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"How to" therapy

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Listening, transference, narcissism
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Chapter Four: How to listen to a patient

Bach, Sheldon Karnac Books ePub

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.

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Chapter Five: How to frame and change perspectives

Bach, Sheldon Karnac Books ePub

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.

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

Bach, Sheldon Karnac Books ePub

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”.

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Chapter Nine: How to understand and manage the transference

Bach, Sheldon Karnac Books ePub

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.

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Chapter Ten: How to tell what the transference is

Bach, Sheldon Karnac Books ePub

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.

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Chapter Eleven: How to deal with the sadomasochistic transference

Bach, Sheldon Karnac Books ePub

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.

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Chapter Twelve: How to manage narcissistic disequilibrium

Bach, Sheldon Karnac Books ePub

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).

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