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Psychoanalytic Technique and the Creation of Analytic Patients

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'This is a book on a neglected aspect of psychoanalytic technique that should be read by everyone who hopes to develop a psychoanalytic practice. Dr Rothstein's emphasis on the value of analyzing a prospective patient's motives for avoiding analysis is of utmost importance. An excellent book by a seasoned and gifted analyst.'- Charles Brenner, MD

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9 Chapters

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1. Beginning Analysis with a Reluctant Patient

ePub

It is a common experience that prospective analysands object to one or another aspect of the anticipated analytic situation: they desire lower fees, different or less frequent hours, and they may object to the supine position. In this chapter analytic data will be presented from two attempts at analysis in which the patients were reluctant about accepting the minimum four times per week frequency of the analytic situation. Although the recent 1993 survey on psychoanalytic practice demonstrated that 27 percent of the analyses conducted by members of the American Psychoanalytic Association who responded to the survey were conducted at a frequency of three times per week, many analysts consider the four times per week frequency an essential aspect of the analytic situation. In addition, most analysts consider the use of the couch as an essential characteristic of the analytic situation. They would view any patient who was unable to begin in this usual manner as not suitable for analysis at this time. They might recommend that the patient be seen less frequently and sitting up in a treatment that they would regard as preparatory psychotherapy rather than psychoanalysis. They might also suggest that when a patient completes this preparatory phase he or she be referred to another colleague to begin an analysis.

 

2. Beginning Analysis with Patients Who Are Reluctant to Pay the Analyst’s Fee

ePub

The purpose of this chapter is the discussion of some of the things an analyst may actually do to help a patient who is able but reluctant to pay the analyst’s fee at the beginning of an analysis. I pursue the goal of this chapter by reviewing selected literature on technique and then by outlining and elaborating my own ways of thinking about what to do with reluctant patients, with particular emphasis on fees, in order to be able to understand and interpret their reluctance so that they may then experience a standard psychoanalysis. Two cases are presented and discussed in which the patients were able to pay but reluctant to do so. Modifications of the usual ways of doing things in regard to fees facilitated these analysands working in standard analytic situations. Although these situations were unusual they served to facilitate discussion of questions of technique with particular reference to questions of the analyst’s functioning in the consultation and opening phase of analysis.

Glover is reputed to have said, “If you want to sleep well choose your patients carefully.” I am suggesting that if you want to be more successful in helping prospective analysands begin an analysis, it is worth reconsidering the practice of being choosy. Implicit in my perspective is a criticism of the pedagogic methodology of institute courses in selection and unanalyzability in which candidate analysts are taught to be selective, to be choosy, to exclude people from the opportunity to “try” analysis.

 

3. On Doing a Consultation and Making the Recommendation of Analysis to a Prospective Analysand

ePub

In psychoanalytic training we have all been taught to do a consultation in which a diagnosis is made and a judgment is rendered as to a patient’s suitability for analysis. We have been taught from a perspective that asks, “Is this patient analyzable?” Following Stone (1954) we have learned to ask, “Is this patient analyzable with ‘modifications’?” Another question that analysts are trained to consider in making assessments of analyzability is, “Is this prospective analysand analyzable with an experienced graduate analyst rather than with a candidate analyst?” Finally, analytic candidates are trained to ask, “Might this prospective analysand be suitable for analysis after a preparatory psychotherapy?” Forty years ago, when Stone published his seminal paper, the collective wisdom was that such preparatory psychotherapy “contaminated” and interfered with the prospects of the therapy evolving into an analysis with the preparing psychotherapist. It is worth adding that forty years ago, at the time Stone wrote his paper, psychotherapy was generally conducted with a less rigorous analytic attitude. The prospects for “contamination” are reduced by the adoption of a psychotherapy technique more in keeping with a truly analytic posture, as is often done today.

 

4. On Analysts’ Evaluating, Diagnosing, and Prognosticating

ePub

Analysts’ interests in evaluating a prospective analysand’s analyzability, and in assessing the progress of an analysis, may be counterproductive to the task of analyzing. This is so because at times analysts’ assessments may reflect their counter-transference responses to the unpleasure evoked by the prospect of working with a prospective collaborator or the unpleasure experienced in an ongoing analysis with a patient experienced as difficult and disturbing.

The emphasis here is on the analyst always working to restrict his functioning to analyzing. By analyzing I mean the analyst’s use of his or her own psychological functioning as a whole to experience and understand the patient, and then with tact and timing communicate that understanding. From this perspective the analyst’s urge to evaluate, diagnose, or prognosticate, rather than to analyze, may be regarded as a possible countertransference signal. The analyst should regard recurrent pessimistic thoughts about a patient’s suitability for analysis and relatedly about their diagnosis, as evoked or induced fantasies. If I find myself thinking about differential diagnosis, rather than considering a patient’s sensitivity, I assume that I am responding to some transference trend that evokes unpleasure in me. Countertransference unplea-sure associated with feelings of revulsion for a patient may be defended against by distancing oneself in the process of considering the prospective analysand’s diagnosis. Conjectures about diagnoses that carry a negative valence such as borderline, narcissistic, psychopathic, or perverse may signal such a countertransference trend.

 

5. Fantasies of Failure, Name-Calling, and the Limits of Analytic Knowledge

ePub

In this chapter I explore the subjective nature of analysts’ experiences of analytic failures. The basic premise of this chapter is that when an analysis fails, an analyst cannot know why it fails because he lacks analytic data to explain the failure. Analytic data derive from a successful analytic collaboration. Once an analysis has failed, all an analyst has is his solitary conjectures concerning the failure of the collaboration. It has been a characteristic of our field that analysts have had difficulty acknowledging this to themselves. Instead they have tended to create theoretical explanations of their failures that place the blame for the failure solely on the shoulders of the failed patient, conceived of as defective.

That said, it is important to state that after working for a number of years with a patient an analyst knows a great deal about that patient. After an analysis fails the analyst, drawing upon her or his knowledge, may construct a valid explanation of the failure. However, the point I am stressing is that without the confirming associations of the departed analytic collaborator there is no way to distinguish a correct explanation of the failure from a self-serving rationalization.

 

6. Couples Therapy Conducted by a Psychoanalyst: Transference and Countertransference in Resistance to Analysis

ePub

In this chapter clinical experience from couples therapy is employed to provide an unusual but valuable perspective on the process of helping patients become analysands. Sander (1988) reminded us of Freud’s (1919) statement that “unhappy marriages can supersede neuroses while satisfying a need for unconscious punishment.” Sander noted that such patients may use externalizing defenses and often do not seek individual treatment but rather seek couples therapy for defensive reasons. Many patients seeking couples therapy find themselves in treatment with a therapist who is not analytically trained. If they do consult an analyst, the analyst may have little experience or interest in that form of treatment and may communicate a denigrating attitude toward it. My therapeutic experience with couples evolved seren-dipitously from a conversation with a fellow analyst who was experiencing an impasse with an analysand. His analysand was employing just those externalizing defenses that Sander noted, a not uncommon phenomenon. A great deal of his analysand’s associations expressed dissatisfaction with his wife and involved reports of discord between them. My colleague expressed his sense that the analysis would not proceed unless the analysand’s spouse accepted a referral for treatment. He had been unable to effect the referral from his analytic vantage point. We wondered together whether my seeing the couple in a consultation might help effect such a referral for the spouse. My colleague referred his analysand for couples therapy with me. The stated purpose of the referral was to help the couple discuss their differences, among them the husband’s conviction that his wife needed an analysis.

 

7. Who Maps Psychic Reality?

ePub

In this chapter I discuss the question, “Who maps psychic reality?” one that reflects a trend that questions the objective authoritarian position of the analyst. Authors writing from a hermeneutic perspective are critical of both Freudian and Kleinian analysts for their objective positivistic stance toward their patients. These colleagues suggest that analytic processes are more accurately described as stories collaboratively created in analytic dialogues.

Perhaps, in part, as a response to the arrogance of past authorities, exaggerated dichotomies have been created when considering important theoretical issues: several examples are “preoedipal” versus “oedipal,” “trauma” versus “conflict” and now “objectivist” versus “dialogic,” or “positivism” versus “social constructionism.”

I believe it is more helpful to think about the ongoing resonant influences of oedipal and preoedipal experience, of trauma and conflict from a perspective that I believe more accurately considers the relationship between past and present. Leary (1994) made the point elegantly, pointing out that an “’interesting’ dialectic for psychoanalysis would involve appreciating how human beings can interact and influence each other even as they are constrained by history, constitution, and biology” (p. 462).

 

8. The Seduction of Money

ePub

As a candidate I remember being impressed by John Weber’s offhand comment that, “It is never difficult to find an analyst with open hours when Elizabeth Taylor is the patient being referred.” In a similar vein most analysts would not find it difficult to find an open hour for an extremely wealthy patient like Donald Trump or Doris Duke.

This chapter will elaborate ideas I presented in ‘The Seduction of Money: A Brief Note on an Expression of Transference Love” (1986a). However, in this effort I will focus on the analyst’s countertransference. My emphasis is on the interminability of countertransference and on the implications of the concept of interminability for the conduct of the postanalytic phases of the analyses of wealthy patients. Before proceeding, I will comment briefly on the status of knowledge in psychoanalysis.

Kuhn, in 1970, suggested that “contemporary psychoanalysis” is like an older nineteenth-century medicine: Its “shared theory was adequate only to establish the plausibility of the discipline and to provide a rationale for the various craft-rules which governed practice” (p. 8).

 

9. Results and Conclusions

ePub

When I consider the issue of helping people become analytic collaborators I am impressed by the paramount importance of the factors of the analyst’s attitudes toward analysis and his interest in particular types of patients and problems. This no doubt influences analysts to modify the “standard” technique and their success in being able to begin analyses with subjects many colleagues might consider beyond their scope of collaborative potential. This perspective emphasizes that, particularly at the periphery of “the widening scope,” the match is at least as important as the assessment of the patient’s functioning and diagnosis. I believe this is what Stone (1954) had in mind when he stated “a therapist must be able to love a psychotic or a delinquent and be at least warmly interested in the ‘borderline’ patient” (p. 592), and “the therapist’s personal tendencies may profoundly influence the indications and prognosis” (p. 593).

I believe that there is heuristic value in addressing the discrepancy between what candidate analysts are taught (or wish to believe) and what experienced graduate analysts actually do in their practices. This discrepancy derives, in part, from an exclusive emphasis on interpretation and insight in conceptions of analytic process and mode of therapeutic action as well as a corollary aversion for considering what else, in addition to interpretation, takes place in well-conducted analyses.

 

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