interpretations he would have expected me to give.

 

10 Clinical example 3: brief case illustration of the predominantly “Bionian” mode of technique

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A 24-year-old recently married woman, who had just emigrated from a Central European country, had begun psychoanalysis with me about four months prior to the episode I am about to report (this analysand has been mentioned previously in clinical vignettes). I assessed her to be high-functioning but suffering from, among other things, culture shock in her new country, with extreme homesickness. She entered analysis on a five-times-per-week basis. The analysis proceeded quite well, and she dreamed profusely.

Suddenly one day she entered my consulting room appearing strange—almost as if she were sleep-walking, or at least in a trance. She walked towards the couch, lay on it for a second or two, and then sat up and relocated herself in a chair facing me. Her demeanor was ominous, mysterious, eerie. While all this was in progress, I found myself becoming more and more uncomfortable, to the point that I became anxious, but I didn’t know about what. Then I found myself becoming terrified! In the meanwhile the analysand remained silent. Actually, she had been silent for about 20 minutes, which seemed like a lifetime to me at the time. I then began to feel that I was dying! I knew that I wasn’t, yet I really felt that I really was. When the feeling became almost unbearable, she suddenly and unexpectedly broke the silence and uttered: “You’re dead!”

 

11 Clinical example 4: a patient analysed in the style (my version) of the Contemporary Kleinians

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The patient, JW, is a 45-year-old married film-maker from a South American country, who has lived in this country for the last 12 years. His wife is pregnant with their first child. Both parents are still living in Z. He has a sister who is two years older and a brother four year, older, both of whom also reside in Z. He first consulted me for depression and for feeling that he was a “loser” in life, in his professional world, and in his marriage. He had many affairs but felt bad about this behaviour of his, especially now that is wife was pregnant. I recommended analysis after the second consultative session, and he accepted. He began analysis at a frequency of five times per week and used the couch from the beginning. Of note, aside from his depression and his affairs in his current life, was his having suffered severe beatings by his mother when he was a child and adolescent. He reported that his father never rescued him from her assaults.

Session

ADAPTIVE CONTEXT: First session of the week; he contemplates returning Friday to his distant home for a week to see his family, particularly his father, who is seriously ill.

 

12 Clinical example 5: “bicycles”

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presented by Shelley Alhanati, supervised by JSG

This case presentation is an example (albeit my version) of the application of standard Kleinian technique—with intimations of Bion—with regard to the analysis of a man who alternated between the paranoid-schizoid and depressive positions but largely dwelt in the former. The second and third presentations demonstrate more of Bion’s (1962b) reverie, which constitutes both an extension and a transmutation of Kleinian technique. Shelley Alhanati, who was trained at a Kleinian institute in Los Angeles, whose own training analyst had been analysed by Bion, and whose formal institute superior I was, is one who utilizes her own unconscious somato-psychic “alpha-function” in a state of reverie with her analysands to enable her to transform her analysands’ “beta-elements” (raw, inchoate, unmentalized proto-emotions) into her own personal O—that is into her own corresponding personal emotions—and from there once again into useful, tolerable knowledge (“K”) as interpretations to her analysands.

 

13 Clinical example 6

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presented by a supervisee supervised by JSG

ADAPTIVE CONTEXT: Creativity blocked; mother visiting next week. Friday session, fifth of five weekly sessions.

Analysand: I called the bank today to see which account I should write your cheque on. I was planning to write your cheque in the waiting room but then I realized I didn’t have my chequebook. I guess I’m going to just have to keep watching this. . . . I thought I had a handle on it, but . . . the handle slipped out of my hand. About an hour ago I started to get agitated. I thought of calling about five different people, but then I thought, oh, it’s about you, and it’s Friday, and I needed to eat. I called John (the boyfriend who has just broken up with her), but then I just hung up. I really don’t like Fridays. And I don’t like this aspect of the work. The bill—why do I have to pay, anyway? The Friday thing and feeling vulnerable. It is so much compared to my pay cheque. I feel deprived. Five times is not enough and two times used to feel way, way too much. Now nothing is enough.

 

14 Clinical example 7

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presented by a colleague

ADAPTIVE CONTEXT: Fifth of five sessions. Creativity blocked (she is a writer); mother visiting next week. Analysand: This could be a very good day—writing seminar, hike, seeing my grandchildren—but I’m afraid to let go of my pain and paralysis. Can’t let it go! Had a dream last night. Can’t remember it. When I woke up I thought it was a critical dream that I must tell you. Then it evaporated. Can’t retrieve it. Maybe I was doing some kind of therapy on others. I was a therapist, some kind of strange therapy, something primitive like a primal scream. Don’t know why, a peculiar image that makes no sense. People almost as if in a box, lying on their sides, all black.

Analyst: What does that image bring to mind?

Analysand: Sort of fetal-like position, so primitive and so, don’t know, sexual or shameful. Maybe I feel all these feelings I’ve been feeling are so childish and primitive, absurd and shameful. Delving into feelings of childhood. So frustrated. Wanted to be noticed. I wanted encouragement. I was ignored or ridiculed or just stupid the way my fears would take over like when I ran hurdles in high school. I couldn’t jump over the hurdle. Gym teacher and coach angry and frustrated. Able to do it before but then not when they were there. My confidence and excitement would evaporate. It was like something from the pit would reach up and snatch my excitement away . . . replace it with fear and self-loathing.

 

15 Clinical example 8

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presented by a colleague

ADAPTIVE CONTEXT: Continuation of Clinical example 7. Third of five sessions. The analysand is writing vigorously after a long dry spell. This week, after a long delay, she followed through on her contacts with writing agents. It seems that she is on the verge of publishing her work. (The analyst, unbeknownst to her, is preparing to teach a course on dreams.)

JSG’s private thoughts: The reader will undoubtedly recall the previously reported session of this analysand. I therefore ask the reader to suspend his memory and pretend, not only that this is the first time they have encountered this analysand’s associations, but that this is, paradoxically, the first session of the analysis again! This state of mind is required of the analyst, according to Bion, to allow for the surfacing of the ever-emerging unknown, O.

Analysand: It feels like I have nothing to say, can’t think of anything to say (unusual for her). (Long pause.) Oh! I had a bit of a dream: I’m in a summerhouse. There’s a shortage of something, but I’m exempt. I don’t know what the shortage was. Maybe something like mobility. It doesn’t make any sense.

 

16 Clinical example 9

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presented by a supervisee supervised by JSG

ADAPTIVE CONTEXT: The analysand comes four times per week. I had to switch her time. I’m going to be out of town tomorrow (Thursday), just for the day, to take a quick trip, so she usually comes Tuesday, Wednesday, Thursday, and Friday. This is the second of four session of the week. The analysand lies on the couch.

Analysand: This is my last day of summer. I’ll guess I’ll just have to see how this all is going to fit, and if I get to do what I really want to do.

Analyst (countertransference remarks by analyst to JSG: I had that same feeling of being tired as I did last week with her when I was coming over here today to see you. Before, when I was getting ready to come, when we talked it about last week, I told you that I said to her: “You probably would prefer just falling asleep here in my arms and not having to face the anxiety about starting school and fitting everything in to school.” She felt it—well, I made reference to it, because she made reference to the fact that she felt it on Friday, and I made reference to the fact that she wanted to sleep in my arms, not having to face that break, and the anxiety about starting school, and fitting everything in.)

 

17 Clinical example 10

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fragment of a session from a colleague’s case

ADAPTIVE CONTEXT: The patient is a married man in three times/ week analysis, on the couch, for many years. He comes Tuesday, Wednesday, and Thursday. This session is a Tuesday, the second week back after a long summer break. His vacations often occur outside the times when I am away. This session follows his cancellation of the last Thursday session and also looks forward to the next week, when there will be a missed session because of the upcoming Jewish holiday. He has a long commute to my office from his home and an even longer commute from my office to his office. When he cancelled last Thursday, it was because of severe weather, which in the past has caused significant time delays in his getting either to his session or to work. In the two sessions before the cancelled Thursday, he revealed that he had begun an affair over the summer break and had imagined substituting time with his girlfriend for the analysis.

Tuesday (second of three weekly sessions)

 

18 Clinical example 11

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from a colleague

ADAPTIVE CONTEXT: Five-times-per-week analysis. Friday, 7 June: last of the week, and when I leave on vacation. (The analysand was 15 minutes late.)

Analysand: Why am I late? Am I trying now to do to you what you’re going to do to me? Actually, I had a 45-minute jog on the beach and then lunch with an old friend in Venice. She was very upset because her husband wants a divorce. I was able to give her some general advice, including the name of a good lawyer. I felt really good about that. She commented about how different I was and that she admired how I’ve moved on.

Analyst: I think it’s much easier and more satisfying to speak to your friend from a position of expertise, to be able to give her helpful tips and be in a position of knowing, than to come here and examine the you who needs help and who doesn’t know everything.

JSG’s private thoughts and proposed interpretation: The analysand seems to be a seasoned one so was able to anticipate what she believed her analyst would have said by saying it first. I would have interpreted the associations about her friend who is being left by her husband as follows: “I wonder if your coming late is your way of divorcing me as I am felt to be divorcing you, not only for the weekend break but for the vacation. One bad divorce seems to deserve another.”

 

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