Rhythms of Psychoanalysis and Counterpoints of Therapeutic Spontaneity

by John T. Sloma, LCSW, L.P.

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Paper presented at the Annual Meeting of the International Forum for Psychoanalytic Education Nashville, Tennessee, October 29, 2010

Conference Title: Psychoanalysis: Not the Same Old Song and Dance

INTRODUCTION

There are many ways of discussing the ebb and flow between patient and analyst for understanding the creations of the rhythms of psychoanalysis and counterpoints of spontaneity so the work of the treatment process can unfold and proceed.

My research has uncovered some old gems of psychoanalytic writing from Freud, Theodor Reik,  J.L. Moreno, who developed psychodramatic theory and technique, as well as current thinking in the field, (Renik, Hoffman, and Farber).

Sigmund Freud (1933) said, “Where id was, there ego shall be.” (New Introductory Lectures, p.80).  In many treatment sessions however, unconscious processes and conscious “ego states” are usually a mix or actual cacophony of differing perceptions, perspectives, anxiety states, resistances, defenses, et.al.  The analyst’s consistently empathically attentive, yet spontaneous energy, a quiet yet firmly committed stance of neutrality and hopefulness in the transference-countertransference matrix, can represent a powerful and calming effect in the treatment process.  As Theodor Reik (1948) says in Listening with the Third Ear:

(It is a)…. quiet attention…that in itself gives…proof of sympathy…driving him(the patient) into deeper layers than he intended. ( p.124)

Speaking further of therapeutic silence, Reik maintains:

…patients become more aware of what is and is not important to discuss.  Silence is profound and powerful; in its purest form it endows patients with enormous respect for the formidable task that faces them. (p. 125)

But what is the place of silence in today’s psychotherapeutic climate of relational immediacy, emotional presence or nearness of both analyst and patient.  As Farber (2006) points out in his study on Self-Disclosure in Psychotherapy:

…empathy has largely replaced silence in humanistic/existential psychotherapies, disclosure has largely replaced silence in contemporary psychodynamic therapies, and confrontation has largely replaced silence in short-term dynamic therapy. (p.159).

One of my first mentors, Martin Sulkow, Ph.D., advised me to read Colby (195l) which validated my own long held belief that being “real in the moment” as a human being, let alone as a therapist in the treatment room, is a most useful and essential baseline aspect of any treatment process.

If the way you act as a therapist is greatly different than the way you are as a person, then the façade will drain energy needed for other aspects of therapy and your patients will soon learn of this artificiality.  In this connection, the therapist should not attempt to “manipulate the transference.  For example, acting like a father for one patient and like a brother for another. The patient must be left freely as possible to develop spontaneously those reactions determined by his childhood experiences. (p. 24)

Sulkow also told me to always start the session by taking stock of myself, how I was feeling in the moment and then being real enough to report that to the patient before the session proceeded.  It is advice I would like to say I never forgot, but as time and other training interceded, I lost touch with this basic tool of existential therapy:  Be Real in the Moment.

I believe that it is the “ebb and flow” of the empathically attuned analyst, with flexibility and attuned self-awareness which ultimately orchestrates the “vibes” of sessions, acknowledging the patient’s cacophonies of psychodyanmic conflicts, while gently, patiently and spontaneously bringing forth the analyst’s own “counterpoint” rhythms of countertransferential energies and feelings.  This co-creates in the moment with the patient the desired goals of clarity, insight, self-understanding and self-acceptance, which are the aims of any therapeutic endeavor.

As Reik (1937) so eloquently states, in Chapter IX of his book, The Surprised

Psycho-Analyst, in an article called,  “Concerning Tact, Time and Rhythm,”

It is my view that the utterances of our patients, in which we recognize the unconscious, instinctive element, also obey the secret power of rhythm in all their variety.  Anyone who has conducted analysis for a series of years will have noticed that what is unconscious and instinctive in his patients’ communications follows a definitive rhythm, though one which we are unable to define, and he will be able to divine when the hidden aggressive and sexual tendencies will appear in these communications, and when they will reach their height, die away, and repeat themselves.  He will often perceive this rhythmical rise and fall of the hidden instinctive process behind the patient’s communications, without being able to tell by what signs he can detect the rules governing the movements of these nameless forces…the most favorable moment to give an interpretation… is conditioned by the unconsciously felt rhythm of the patient’s instinctive processes. (p. 123)

So, are we to remain analytically neutral, empathically supportive, or authentically spontaneous at any given moment in the therapeutic process of the unfolding energies of a treatment session?  What therapeutic stance or technique works best and when, how and why? This paper will discuss some answers to these questions that I have learned over my 40+ year career in the pursuit of psychotherapeutic effectiveness via my days with Moreaneans (1967-1980), psychoanalytic training (1981-2006) and recent explorations with direct self-disclosure, including spontaneous feedback in the analytic dyad and the successful or disastrous consequences.

DEFINITIONS

Let’s begin with some definitions essential to this paper:

  1. Spontaneous:  (from the Latin “sponte”, meaning, “of free will, voluntarily.”)J.L. Moreno (1959): Spontaneity is either a new response to an old situation, or an adequate response to a new situation.  For J.L. Moreno, spontaneity seems to have been a kind of self-generating inner responsiveness to life’s presentations, not necessarily triggered or stimulated in any predictable manner, so much as born of the individual’s unique moment of being in time and place. As such, it is a “slice of time” which can never again be experienced or reproduced in its unique existentiality.Webster defines spontaneous as proceeding from natural feeling, temperament or disposition…acting by internal impulse, energy or natural law, without external force, self-acting.

  2. Psychoanalytic Frame:“The analytic frame, of course, provides the general boundaries for the relationship, a multi-faceted scaffolding of protection for both patient and the analyst.  It sets up the special “potential space” in which the “play” of psychoanalysis can go on (Winnicott, 1971; Modell, 1990).  As Modell says, “Despite the spontaneity and unpredictability of the affective relationship between the analyst and the analysand, there are also certain affective constants that are institutionalized as part of technique and contribute to the frame or the rules of the game.” Hoffman (1998) ( p. 30)
  3. Transference:The patient sees in his analyst the return – the reincarnation – of some important figure out of his childhood or past, and consequently transfers on to him feelings and reactions that undoubtedly applied to this model. It soon becomes evident that this fact of transference is a factor of undreamed-of importance – on the one hand an instrument of irreplaceable value and on the other a source of serious dangers.  This transference is ambivalent:  it comprises positive and affectionate as well as negative and hostile attitudes toward the analyst, who, as a rule, is put in the place of one or other of the patient’s parents, his father or his mother. …Therapeutic successes that take place under the sway of the positive transference are under the suspicion of being of a suggestive nature.  If the negative transference gains the upper hand they are blown away like spray before the wind. Freud (1933) ( p.190)
  4. Rhythm:…from the Latin “rhythmus”, meaning “measured motion, measure, proportion, akin to Gr. “rhein”meaning “to flow”. The flow of cadences in written or spoken language.

SOME PERSONAL HISTORY

Long before I was to become aware of the true depths of psychoanalytic self-exploration, I wrote poems of self-expression in high school.  My poetry was of loss and suffering and joy and celebration.  In college, I majored in Literature, where I was a published poet in the college literary magazine.

As Theodor Reik discussed in Listening with the Third Ear:

The person who approaches psychoanalysis is not psychologically unprepared for it.  Long before he enters the consulting room with the analyst, he has become aware of strange experiences, has felt anxieties or inhibitions, and has observed symptoms and behavior traits that have made life difficult and sometimes unbearable for him… He has himself tried to find the way out of the labyrinth of his emotions.  It was a kind of abortive self-analysis, attempted with insufficient insight and knowledge, performed with inappropriate tools… Long before he saw a psychoanalyst the patient became interested in psychological problems by inner necessity, because they were his own problems. (p. 9)

Unsatisfied in the understanding of myself, I switched my major to Philosophy after taking a course called, “The Philosophy of Mind”.  I became involved in my own orthodox psychiatry and psychoanalytic psychotherapy and became immersed in the unorthodox world of J.L. Moreno, where I learned role theory, psychodrama, group psychotherapy, sensitivity and encounter training.  It was at a group psychotherapy conference that I met my first analyst and began my first psychoanalysis.  My varied academic and experiential training/education over the next 30 years has evolved into a spontaneous and hopefully rhythmic treatment style, which has produced a psychodramatically-oriented psychoanalyst. This is best described as my own “rhythmic amalgamation” of techniques integrating psychoanalytic silence and neutrality with psychodramatic notions of spontaneity and self-disclosure.

As Reik (1937) says in his discussion in “Concerning Tact, Time and Rhythm,”

I propose a provisional definition of Tact.  I hold that Tact is the expression of a certain adaptation of our own vital rhythm to that of our surroundings for the time being… Rhythm is a universal vital function, belonging to every living creature… It regulates the flow of vital processes, governs waking and sleeping, hunger and satiety, work and fatigue, ebb and flow, warmth and cold, and the changes of day and night and the seasons…. Without intending or knowing it, the analyst becomes aware of the rhythm of his patients instinctive impulses, and this unconscious knowledge will tell him when to make his communications. Unconsciously he follows this rhythm of instinct, vibrates with it.  Perhaps it is better to say that he is a fraction ahead of the patient, a bar let us say, so that he divines in what direction the unconscious will move…. It is still our own mental reaction to the communications of the patient which illuminates our path, the response, as I should prefer to call it. (p. 122)

So, is there a rhythm to the beat of the unconscious, or shall we say instead it is the task of the mutual energy of the working alliance to explore the depths of the co-unconscious for whatever beats or rhythms which may be discovered?

PERSONALITY OF THE ANALYST

The personality of the analyst needs to become sufficiently sensitized to the profoundly traumatic potential for harm when psychoanalyzing another person.  Again Reik (1937) states in his article, “Concerning Tact, Time and Rhythm,”

Was not the American lady patient right when she complained at the beginning of her treatment: “Analysis is so intrusive”?…It would be tactless to fling at a patient’s head the statement that he had been sexually in love with his mother and had wanted to kill his father. A certain mental introduction and preparation is needed, an understanding of the contrast between conscious and repressed ideas and so forth. (p. 113)

No consideration for others will help anyone who does not pay attention to the guiding voice within himself,…(p. 118)

Let us then not forget that tact is the outcome, not only of consideration for others, but also of attention to our own impulses, and especially our own reactions. (p. 119)

(and these sometimes offer wisdom, but more often “screw-ups”,  Tom Wagner (personal communication)

Reik’s admonition that we listen to and obey our own inner voice is the start of his discussion of the essential and inescapable truth that we are all of the natural rhythms of  nature, and of our own human nature as well.  The ebb and flow of our aggressive and libidinal energies creates the inner rhythms of our own unique and particular capacity for our patterns of response to other fellow human beings.  And while our unique ebb and flow energies may be quite determined by our individual histories, yet and still our unique ways of synthesizing our experiences into our own ‘cranial computers’ creates that special set of character traits and attributes known as personality, similar perhaps to many others in many ways, yet ultimately unique and responsive in our own patterns, known best and perhaps only to ourselves as individuals.

It is this unique sense of ourselves, which Reik maintains is the single most important tool for the successful practice of psychoanalysis. In an article called, “The Surprised Psychoanalyst,” reprinted in Wolman’s (1988) review of seminal papers on Countertransference,  Reik (1948) states:

I am of the opinion, not shared by many New York analysts, that the personality of the psychoanalyst is the most important tool he has to work with.  My stand here is in sharp contrast to that of those teachers who train their students to forget themselves when they try to understand unconscious phenomena.  I admonish my pupils to be acutely alert to their own responses. The most important advice on the technique of psychoanalysis is nowhere to be found in the textbooks.  The teacher who has discussed technique and technicalities should at the end remind his student: “This above all: to thine own self be true.” (p.63)

The analyst, as he is often trained in psychoanalytic institutes, is an interpreting automation, a robot of understanding, an independent analytic intellect who has become a person without ever becoming a personality. He confuses the calmness and control of the observer with lack of sensitivity, objectivity in judgment with absence of sensation and feeling.  When he sits behind the patient, he tries to be everything else but himself.  But only he who is entirely himself, only he who has the sharpest ear for what his own thoughts whisper to him, will be a good psychoanalyst. (p. 63).

My early training, then with the Moreneans convinced me, rightly or wrongly, that my feelings count too, and are not just reactive, but original and therefore proactive, in some sense.

I was a difficult analysand to be sure!  Just ask my two analysts:  my first, a wonderful man named Murray, found me to be “too much myself!” My second analyst, still living so nameless here, found me to be “too articulate and quick-witted” to allow myself to internalize her well-meaning introjects without question or suspicion.

So here I am, now licensed in the field myself after 30 years of training, including two training analyses, still questioning what goes on in the session and what are the meanings of the patient’s productions and responses to me, and what are the meanings or true needs which I may be experiencing as countertransference as I listen empathically and respond spontaneously to my patients’ productions and self-representations.

I think this places me squarely in the present-day camp of analysts known as “Relational.”   These analysts theorize on that endlessly eternal focal point in the analytic process known as The Moment.  What happens in The Moment of A.H. Modell’s (1990) ‘analytic relatedness’?  The patient and the therapist are in that inevitable dyad of conscious and unconscious needs, forces, feelings, observations, reflections, self-control, self-censorship, risk, fear.

It is this excitement about the unpredictable nature of any such moments which underlies the ritual rhythms of defense, analysis, trust, openness, anxiety, relaxation, love, fear of intimacy, fear of abandonment ( I can freely associate here in an almost ‘stream-of-consciousness’ fashion ad infinitum, or would it be ad nauseum?)  But I think we can agree as analysts and as human beings, we all know this dance, this rhythm of ebb and flow between the patients’ productions and our own thoughts, feelings and formulations of  interpretations floated in our own heads while our patients wonder what we feel and think about them.

As Reik (1948) says in his book,  Listening With the Third Ear,

I only now, after thirty seven years of analytic practice and theory, venture to speak on the subject of  technique…. The first is an inability to learn from other people’s mistakes.  All the wisdom of proverbs and all exhortations and warnings are useless to me.  If I am to learn from the mistakes of others, I must make them on my own, and so perhaps cast them off.  I am almost incapable of learning from my own mistakes unless I have repeated them several times. (p. 12)

So, as my trusted friend and colleague is always reminding me,

Personality is both an asset and a liability in this work.  Possibilities for connection and rupture always abound, and good cases are always messy.  Even those of the masters.  Especially of the masters!” (T. Wagner,  personal communication)

COUNTERTRANSFERENCE, SELF-DISCLOSURE & CAUTIONS

I would like to say a few words about self-disclosure as counter-transference. It is my contention that although my natural sense of my own spontaneous flow of free-associations to the productions of my patients may at times be useful, humorous, confrontive, even challenging or insulting, nonetheless the “shock value” of the self-awareness often induced in the patient is frequently, though not always, worth the risk. In other words, regardless of the psychoanalytic frame, tactfully timed interpretations, and/or other cautions notwithstanding, a well-placed joke, humorous reflection or even self-disclosing, self-deprecating self-reflection will often catapult or “finesse” a dull, boring, repetitive routine session into a major new set of avenues for further inquiry.

As Renik (2006) says in his book,  Practical Psychoanalysis for Therapists and Patients,

The truth is that every interaction between analyst and patient expresses the unconscious motivations of, realizes some unconscious fantasy or other of, both participants.  For an analyst to think otherwise is naïve and will lead the analyst to underestimate his or her personal participation in clinical work. (p.91)

For example, if I were to suddenly share personal reflections of my own history of the dynamic with my mother, (admittedly probably triggered by some unconscious counter-transferential response to the patient’s ruminations about his mother), nonetheless, such spontaneous sharing on my part eases the patient’s anxieties about the same dynamic he may be recounting without yet the benefit of the analyzed perspective of the analyst.

Again, Renik (1995) boldly states, “We need to begin by not just discarding the principle of analytic anonymity, but by contradicting it.” (p.482).

And as Barry Farber (2006) notes in his book on self-disclosure,

Renik is quite clear about his use of self-disclosure, avowing that he is consistently willing to make his own views “explicitly available to the patient” (1999, p. 522).  He argues that all analytic interventions require some degree of self-disclosure and that the ultimate effect of judicious self-revelation is that patients will follow suit.  Although he recommends that the analyst create guidelines about the types of disclosures that promote positive outcome, he is not concerned that the act of self-revelation will lead to exploitation, believing that the analyst’s superego will keep his or her impulses in check (Wasserman, 1999) (p. 130)

So here it is that we come to the cautions, the sense of tact, timing, propriety. Reik (1937) seems of two minds in his article on “Tact, Time and Rhythm”.  While he questions and observes,

What happens when we do not communicate the interpretation to the patient at the right moment, that is to say, when we are not guided by tact but by other considerations, when we allow ourselves to be ruled by the strong feelings or rational arguments!  The results are not uniform; they vary, from the absence of success to the rousing of violent resistance. (p. 120),

he also admits elsewhere that in more than a few sessions,

I did not give a damn about logic and what I had learned in the books.  I did not think of any psychoanalytic theory.  I just said what had spoken in me despite and against all logic, and I was correct. (Italics added for emphasis) (p. 57)

He discusses brilliantly just why and how he had come to be correct in his wonderful masterpiece, Listening with the Third Ear, specifically, Chapter 23: “The Surprised  Analyst .” In that inspired narrative of self-disclosure that was essentially Reik’s autobiography, he elaborates the importance of learning of one’s own inner voice and the rhythms of one’s own nature by becoming self-aware through one’s own analysis.  Only then will the tendency to give in to one’s impulse to share the insight of the Moment become perhaps somewhat tempered by the long-accumulated awareness of the unconscious patterns and functional ego-strengths or deficits of the patient.

But what about those painful awkward moments in the psychoanalytic processes which inevitably evolve over time during the course of any lengthy treatment?  I know the patient’s rhythms of defense, his or her patterns of avoidance, displacement, transferential paradigms or dyads of well-worn role-conserved stalemates in the “ritual affective constants” that are part of the rules of the game, as in Modell’s  (1990) definition of the psychoanalytic frame.

At such times, I believe the frame can feel like a psychological or emotional straitjacket for patient and analyst alike.  The sense of struggle, stalemate, lack of progress, discouragement, and eventual premature termination (usually by the patient, but sometimes by the analyst, also burnt-out by the impasse) results in a profound sense of failure for one or both parties to the enmeshment.  As my  colleague, Tom Wagner says,

An enmeshment involves pathological elements in the analyst that are played out in enactments with the patient.  Any discussion of spontaneity of self-disclosure should include destructive potential unconscious elements in the analyst.  If they are not scrupulously examined they cannot be put to good use.  I think you have to indicate that you are open to examining negative countertransference, that you are struggling with your blind spots.  This is the benchmark of good analysis.  (personal communication)

But in such scenarios, the iconoclastic spontaneity of the analyst can be most helpful, if somewhat shocking, discordant, and seemingly violating all the rules.

I believe at such junctures, it is the analyst’s unconscious awareness of the resilience of the patient’s demonstrated ego-strengths, revealed here and there, little by little, or perhaps occasionally in some unmistakable manner, during innumerable prior treatment sessions, which accounts for the analyst’s “induced countertransference” (induced by the patient unconsciously).

The resulting sudden spontaneously (seemingly impulsively) uttered observation, interpretation, construction, or other analytic feedback may startle and even shock the patient; but the ensuing consequence will always be useful and diagnostically indicative of further emotional health or psychopathology.

CLINICAL VIGNETTES

The following clinical examples will, I hope, illustrate the integration of “therapeutic spontaneity” with the expectations of  “psychoanalytic rigor.”

(1)

The patient, a woman I had been working with for 3 ½ years or so, has had ongoing trust issues.  During one session, as we were discussing various aspects of her mistrust of me,  as these aspects had emerged in treatment, I became silent, contemplating whether I should yet again, as I had so many times before, offer the interpretive perspectives regarding her oppressive father, history of apparent childhood sexual abuse/molestation, and other abusive episodes she had previously reported.

As I was remaining silent while she sat on the couch, she became quite angry with me, accusing me of withholding interpretations from her.  So I said, ‘It’s not me you are angry with and can’t trust, it’s your father!”  (In retrospect, I may have also asked her to tell me more about how I have neglected her, but the heat of the transferential dynamic at that point was more of the “power struggle” I think I was unconsciously responding to.) Consequently, my statement caused more (transferential?) anger and she began discussing her history with her father (unavailable, verbally abusive, oppressive).

In her expression of anger she began telling in more detail than ever, how her neighbor had hurt her, abused her sexually when she was six years old, which then led to how she was raped by her college professor after a night of drinking together with him (he plying her with several beers after a student gathering at his home).

She began to feel flooded with anxiety.  I listened as she began now to speak of each man interchangeably, skipping from one to the next.  The stories became blurry and vague.  I couldn’t get a clear picture, as she said “He, He, He,” in a frenzy of confused enragement.

At this point, I suggested some “Empty chair work”, a psychodramatic technique which allows the patient to imagine her internalized, demonized objects (father, neighbor, professor) to be sitting before her in 3 empty chairs.  I lined up the chairs and placed a magazine on each one, to signify to her each abusive man.  I told her this could help us sort out her feelings about them.  I stood out of view as she told stories of her father, then moved to the neighbor, and finally the college professor.  I was able to get a much clearer picture of her cumulative and layered sexual and emotional traumatizations and compounded sense of almost total mistrust of male authority in any guise.  She reported feeling significantly less shame with me out of view, compared with our eye-to-eye contact when the interpretive comment first fueled her rage.

This example has several aspects worth reviewing, I believe.  Firstly, had I not hesitated with my interpretive statement, uttered many times previously, and usually to her marked resistance (“Why does it always have to be about my father?” she would whine, or angrily protest), my patient would NOT have been prompted/provoked/stimulated? to feel the initial angry frustration that here was her father. Here he was, yet again withholding his love and attention. I may have been making assumptions here about what she was angry about, and what I was saying that might have irritated her, and I probably should have stayed closer to her affect.  But I was quite familiar by this time with her pattern of “defaulting” to the role of the victim as a means of avoiding the responsibility to “own” her real need for her father’s love and attention.  In this context, the feared and yet longed for interpretation had been frequently resisted, and rejected by her time and again. She would then have likely argued with me yet again as to it’s repetitive nature (the same ol’ song and dance!), thus repeating our transferential  dyadic norm of  “ritual analytic interpretation along classical lines”.

However, this time, my hesitation proved to be just the goad or prompt she needed to get more authentically  ‘in touch with that “reservoir of rage” that had been so long dammed up inside, awaiting the right trigger that would push her “over the edge” to a more affectively productive session.

Did I consciously know she would react with deeper frustration, more ready to “spill the beans” than ever before?  No, I did not, but my unconscious accumulation of data, the gathering of  all the many details of her history of abuse over the 3+ years of our work together, had coalesced into an uncanny awareness, as well as a growing frustration with her avoidance.  It was an awareness that if I withheld, and then let her have the interpretation yet again, somehow something different was going to occur, and by acting on my frustration I was able express some real personal feelings in the moment that perhaps the time had come for some more direct confrontation and self-expression of some of her long-feared rage at these abusive men.

Such unconscious knowledge of the rhythms of the patient can only come about after numerous hours of ritual dyadic patient-therapist discourse, dialogue, and fencing, jousting.   The unconscious resistances of the patient to explore and recall more deeply the psychically painful affective level of sexual and emotional abuse, betrayal by the trusted father, neighbor, and professor, profound mistrust of any authority in pants!, et.al. is at times a seemingly endless dance of discouraging rage at the therapist, simply for daring to pretend that such a phenomenon as Trust might really still be available to the patient!  (“It makes sense.  She is traumatized. Why should she behave any differently.”)—T. Wagner

Only by provoking her rage at having anything withheld, were we able to move to new ground in the analysis.  She was able to explore more deeply and accurately, and with much more affect and much less shame, the events of her traumatic childhood nightmares of feeling terrorized by her emotionally oppressive menacing father, from whom she sought escape in the home of the kindly fatherly neighbor, only to have him molest her repeatedly, sometimes at knife-point, with threats to kill her if she ran home to tell Mommy!

However, a deeper layer of mistrust between my patient and me was operating still behind all of the above levels of fear, mistrust,  & suspiciousness.   She feared she was not my favorite female patient, fearing her own negative self-image of unattractive-ness was hopelessly and eternally to keep her from ever feeling and being Daddy’s special girl.  And her rage with me at withholding my interpretation from her proved ultimately to be more about this feared loss of status as my special favorite rather than any of the aforementioned authentic affective discharge.  She was essentially enraged with me the real person for daring to hesitate with her on any level about anything, even if it was only the ole familiar refrain of “It’s your father you can’t trust!”

But my patient is still also understandably angry and protective against being annihilated, and requires someone who can sit with her empathically.  This is not someone who needs simply to discharge her rage, but also to be “fed “ (nurtured), reassured in some sense that she is surviving, and NOT being annihilated

So our unconscious rhythms of trust and mistrust, the ebb and flow of cacophonous discordant unharmonious “session work” continues.  It is punctuated by euphonious episodes of concordant familiarity, trust at a superficial level, caution to plumb the depths of painful recall of trauma, et.al. Thus the work is ultimately a classic mix of “one step forward, two steps back, three steps forward, one step back, et al.”

Her frequent tendency to displace her mistrust of men onto me now also often takes the form of jealousy of my female patients. This is likely part of a massive dissociative defense against invasive assault. “I don’t trust you or your work!”  She will exclaim angrily and fearfully.  This basic mistrust of me and my work with others becomes an easy target for her rage and fears to become displaced from the “remembering, repeating and working through” phase of her analysis.  She now wails on endlessly, after “good” sessions or “bad” sessions, that  she can’t trust me and will never be able to trust me because “sex is so much a part of what I do!”

She reads that Freud’s office was “saturated with sex.”  She obsesses about “erotic countertransference.”  This painful “truth” about me and my work now becomes utilized as her primary mode of resistance to the deeper recall, self-exploration, traumatic memory content, and hopefully, the eventual purging or cathartic release of the affective levels of fear, terror, abandonment, loss of love, betrayal of trust, and whatever else lies beneath the surface of her childhood memory content.  Translation:  “If men are sexual, and you are a man, then I can’t trust you!”  (Because you are sexual!)

This layer of seeming “bedrock” of psychological/emotional “truth” for the patient may be inviolable at this point in her analysis.  Again, Wagner points out: “That’s right and you cannot push against it.  Interpretations are sexual assaults. You have to respect that and communicate that given her history that is a perfectly expectable way to feel about it.” (Tom Wagner, personal communication)  But I want to add, “For now, until her ego strengths are developed more sufficiently to confront this traumata more courageously.”

(2)

Joe P., a very successful businessman, came for marital therapy with his wife.  Her chief complaint:  “he’s overbearing, oppressive, demeaning, dictatorial, is probably lying to me, having an affair,” et al.  His complaint about her: “she yells and screams at me incessantly over everything for the past 10 months if not longer.”

I sat for several sessions allowing them to complain angrily and loudly about each other.  Finally, I said “Here, I want you to fill this out: “3 to 5 ways I can/want to be a better spouse.” It immediately “shut them up,” and caused them to re-focus on themselves and not castigate each other!

What was my countertransference to this acrimonious non-stop marital “cacophony?” aside from a headache from their sheer vocal volume?  I was sad and uncomfortable for the husband, who had no clue as to the consequences of his intelligent, aggressive, no-nonsense style of dialogue, criticism, interpretiveness and general righteous posturing towards his wife; and I felt support and sympathy for her growing capacity to stand up to him, albeit so vociferously as to be verbally abusive.  So she was developing some emotional courage in her 23-year marriage, and he was becoming “unglued” and emotionally “disoriented” from his formerly dominant position of “boss” of the family.  His style of countering her loud rage was to say, “She is crazy, needs medicine, even Jesus would not be able to tolerate her venom and toxicity without capitulating!”

My “spontaneous” countertransference was a creative alternative to their “embattled acrimonious engagement” – Call it “common sense” if you will.  It was a message to stop yelling and look at yourselves as individuals instead of deteriorating into the endless demonizations of each other!!!  This is the role of the analyst as neutral arbiter, calming the waters of rage, hurt, pain, mistrust, misunderstanding, victimization, self-pity, righteousness: in short, the whole gamut of human emotions flooding this couple at this time.

And why did it “work” at all?  Because of their implicit trust in the external authority of the analyst to be sure, but also, I think because of their feelings of helplessness, fears of abandonment, fears of shame around divorce, loss of marital stability, et al.  All my conjectures to be sure are not confirmed or validated until “checked out further” in future sessions.  But these were useful conjectures, I think, leading to a useful intervention.

And, of course, all of this is based as well on my own conscious and unconscious anxieties about feeling helpless, abandoned, ashamed, losing marital stability, et al.  In other words, the identification with my patient’s probable anxiety states was based on an awareness of my own vulnerabilities to such a challenge as was staring at me and screaming at me in my office!


(3)

This final vignette refers to my “courage” to risk the possibility of a patient “shut-down” due to an empathic failure perpetrated by pushing, forcing, acting on an insightful interpretation and the egoistic need of the analyst to show how smart he is, rather than remaining “in touch” with the patient’s inner emotional life, the presumed struggle and suffering.

I use to have a patient who came for therapy to help her workout her inability to find a suitable partner for a long-term relationship and maybe marriage and children.  She also had severe low self-esteem issues due to early abandonment by her father, and mother’s disapproval of the acting career my patient had set her sights on for herself in NYC.

She would habitually go for auditions, only to be rejected, unable to find an agent aggressive enough to “market” her more effectively, and ultimately having to abandon the acting career for work producing documentaries. I had a great deal of empathy for her “struggles” to “make it” in the Big Apple.  She was attractive, intelligent, educated with a MFA in Drama, energetic, well organized, yet unable to succeed in a very competitive business (theater) in NYC.

I would like to discuss a “failure of empathy” on my part, disguised even to myself at the time, as an “empathic attunement” to my perceived sense of her inner struggle with loneliness, anxiety, fears of inadequacy, little family understanding of her goals or value system or esthetic sensibilities.  I too was just starting to work with patient’s analytically, and identified with what I was sure were her valid, challenging, at times overwhelmingly discouraging “inner struggles” to achieve her dreams.  But whenever I would attempt to refer to or validate her “struggles” she would balk and become vaguely uneasy.  I never knew why until one day she finally confronted me, stating she didn’t like the word “struggle”, and doubted it was accurate or useful in applying to her situation.  I interpreted her challenge as a resistance to “owning” just how difficult and lonely her life had become in NYC over the past decade.  She herself had begun talking of only giving it another six (6) months before giving up the acting dream. Yet when I used the word “struggle” to refer to her dilemma, she rejected it consistently, preferring eventually to just say “things were difficult”, “life was challenging,” et al.

Her rejection of what I thought was my “accurate empathy” annoyed and frustrated me: it was evident to me that I was failing as a therapist to be sufficiently attuned to her inner emotional life.  So I interpreted her rejection as “resistance”, even going so far as to tell myself it was her own fear of a more intimate connection with me that was behind her refusal to acknowledge my wonderful empathy.

She eventually met someone and after several months of dating they moved in to his loft together and became a family. (He had a young son from a previous marriage.) She even brought him to her sessions for a while in an attempt to get him to change, to perhaps understand him better through my lenses, et al.

Years later, I am now realizing I was projecting an interpretation of the affective content of her inner emotional life (“struggle”) from my own sense of myself at the time. While  “plausible” in every obvious dimension of accuracy, it lacked validity: and yet my “narcissistic interpretive myopia” caused me to force a word on her which failed to resonate with her true inner sense of herself, which I now suspect was that of the misunderstood “survivor”, prevailing courageously in a world of harsh insensitivities and cruel indifferences.

CONCLUSION

As Reik (1948) points out, this work is not easy; we make all kinds of errors, technical and theoretical, in our quest for true and useful therapeutic effectiveness.

When it resonates with the rhythms of our own natural empathetic capacities and the emotional needs of our patients, it is a joyous sense of achievement: “Music” – when we fail it is cacophonous, dissonant, unfulfilling and discouraging for analyst as well as patient.

But it is the persistence, commitment and devotion to the passion and vision of people like Sigmund Freud, Socrates (The unexamined life is not worth living!), J.L. Moreno, Theodor Reik, and countless others that impels the work forward:  we struggle to achieve ever greater self-acceptance thru deeper and deeper self-understanding, for ourselves as analysts and for our patients as well.


REFERENCES

Colby, Kenneth Mark MD. (1951),  A Primer for Psychotherapists. New York: The Ronald Press Company.

Farber, Barry. (2006),  Self-Disclosure in Psychotherapy.  New York: The Guilford Press, New York.

Freud, Sigmund. (1967),  A General Introduction to Psychoanalysis. New York: The Washington Square Press.

Hoffman, Irwin  Z. (1998),  Ritual & Spontaneity in the Psychoanalytic Process. Hillsdale, New Jersey: The Analytic Press Inc.

Modell, A.H. (1990), Other Times, Other Realities: Toward a Theory of Psychoanalytic Treatment. Cambridge, MA: Harvard University Press.

Moreno, J. L., MD. (1959),  Psychodrama (Vol. 2.). Beacon, NY: Beacon House Inc.

Reik, Theodur, MD. (1937), Surprise and the Psycho-Analyst. New York: E.P. Dutton and Company.

Reik, Theodor, MD. (1948), Listening with the Third Ear. New York:  Jove Publications, Inc.

Renik, Owen. (2006), Practical Psychoanalysis for Therapists & Patients. New York: Other Press LLC

Wolstein, Benjamin, editor. (1988), Essential Papers on Countertransference.  New York: New York University Press.



John T. Sloma, LCSW, L.P. (NY) is a practicing psychoanalyst, and is Board Certified in Clinical Social Work, with a practice in the New York Metropolitan area. He earned a Master’s in Clinical Social Work from Fordham University. He was Senior Clinician at the New York State Newburgh Mental Health Clinic for several years before becoming the Associate Director of Associated Counseling Service in Middletown, New York. He has completed his analytic curriculum at NPAP and has appeared in an Anger Management Documentary for MTV. He has now twice presented papers on his thinking and practice style at IFPE conferences (2008, 2010). He also still writes poetry occasionally.

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