Psychoanalytic Technique and the Creation of Analytic Patients

Arnold Rothstein

• Publisher: Routledge
• Year: 2018
• eBook ISBN:
  9780429918087
• Topic: Psicología
• Subtopic: Historia y teoría en psicología

This is a book on a neglected aspect of psychoanalytic technique that should be read by everyone who hopes to develop a psychoanalytic practice. The author'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'Psychoanalytic Technique and the Creation of Analytic Patients is clear, practical, and above all courageous. On the central issues from the idea of analyzability, to the objectivity of diagnosis, to attitudes toward fees, Rothstein challenges received wisdom and skewers sacred cows. The result is a book that will help all clinicians - therapist and analyst alike - to work more effectively within the realities of contemporary practice. The author forces us to re-examine many fundamental assumptions, thereby contributing to radical re-evaluation of the nature of the psychoanalytic process itself.' - Jay Greenberg, PhD'In Psychoanalytic Technique and The Creation of Analytic Patients, a successful practicing analyst shares with us many of the secrets of his success.

Part I
Introductory Phase Work

Chapter 1
Beginning Analysis with a Reluctant Patient

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.

In this chapter I propose advantages to conceptualizing these beginning efforts that involve fewer weekly sessions as modified introductory phases of psychoanalysis. I emphasize that, particularly in the introductory phase, it is the analyst’s attitude toward the patient and his or her behavior and verbal associations, rather than the frequency of sessions or the use of the couch, that is the essential characteristic of the analytic method. But I do consider a patient’s ability ultimately to accept and experience the four or five times per week frequency and the use of the couch, as important characteristics of a successfully completed psychoanalysis.

In this chapter I will discuss a group of analysands who at the beginning of their analyses were unable to accept aspects of the characteristic elements of the analytic situation, although they later completed successful analyses. I have conceptualized these patients’ initial objections as enactment resistances. It is a premise of this chapter that a particular analytic attitude toward their objections enables some patients to begin an analysis. The prospective analysand’s objections are viewed as enactments that are analogous to symptoms. These symptomatic enactments often have a transference significance and derive from unconscious fantasies that are best understood as compromise formations. The analyst has to be able to accept that the patient must do it his way first before the enactment can be understood. Stated another way, the analyst has to be able to accept being frustrated by the patient while the patient is gratified. An analytic attitude that accepts the patient’s imperative desire for gratification as an aspect of a symptomatic enactment, may engender a collaboration with the analysand so that his or her objections to accepting the analyst’s recommendation can be understood as resistances. When these defensive aspects of the enactments are sufficiently understood as resistances, the analysand, if analyzable with the particular analyst, should be able to proceed with the analysis at the recommended frequency. In a sense my attitude toward the patient’s enactments is similar to my attitude toward a child in play therapy. The prospective analysand’s enactments are conceived of as analogous to his playing in the transference. The “play” must first be a shared experience before it can be understood and discussed. A sense of humor is helpful.

I inform the patient that I am willing to begin his analysis with him sitting up, and at the frequency he suggests, with the understanding that we will attempt to understand why he is unable to accept the recommended frequency. I frequently refer to the recommended frequency as the minimal frequency for the optimal treatment, and I often suggest that the patient seems afraid to allow him- or herself to have an analysis or be in analysis.

In a sense my approach frames the patient’s reluctance as a self-defeating masochistic enactment, and in collaboration with the patient focuses aspects of the early work on understanding this expression of the neophyte analysand’s character. It is a not infrequent finding that this symptomatic expression of their character reflects the expression of more pervasive masochistic conflicts.

I suggest two distinct reasons for considering these beginnings as modified analyses rather than preparatory psychotherapies. First, the analyst and analysand have agreed to consider these less intense beginnings as resistances and to work toward the goal of establishing a usual analytic situation by understanding which fantasies concerning the analyst and analysis are interfering with the patient’s ability to accept the analyst’s recommendation. Second, because many colleagues, including this author, prefer doing analysis to psychotherapy, the analyst, thinking of himself doing analysis, feels better about himself and his patient and is more likely to be successful in working with the types of resistances being considered in this chapter. This second point was demonstrated clearly in the 1993 survey on practice. Brauer (1993) noted, “Identification with psychoanalysis and satisfaction with the profession grow with an increase in the size of practice, and both identification and satisfaction are quite high if the member has four or more cases” (p. 22).

It is beyond the scope of this chapter to discuss in detail questions of indications for analysis and analyzability. I am emphasizing, however, that definitive assessments of analyzability can only be made after an analysis is completed. At the beginning all that is required is a judgment of with whom it is suitable to begin a trial of analysis. Integral to this judgment is the question of who might be irreparably hurt by such a trial.

At this point I will present brief descriptions of “trials” of analysis with two patients with whom significant modifications were employed during the introductory phases of their analyses.

Mr. S, a very angry 38-year-old engineer, sought couples therapy for himself and his current lady friend. Mr. S had two previous experiences with twice weekly individual psychotherapy with analysts because of his difficulties in getting along with people. These therapies “dried up” after six to eight months. Mr. S never worked in the transference in these endeavors. After a consultation that consisted of a joint session with the couple and a number of individual sessions with Mr. S and his friend, the analyst recommended analysis to both parties. Mr. S was outraged and insisted on working with the analyst once a week. He seemed impressed with the fact that two previous therapies had failed. This time he would succeed. The analyst agreed to work with him on the understanding that we would attempt to explore his reasons for resisting an analysis. After two months the analyst told Mr. S that the analyst felt he was wasting his time in once-a-week therapy. Mr. S expressed his feeling that he had to try it “his way” until he was 40. If he didn’t solve his problems “his way” by that time he would start an analysis. Mr. S did it “his way” and slowly increased his “modified” analysis to three times per week over a six-month period. In analyzing his rage at the cost of his treatment, the analysis of a silent moment revealed that Mr. S was angrily ruminating about the cost of a four times per week analysis. In response to these associations the analyst offered Mr. S a fourth hour. He responded, “Four times per week is your religious belief. You don’t know it’s any better than three times per week. It’s a ritual.” He added angrily, “Anyway, the time is impossible; it’s bad enough I have the frustrations of coming here and paying. At least the time should be convenient…. I’ll just wait until another time becomes available…. A patient will leave or die.”

After nine months Mr. S was able to accept the prescribed analytic situation. Although Mr. S’s analysis has been long and characterized by a series of acting out resistances, it has been productive. It is worth emphasizing that during the consultation I experienced Mr. S as a very “difficult” patient. In fact, there was something about Mr. S’s anger that frightened me in a manner I experienced as “different.” These feelings and fantasies influenced my view of Mr. S’s prognosis as guarded. I learned subsequently that some of my apprehension was related to countertransference. These data emphasize that at the beginning of an analysis only a judgment of the suitability for a trial of analysis is possible.

Mr. F was 44, an only child, in his second marriage, and the father of two children. He sought a consultation in response to complaints from his wife. He reported that although his wife was quite dissatisfied with their marriage, in spite of certain symptoms, he was quite satisfied with his life and with their life together. In addition, he reported he had had two experiences with therapy in response to a variety of life crises. These therapies were brief and helpful. In the first session, the analyst shared with Mr. F his tentative impression that analysis was the optimal treatment for Mr. F’s life-long difficulties. Mr. F stated emphatically that he had no interest in analysis, he was too busy, it took too long, he knew too many dissatisfied patients, and he didn’t believe in it. He added, however, that he liked the analyst’s style and what the analyst had to say, and he would think about seeing the analyst for further consultation.

Mr. F called three weeks later and made another appointment which he subsequently canceled. He arrived at his second session a week later dressed in an obviously expensive suit, silk shirt, and tie. He reiterated his appreciation of the analyst’s comments and his disinterest in analysis. Analysis was not for him. In striking contrast to his costume, clubs, and hobbies, all of which were for the privileged wealthy few, Mr. F expressed his feeling that an important determinant of his aversion to analysis was that it was pretentious. The analyst asked Mr. F what that meant and listened to what the analyst considered rationalization as Mr. F spoke of it being only for the rich. The analyst told Mr. F that the analyst did not understand his objections to analysis as pretentious when so much in Mr. F’s life centered on the enjoyment of expensive possessions and hobbies. Mr. F proceeded to inform the analyst that he would like to see the analyst once or twice a week. The analyst suggested that if he really wanted a less intense psychotherapy he should seek it with a therapist who believed it was the optimal treatment for him. In response to Mr. F’s objections, the analyst added that if he was intent on working with the analyst, he would collaborate with Mr. F twice weekly with the understanding that we would work to understand better what the analyst understood as Mr. F’s fear of analysis. Mr. F then found it impossible to accept any of the hours the analyst offered him. Sensing that his character resistances were threatened by the ordinary parameters of the analytic situation, the analyst offered a second modification: we could make weekly appointments on a “catch as catch can” basis. Mr. F liked this idea.

Mr. F began the next hour by telling the analyst that he liked the flexible arrangement in regard to hours. He added, “It would kill me to pay for a missed hour.” Inquiringly the analyst repeated the word kill In response to his rationalizations the analyst suggested that even though he knows better it felt like it would kill him. The analyst added that this was his way of saying he was very frightened. Mr. F stated, “I would feel like I was in jail if there were fixed times and I had to be here four times a week. I want to do what I want to do when I want to do it. Control is a big issue for me.” Mr. F paused and then associated to a friend’s analyst who was indicted for sexually abusing his patients. Mr. F added, “I also like to know everything that’s happening here.” The analyst interpreted, “In analysis you’re afraid that I’d know more than you.” Mr. F concurred and associated that his father always had to have his own way. It’s as if he’d only be satisfied if he were king. Then he commented on my fee being on the upper end of the spectrum of analysts’ fees and on his being a millionaire.

He began the next session talking about people using him. He spent the entire session telling me of a passionately important business relationship in which he saw his friend and colleague every day for six years only to be abandoned when he was no longer of use. The analyst interpreted his fear of a similar experience with the analyst.

In the next session he spoke about his fear of analysis and intense involvement with the analyst. He associated to his father who he felt swallowed him up if he allowed himself to get too close to him. He added, “I cease to exist.”

In the ensuing month Mr. F worked on his rage when his sense of entitlement to ideal hours was frustrated. In the eleventh session he reported his first dream. “I had a dream last night I don’t understand. I dreamt I was in a church or maybe it was a bombed out city. I’m who I am only I’m a bit younger. There was a young child going out of control biting and eating everything in sight. I was frantically trying to control him.” Mr. F conjectured, “I guess maybe both people are me.” Then Mr. F described being at his father’s birthday party the previous day. Mr. F stated, “Everybody I love and hate was there.” The analyst interpreted, “You’re afraid of losing control with your family and with me when you’re frustrated. You speak of wanting to control people and situations when you’re afraid of losing control of yourself.” In response to the interpretation Mr. F associated to a fantasy of throwing his wife out of the window and of an urge to open his fly and exhibit his penis at a party. The analyst interpreted his fear of experiencing similar murderous and sexual feelings with the analyst.

Mr. F began the next session by telling the analyst that he began seeing the analyst with the fantasy that talking to the analyst would magically cure all his problems. He felt anxious in response to his awareness that analysis was hard work that didn’t yield ideal results.

Six weeks later Mr. F began the session before the analyst was scheduled to leave him for two weeks, by requesting two scheduled hours. He associated to his rage at his father. The analyst interpreted the displacement and interpreted that he was similarly enraged at the analyst for leaving him and for not giving him ideal hours. The analyst added that Mr. F had a fantasy of being treated as “special” which meant never being disappointed. Mr. F confirmed the interpretation by adding that the pursuit of that fantasy was why he didn’t enjoy his children and was at the root of some of his other problems. He stated, “I want to be a special child and be taken care of.”

During the fourth month of Mr. F’s modified introductory phase, Mr. F began a session by telling the analyst how meaningful treatment was becoming for him. He stated, “I’m beginning to ask questions about why I do things.” The next day Mr. F came to the analyst’s office for an imagined additional third session that was not scheduled. The analyst interpreted this acting in the transference as reflective of a frightening wish to be closer to and more involved with the analyst.

At the beginning of the fifth month the analyst identified that Mr. F never raised the issue of his fear of a four times per week endeavor. The analyst added, “You wait for me to raise the issue in relation to one of your thoughts. You treat the issue as if it were my concern.” Mr. F responded, “Yes. It’s like with Margaret and my parents. If they say something is good for me I have to prove they’re wrong and my way is correct. If Margaret tells me to eat in a manner that is good for my health, I defiantly eat fat. You say four times a week and I say I’ll show you twice a week is as good.” The analyst interpreted, “So the substance of the recommendation drifts into the background and it becomes an issue of self-esteem. You feel you defiantly want to prove that you’re right and I’m wrong.”

During the ensuing months, Mr. F deepened his appreciation of the defiant meaning of his modified treatment plan and its narcissistic gratifications. He felt “special” and victorious doing it his way. This work was associated with an increase in trust in the analyst and a decrease in anxiety. After seven months Mr. F was able to accept a four times per week endeavor.

Discussion

In a letter written on January 4th, 1928, Freud commented on his papers on technique and the tendency of his followers to ritualize his suggestions. He wrote, “My recommendations on technique… were essentially negative. I thought it most important to stress what one should not do, to point out the temptations that run counter to analysis. Almost everything one should do … I left to … tact. What I achieved thereby was that the Obedient submitted to these admonitions as if they were taboos and did not notice their elasticity. They would have to be revised someday, but without setting aside the obligations” (Grubrich-Simitis, 1986, p. 271).

In this chapter I have presented analytic data that emphasize the elasticity of the parameters of the analytic situation in its opening phase. I have presented data from the introductory phases of two trials of analysis in which the prospective analysands were unable to accept the minimum four times per week frequency of the analytic situation. The basic premise of this chapter is that the analyst should begin the analysis in anyway the patient is able to, so that together they can begin to understand the defensive aspects of the analysand’s objections as resistance. In addition, I am suggesting that at the beginning of a trial of analysis a great deal of attention to questions of diagnosis and analyzability is not required and may be counterproductive. I am not suggesting that evaluation is unnecessary. Clearly every analyst would maintain some counterindications to a trial of analysis. However, I am emphasizing that an analyst’s excessive interest in doing an evaluation of ultimate analyzability and making a specific diagnosis may contribute to creating an analytic situation that may hinder a trial of analysis.

In this chapter I am emphasizing that an analyst’s attitude toward questions of indications and contraindications for an analysis, and the related question of the relationship of diagnoses to considerations of analyzability, influence his or her attitude toward prospective analysands and the resulting outcome of consultations and attempts to recommend and begin an analysis.

Although a trial of analysis is not indicated for all patients, I consider a trial analysis indicated for most patients I see...

Table of contents

• Cover
• Half Title
• Title
• Copyright
• Table of Contents
• Dedication
• Preface to the Second Edition
• Introduction
• I. Introductory Phase Work
• II. Midphase Work
• References
• Name Index
• Subject Index