Another Kind of Evidence: Studies on Internalization, Annihilation Anxiety, and Progressive Symbolization in the Psychoanalytic Process

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In our current professional climate, with calls for 'evidenced-based treatment', and in light of the prestige accorded to this emblem, we can ask: for what purpose do we seek evidence? For our students? For the public at large? For an inner sense of feeling supported by science? Most disciplines are concerned with cumulative knowledge, aimed toward self-affirmation and self-definition, that is, establishing a sense of legitimacy. The three parts of this volume are directed toward the goal of affirming a public and private sense of the legitimacy of psychoanalysis, thereby shaping professional identity. In each contribution we adhere to the precepts of 'scientific inquiry', with a commitment to affirming or disconfirming clinical propositions, utilizing consensually agreed upon methods of observation, and arriving at inferences that are persuasive and have the potential to move the field forward. Beyond this, each part of this book describes distinct methodologies that generate evidence pertaining to public health policy, the persuasiveness and integrity of our psychoanalytic concepts, and phenomena encountered in daily clinical practice.

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CHAPTER ONE: The effectiveness of psychoanalytic psychotherapy: the role of treatment, duration, frequency of sessions, and the therapeutic relationship

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Norbert Freedman, Joan Hoffenberg, Neal Vorus, and Allan Frosch

The above title of the 1999 study names the implicit ingredients of both psychoanalysis and psychoanalytic research. With effectiveness, we emphasize the need for the treatment to be registered in the consciousness of the patient. With duration, we note that the consequence of psychoanalytic treatment is cumulative, leaving its imprint over time. With frequency of sessions, we underscore the idea of therapeutic intensity. And, with treatment relationship, we affirm that the therapeutic effort is an intrinsically dialogic undertaking. In our 1999 study we sought to capture the common ground in our psychoanalytic community, if not the essence of the psychoanalytic enterprise. Just as we can speak of a foundational transference (Frankel, in press), with this study we develop a foun-dational psychoanalytic research undertaking.

In a recent review article based on a comprehensive meta-analysis of a wide range of studies, Shedler (2009) finds significant efficacy and effectiveness with psychodynamic treatment. Two findings stand out: (a) “effect sizes for psychodynamic therapy are as large as those reported for other therapies” designated as “evidence-based” (p. 98); and (b) “patients who receive psychodynamic therapy maintain therapeutic gains and appear to continue to improve after treatment ends” (p. 98). In his definition of dynamic therapy, Shedler cites procedures which focus on the consciousness of the patient, such as raising affect awareness, emphasis on the therapeutic relationship, and concern with a patient's history, all of which are part of the psychoanalytic perspective.

 

CHAPTER TWO: Patients' representations of the therapeutic dialogue: a pathway towards the evaluation of psychotherapy process and outcome

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Jesse D. Geller, Donna S. Bender, Norbert Freedman, Joan Hoffenberg, Denise Kagan, Carrie Schaffer, and Neal Vorus

The next three chapters explore the hypothesis that the operationalizing and measurement of the construct “representations of the therapeutic dialogue” can serve as a valid source of evidence about the outcomes of psychoanalytic therapy and the internalization processes whereby psychoanalytic therapy becomes and remains an adaptive resource in patients’ lives after termination.

The research strategy we have adopted to explore this central idea is based on our shared commitment to three basic operating premises:

1. We conceive of representations of the therapeutic dialogue as the intrapsychic equivalents or analogues of the types of verbal and nonverbal exchanges patients have with their therapists. As early as 1926, Freud came to the view that the very essence of psychoanalysis is that it is a conversation in which “… nothing takes place between [the patient and the analyst] except that they talk to each other” (1926b, p. 187).

 

CHAPTER THREE: The RTD Coding System and its clinical application: a new approach to studying patients' representations of the Therapeutic Dialogue

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Jesse D. Geller, Donna S. Bender, Norbert Freedman, Joan Hoffenberg, Denise Kagan, Carrie Schaffer, and Neal Vorus

The Schedule of Therapy Remembered (STR) produced a rich narrative of people's recollections of their therapy experiences. How to use this information to get a measure of patients’ judgments about what was and what was not accomplished during a course of therapy now became the question to be answered.

The primary aim of Chapters Three and Four is to demonstrate the potential of the Representation of the Therapeutic Dialogue Coding System (RTDCS), as well as its operational definitions, scoring principles, and instructions. This will be followed by a presentation of the ways in which RTD scores can be analysed to be specifically responsive to the need for normative information about patients’ retrospective reconstructions of the verbal and nonverbal aspects of the therapeutic dialogue. Included are the first steps in analyses of RTDCS data sets used on a case by case basis to arrive at highly particularized outcome criteria and to try to test the hypothesis that the likelihood of benefiting from a course of treatment is increased if a patient avails himself/herself of the opportunity to construct, remember, use, and identify with benignly influential representations of the therapeutic dialogue in the physical absence of the therapist.

 

CHAPTER FOUR: Representations of the therapeutic dialogue and the post-termination phase of psychotherapy

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Jesse D. Geller and Norbert Freedman

The hope and expectation that the ending of an effective therapy will be a prologue to further growth and development occupies a central role in psychoanalytic theorizing. The primary aim of this chapter is to present preliminary findings of an empirically-grounded perspective on the hypothesis that patients will continue to build upon what they accomplished during the course of therapy after termination if they rely on enduring and benignly influential representations of the therapeutic dialogue to serve adaptive functions.

Some of the questions we have been thinking about are:

•  How do memories of a relationship with a former therapist exert their influence on a person's current functioning?

•  How do former patients continue to build upon what they accomplished during therapy after termination?

•  What roles do the experiences of separation and loss play in shaping a patient's post-termination involvements with representations of the therapeutic dialogue that were constructed during the course of therapy?

 

CHAPTER FIVE: Reminiscing and recollecting

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Jamieson Webster and Norbert Freedman

Let us revisit the Effectiveness Study where we encountered ten patients who elected to speak to Dr V, an analyst, about their earlier experience in treatment. The group had been divided in half with respect to their scores on the Effectiveness Questionnaire: five patients experienced the treatment as satisfactory and the other half reported a sense of dissatisfaction. Once more, we ask the question: what is meant by effective treatment?

In further studies of these patients and their recall narratives with Dr V, the division five and five holds over a number of telling categories with satisfaction correlating with measures of reflective functioning (Fonagy, 1995), secure attachment (Roy, 2007), absence of annihilation anxiety (Hurvich, 2002), and high referential activity, as measured by the referential process (Bucci &Maskit, 2007). One might conclude that satisfaction with therapy is a good quantitative indicator of the success of a treatment with all the concomitant benefits: more secure attachment to the therapist, decrease in anxiety, a widening of one's self-reflective capacities, and so on and so forth.

 

CHAPTER SIX: The Propositional Method for the study of psychoanalytic concepts

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Marvin Hurvich and Norbert Freedman

The Propositional Method to be described in this chapter is being presented as a way of generating another kind of evidence for the study of psychoanalytic concepts. Propositions become vehicles for framing this other kind of evidence, for facilitating new clinical observations, and for offering a structure for comparative psychoanalysis. It is both propositional and generative.

The Method to be described is a procedure to highlight the key features of psychoanalytic concepts, through a reliance on clinical observations and clinical generalizations, and an effort to decrease metapsychological language and formulations. It is intended to facilitate a systematic study of psychoanalytic concepts, and their application to the psychoanalytic process.

Concepts are not only elastic, changing over time, but they are also sources of controversy and conflict. They are statements evoking concordance, spelling out what we are thinking, doing, and inferring clinically, and they are sources of discordance. What we look for is a method that offers a genome that can encapsulate both the commonality and the diversity of thought, and then distil it so that it becomes available for analysis within a single frame. With the method in hand, we hope to find a coherent path towards confirmation or disconfirmation, thus enhancing coherence without succumbing to the search for universals.

 

CHAPTER SEVEN: Meet Mohamed and the method implemented

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Marvin Hurvich and Norbert Freedman

The recorded psychoanalytic therapy of Mohamed, a refugee from torture in Somalia, treated in Oslo, Norway is the subject matter of this chapter. We begin with a brief portrait of Mohamed, sketch out our method of analysis of the transcripts of sessions,2 present an account of the major variables of concern, Annihilation Anxiety (AA), and the symbolizing process (Symbolization and Desymbolization), and then return to the theme of our Propo-sitional Method with the question: how to infer clinical change or a process of transformation?

Mohamed was a political refugee from an African country. He was in his early forties and was an active Muslim. He had a wife and six children at the time of his arrest in the mid-Eighties for his association with groups opposing the dictator of his country. He was in prison for nine years, where he experienced severe torture, maltreatment, and under-nourishment, and was also sentenced to death. He was forced to watch the torture of his wife and one of his daughters, as well as to witness torture and other inhumane acts being inflicted on fellow prisoners, including children. A recurrent theme in therapy was his agony about what he had seen the soldiers and prison guards doing to others. This tormented him as did the physical suffering he himself had experienced. He managed, in spite of this, to find some comfort in his religious beliefs all through his time in prison. However, it was a hard blow for him when the authorities circulated a rumour that he had betrayed his comrades during torture.

 

CHAPTER EIGHT: Annihilation Anxiety and its transformation during early transference engagement: sessions 3 and 4

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Norbert Freedman, Marvin Hurvich, and Alexandra Petrou

This early phase of transference engagement comprises two salient sessions which are distinctly different in character. Session 3 offers a retrospective account of the traumatic situation which we label “trauma retold”. Session 4 is a retrospective report now revived in early transference engagement, termed “trauma relived”. The reader is alerted that this early phase of the first month stands in sharp contrast to the situation a year later when Mohamed had been confronted with a series of disappointments, failures, and crises, followed by the anticipation of a panic attack and then a panic attack proper in the treatment situation. In each circumstance, Annihilation Anxiety dimensions and Symboli-zation processes reveal a distinct interplay between Annihilation Anxiety and its modification through a process of Desymbolization and then, Symbolization. It is with this perspective in mind that we enter the detailed examination of sessions 3 and 4.

 

CHAPTER NINE: Termination crisis and a panic attack: sessions 41 and 42

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Norbert Freedman, Marvin Hurvich, and Alexandra Petrou

About a year and a half after the phase of Mohamed's early treatment engagement, the psychotherapy came to an abrupt halt. The analyst described how the earlier sessions reflected a process of rapprochement in the phase of the working alliance, next a middle phase of depression and hopelessness, and then a final phase which necessitated a return to his home country. The anticipated departure was a subtext that defined the last two recorded sessions (see Chapter Seven). It is in anticipation of despair that our final observations of the recurrence of Annihilatory Anxiety and its transformation will begin.

Throughout this year of treatment the themes of past torture, torture remembered, and torture relived permeated these sessions: the torture in camp, undernourishment, having been sentenced to death, and recounting what prison guards had done to others. Once more, however, a reading of the clinical material (as well as the therapist's comments) suggested that the impact of trauma progressively permeated the patient's state of consciousness, and led us to consider sessions 41 and 42 to reflect a process of cumulative trauma. When these memories were revived in therapy, they peaked once again in the anticipation of panic, and this concern was activated in session 41. But then, through the coincidence of a fire alarm, the total spectrum of terror was activated and relived during the therapeutic hour. That becomes the central theme of session 42. It is for this reason that we designated session 41 to be anticipatory of the panic attack, and then session 42 became the panic attack proper session. Once more we will offer the highlights of each session scene by scene.

 

CHAPTER TEN: Transformations in long-term psychoanalytic psychotherapy: the case of Ms K

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Rhonda Ward, Norbert Freedman, and Marvin Hurvich

In the two preceding chapters, it has been shown how a patient's psychic functioning can reorganize dramatically in diverse directions with the presence of Annihilation Anxiety. It was noted in Chapter Eight how, within the first four weeks of psychotherapy, Mohamed, a severely traumatized patient, revealed such a transformation. His telling of extreme torture, at first desymbolized and concretized, appeared within a new context during active transference engagement. This was a transformation arising through a symbolized transference.

In Chapter Nine, a clinical regression was described and an alteration in the opposite direction was noted. During the “eye of the storm”, the panic attack proper, there arose an accentuation of Annihilation Anxiety, a regressive transformation, creating experiences of psychic blankness. Under these conditions of helplessness, thinking came to a halt. As an epilogue to this second pathway, a fleeting moment of recovery appeared in conjunction with a coun-tertransference enactment, thus depicting the nonlinearity inherent in psychic transformation.

 

CHAPTER ELEVEN: Severely traumatized patients' attempts at reorganizing their relations to others in psychotherapy: an enunciation analysis

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Sverre Varvin and Bent Rosenbaum

Several attempts in psychoanalysis have been made to arrive at a comprehensive understanding of symbolization processes leading from “raw” sense and perceptual impressions to mental representations, and further on to the establishment of emotional and symbolic meaning. The understanding of these processes is highly important when it comes to trauma. Post-traumatic states are dominated by deficits in mental processing and disintegrated images, thoughts, and feeling states that haunt the traumatized. The personality changes as a result of adaptation to these changes in the mental condition. This tends to diminish or incapacitate ego-functions, such as the ability for emotional regulation and symbolization.

In dealing with trauma it is of central importance that our psychoanalytic understanding covers the whole range from nonverbal, not-understandable, unconsciously sensed or apperceived mental states to a narrative integrating capacity with contained emotions, subjective truth, and the ability to take a third position, that is, the ability to reflect on one's own mental states.

 

COMMENTARY: Three pathways towards the modification of Annihilation Anxiety

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Marvin Hurvich and Norbert Freedman

In the course of the preceding chapters and the three successive pathways of modification we have encountered several issues concerning the structure of the annihilatory process and its relation to Symbolization, which are not specific to each chapter but have a general relevance to our entire enterprise. Here are some of the salient issues.

That the meaning of a psychoanalytic concept and its clinical implications vary with the clinical or social context in which it appears has been a tenet of the Propositional Method (Chapter Six). The very title of this essay, “Three Pathways towards the Modification of Annihilation Anxiety”, implies three clinical contexts: pathway 1—early transference engagement; pathway 2—clinical regression one and a half years later; and pathway 3—revisiting a traumatic episode after ten years of psychoanalytic work. In all three situations Annihilation Anxiety, its prevalence and intensity, was essentially high; it was a relative constant. Annihilation Anxiety indeed is a constant confrontation with dangers to psychic survival. What changes vastly are its modifiers.

 

CHAPTER TWELVE: A very broad concept seen through a very narrow lens

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Norbert Freedman and Rhonda Ward

What we are about to explore is a very broad concept seen through a very narrow lens. The concept is working through and the lens is a specimen from a recorded psychoanalysis. The concept has evolved over decades of psychoanalytic experience and clinically can cover years of analytic work. The lens comprises 25 sessions from the third year of a four-times-a-week psychoanalysis. The concept gets at the very heart of the efficacy of psychoanalytic work, but the lens, hopefully, pinpoints those ingredients that matter. One of those ingredients we have discovered and believe is essential to working through is termed the nodal moment.

In the course of this specimen, the repeated theme of torture can be heard. Torture is desired, feared, dreaded, confronted, imagined, reflected upon, and resolved through contrition. For Ms Y, the patient, torture appears within the context of an anticipated inner storm, a theme running like a red thread throughout the specimen, representing an effort towards transformation.

 

CHAPTER THIRTEEN: Method and findings: the case of Ms Y: the patient and her analyst within the context of a recorded psychoanalysis

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Norbert Freedman, Richard Lasky, and Rhonda Ward

At the time of this research, Ms Y was a professional woman in her thirties, and a mother of a three-year-old boy and a newly adopted infant daughter. She and her husband were residing in a suburban community in the US Midwest, enjoying a secure income. About six years prior to this study, she began a twice weekly psychotherapy and in her second year of treatment converted to a four-times-a-week psychoanalysis.

According to the analyst, the tone of the treatment shifted dramatically during the first two years of the analysis. The initial transference, one of non-engagement and affective withdrawal, developed into a sadomasochistic transference and then into one that was explicitly erotic. This intensity, one of over-engagement, seemed to have been a defence against the initial schizoid-like position, though, as the treatment progressed, acute neurotic conflicts also surfaced. It was at this stage that we entered the study of the treatment process.

 

CHAPTER FOURTEEN: The induction of transference regression during the symbolizing phase: sessions 232 to 243

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Norbert Freedman and Rhonda Ward

In 1950, Macalpine published a memorable paper on the nature of transference, in which she asserted that a regressive transference is not only inevitable, but is evoked and actually induced by forces inherent in the frame of the psychoanalytic process. For us, the regressive transference is a paradoxical situation in which the patient may feel received, even supported, yet at the same time confronted by an enigmatic force that pulls in a downward direction. This precise situation was encountered by Ms Y during the symbolizing phase of this transformation cycle.

Macalpine's statement, based on an extensive review of the cumulative psychoanalytic knowledge up to 1950, raises for us two fundamental issues deserving separate consideration. The first concerns what we might call the induction hypothesis, the other we will call the reverberation hypothesis. Regarding the induction hypothesis, Macalpine spells out a series of specific transference forces, mobilized by the explicit and implicit analytic frame, which activate a pull towards a lower level of mental organization. This implies a paradoxical situation: the patient experiences an enigmatic force, pulling in the direction of lesser differentiation, and occurring at the very point of feeling heard and received. In the reverberation hypothesis, what we call regression is not only experienced by the patient, but is also communicated to and experienced by the person of the analyst, lending depth to analytic work.

 

CHAPTER FIFTEEN: The emergence of nodal moments during the desymbolizing phase: sessions 245 to 249

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Norbert Freedman and Rhonda Ward

While in church after communion, connecting within her heart to God, holding her baby on her lap and feeling love for her, Ms Y encountered a moment of a coming together of meaning, of uniting disparate parts within herself, be they a linking of hallucinatory wishes to reality, subjective self-awareness with objective self-awareness, or the splits arising from triangular conflict. This scene from the end of session 243 (Chapter Fourteen) was a nodal moment preceded by a transference regression. It was a moment of unification, marked by a surge of libido, a crucial ingredient of ego synthesis. When such a nodal moment occurs during a regression, it is a first step in the direction of the upward slope and of Progressive Symbolization.

Nodal moments highlight paradoxical transformations at work. These crucial events are preceded by episodes of desymbolization, where the underlying meaning is implicit and unformulated. But when the nodal moment appears, meaning becomes explicit, formulated, symbolized. It is in the transformation from the unformulated to the formulated that the paradox can be discovered, processed, and confronted.

 

CHAPTER SIXTEEN: The enactive phase: sessions 252 to 255

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Norbert Freedman and Rhonda Ward

Almost immediately following the nodal moments of the desymbolizing phase, there appeared a sequence of sessions which we could not classify as either A or Z, and were, thus, neither predominately symbolizing nor desymbolizing sessions. Even more striking was another “objective fact”, alerting us to a potentially informative event: during these sessions, the analyst's scans increased in length. This could mean that the patient had more to say and/or that the analyst was more engaged, but whatever the interpretation, there was a veritable surge of analyst's comments at this point. During the desymbolizing phase, the length of the analyst's scan (expressed in words spoken) was for session 245, 247, and 249, 555, 719, and 452 words, respectively. For sessions 252, 253, 254, and 255, the word output was 823, 1010, 1003, and 709, respectively. Noteworthy is that the scan for session 257, an unambiguous A session and the last of this specimen, had a word count of 1475. From the vantage point of referential activity, there also appeared to be an upward trend: the RA score for session 252 was 0.449 and for session 255, 0.467. It seemed we had entered a new phase in the analytic process, be it patient activity or analyst engagement. Perhaps we were, to use Palombo's memorable metaphor, “[At] the edge of chaos when a small change in input from the environment can lead to a reorganization of the system's structure at a level of increased complexity” (1999, p. 175). Perhaps the upward slope involves a process of differentiation occurring only “at the phase transition between frozen ice and chaotic fluid states” (ibid., p. 176).

 

CHAPTER SEVENTEEN: The cycle and the spiral during the re-symbolizing phase: the erotic transference, the extraordinary countertransference, and the preservation of the analytic process: session

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Norbert Freedman and Rhonda Ward

Session 257 represents a stellar moment in this specimen of working through. It is an unambiguous symbolizing hour, marking a return to symbolization and the completion of the transformation cycle. But it is more than this, for it not only contains the highest level of symbolization in this cycle (as reflected in the peaking of referential activity measures), but it also contains the highest levels of non-integration (as reflected in low measures of interactional synchrony). Thus, this session not only completes the cycle but in its peaks and troughs has the properties of a spiral.

Furthermore, this session contains within its structure all the phases of this transformation cycle, that is, a phase of symbolization, desymbolization, and re-symbolization. In the broadest sense, this replication allows us to translate and revisit the specific way-stations encountered in this specimen. The symbolizing phase of this session reveals paradoxically a downward slope and with it the induction of regression reverberating in the transference (Chapter Fourteen); patient-induced and analyst-induced enactments, resulting in a moment of mutual enactment, reflect a peak of desymbolization and paradoxically initiate the upward slope (Chapter Sixteen); and finally, a nodal moment at the end of the session results in a reversal and a return to symbolization (Chapter Fifteen).

 

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