Coasting in the Countertransference

Conflicts of Self Interest between Analyst and Patient

Irwin Hirsch

• Publisher: Routledge
• Year: 2011
• Print ISBN: 9780881634556
• eBook ISBN: 9781135469436
• Topic: Psychology
• Subtopic: History & Theory in Psychology
• Index: Psychology

Winner of the 2009 Goethe Award for Psychoanalytic Scholarship!

Irwin Hirsch, author of Coasting in the Countertransference, asserts that countertransference experience always has the potential to be used productively to benefit patients. However, he also observes that it is not unusual for analysts to 'coast' in their countertransferences, and to not use this experience to help treatment progress toward reaching patients' and analysts' stated analytic goals. He believes that it is quite common that analysts who have some conscious awareness of a problematic aspect of countertransference participation, or of a mutual enactment, nevertheless do nothing to change that participation and to use their awareness to move the therapy forward. Instead, analysts may prefer to maintain what has developed into perhaps a mutually comfortable equilibrium in the treatment, possibly rationalizing that the patient is not yet ready to deal with any potential disruption that a more active use of countertransference might precipitate.

This 'coasting' is emblematic of what Hirsch believes to be an ever present (and rarely addressed) conflict between analysts' self-interest and pursuit of comfortable equilibrium, and what may be ideal for patients' achievement of analytic aims. The acknowledgment of the power of analysts' self-interest further highlights the contemporary view of a truly two-person psychology conception of psychoanalytic praxis. Analysts' embrace of their selfish pursuit of comfortable equilibrium reflects both an acknowledgment of the analyst as a flawed other, and a potential willingness to abandon elements of self-interest for the greater good of the therapeutic project.

1

Coasting in the Countertransference

Analysts’ Pursuit of Self-Interest

I have had, over the years, many informal conversations with psychoanalytic colleagues who are also close friends that focus on some of the selfish motivations both for our work with patients and in our broader professional pursuits. These conversations are often in a humorous vein, sarcastically tweaking both our own self-serving interactions and the myth that those of us in the helping professions are possessed by especially altruistic spirits. In the candor of friendship we have teased one another about a variety of familiar themes; for example, the joys of being the object of sexual desire, especially in the eyes of patients toward whom we are physically attracted; the pleasures of being admired in a myriad of ways, in contrast with being the target of hurtful criticism or scathing anger, even though it is clear to all in the field that anger in the transference is an essential part of any depth analysis; the high that comes from the affirmation of receiving new referrals, having most of our available hours filled, and earning a satisfactory living; and the ever present specter of boredom, and the frequent temptation to not listen carefully to patients. I recall one specific moment of shared laughter and recognition when a colleague quipped to a small group of us that, by far, his favorite form of transference was idealization.

Though conventional wisdom dictates that self-interest is a significant, though not exclusive, motivation for much of what all living creatures do (Slavin & Kriegman, 1992, 1998), psychoanalytic literature has, for the most part, avoided addressing the degree to which this impacts analytic therapy in ways that are sometimes helpful but sometimes harmful to patients. Analysts’ pursuit of money, or, put more colloquially, the need to earn a living, has received more attention in the literature than other dimensions of analysts’ selfish pursuits (see, e.g., Aron & Hirsch, 1992; Josephs, 2004; Lasky, 1984; Liss-Levinson, 1990; Whitson, n.d.), and I intend to address this important question again in chapters 7 and 8. Recently, Maroda (2005) has emphasized the importance that analysts recognize that, inevitably, they seek gratifications from patients, and that this should be seen as normal and inherently human (Slavin & Kriegman, 1992, 1998). Maroda referred, for example, to desires to be important and effective as virtually standard features of all interpersonal engagement, though she was aware that pursuit of these “normal” gratifications can become overly narcissistic, excessive, and ultimately harmful to patients. In an earlier generation, iconoclastic analytic writers like Singer (1965a, 1965b, 1968, 1971, 1977) and Searles (1960, 1965, 1979) both suggested the ubiquity of analysts’ self-interest, and the need to be aware of it, so that the analytic process is neither a sham (i.e., analysts’ portrayal of themselves as selfless and as caring only about what is best for patients) nor a vehicle for unrestrained pursuit of this self-interest. Singer implied what is essentially a capitalist ideal—the pursuit of financial compensation and professional recognition is best served by being an optimally competent analyst for patients. Searles suggested that vigorous enjoyment of one’s interaction with patients is likely to lead to more authentic and passionate engagement with them. Needless to say, past a certain, difficult-to-determine point, an emphasis on self-interest usually involves at least a measure of disregard for the other.

In this volume I write about the kind of analyst self-interest that is not an aspect of the analyst’s character alone, nor simply an expression of a wish to be successful in one’s work. My interest lies in pursuits of self-interest that emerge as potentially useful data from the transference–countertransference matrix, though are not necessarily used to further the analytic work. Instead, the analyst can be said to coast in the countertransference, choosing comfort or equilibrium over creating useful destabilization (Mendelsohn, 2002; Slavin & Kriegman, 1992). In this chapter and in what follows, I plan to address a variety of ways that, with at least some consciousness, analysts commonly pursue their own interests at some cost to patients. The first issue I address in this chapter reflects momentary indulgences, the countertransference implications of which the analyst does not use to deepen the analytic process. Lapses in attention and daydreaming are quotidian examples. The second theme in this chapter refers to the way analysts structure their practice, including the length of the workday, spacing between analytic sessions, and competing professional activities. In subsequent chapters (chapters 2, 3, and 4), my attention focuses upon analysts’ unique personalities and the situational factors in analysts’ lives. These enduring and/or transient states generally lead analysts, usually unwittingly at the start, to shape the analytic relationship to conform, more or less, to their most comfortable and preferred relational states. At some point these interactions inevitably become conscious to the analyst, and the choice presents itself whether to create a disquieting disequilibrium by using these interactional data to productively address the transference–countertransference theme, or, conversely, whether to coast with the status quo and maintain what might be a mutually comfortable equilibrium between patient and analyst. I am suggesting that it is more common than one would suspect from the psychoanalytic literature for analysts to consciously choose to maintain personal and/or mutual states of equilibrium with patients over the promotion of therapeutically useful mutual destabilization. Perhaps the most common example of this can be seen in many long analyses, where a dependent patient wishes to remain eternally, and an analyst, gratified by both a sense of importance and an economic annuity, chooses not to address the mutually gratifying nature of the transference–countertransference relationship (Renik, 1995, 2006). Along the same lines, a situational factor of analysts’ loneliness (Buechler, 2004; Fromm-Reichmann, 1959) may readily lead to efforts, unconscious at first, to facilitate patients’ excessive dependency and to discourage separation and autonomy.

In chapter 5, I address the often powerful role that any analyst’s cherished psychoanalytic theory may have in both structuring and understanding the therapeutic dyad. Analysts’ respective theoretical heritages provide comfortable and familiar homes for them, and patients are commonly shoehorned into a conceptual space that is designed to reinforce analysts’ sense of stability. In chapter 6, I discuss the rarely addressed issue of male analysts’ and/or patients’ baldness, and the enormous anxiety that either state may create within the analytic dyad. I argue that analysts’ avoidance of dealing with this issue is more characteristic than otherwise, for it may readily create in both parties what could be experienced as a premature confrontation with mortality. In my final two chapters (7 and 8), I emphasize the degree to which analysts’ economic needs may influence every aspect of the analytic relationship. I underscore that the impact of therapists’ economic concerns reflects the single biggest dilemma in any of the helping professions.

Slochower (2003, 2006), referring to what she called everyday “crimes and misdemeanors,” wrote with unusual candor of the inherent conflict that may exist at any moment of analytic work between attention to patients’ and analysts’ wishes and/or interests. Though it seems so obvious after it is noted, Slochower highlighted what has rarely been acknowledged in the literature—the difficulty of suspending attention to one’s interests and listening carefully to others for even one analytic session, much less all day long. The joke that ends in the analyst’s shrug of his shoulders and his question “Who’s listening?” is a reflection of how well most analysts know privately that they do not always listen to patients, choosing instead, at any given moment or for much longer, to attend to themselves in priority. Slochower argued that pursuit of self-interest of any kind is most harmful when analysts fail to acknowledge this phenomenon as a powerful force in any given analytic experience. Needless to say, analysts who face themselves and embrace their deficiencies with a good measure of honesty are less likely to persistently pursue selfish interests to the severe detriment of patients. For instance, because most lapses in attention by the analyst have something to do with the patient or with the analytic interaction, each instance of this becomes an opportunity for analytic inquiry. Few of us use productively each such instance. However, though no analyst can operate with this degree of presence all of the time, some approach this ideal more consistently and, of course, with some patients more than with others.

Self-awareness, however, is not a guarantee that any given analyst will change the way he or she is relating to a particular patient, either at specific moments or over extended time periods. The power of the quest for personal comfort and equilibrium, with each unique individual patient, is always potent. In the dyadic work of analysis, it is quite common that analysts’ self-interest and patients’ comfort levels dovetail, and persisting in perhaps stagnant but relatively anxiety-free enactments or mutual configurations is compelling for both parties (Feldman, 1997). For instance, think of the schizoid patient who is quite comfortable with the analyst’s withdrawal, the overdependent patient who relishes the analyst’s infantilization, the sexually provocative patient who enjoys the analyst’s flirtations, or the masochistic patient who expects to be ignored. Analysts’ awareness of such engagements or enactments has the potential to lead to a useful deconstruction of them, but because they can be so mutually gratifying, this is often not the case. On a conceptual level, most contemporary analysts agree that the analysis of a mutually constructed configuration is the sine qua non of the process and that such interactions are hard to meaningfully address unless they have been enacted within the transference–countertransference matrix (Black, 2003; Bromberg, 1998, 2006; Gabbard, 1995, 1996; Greenberg, 1991, 2001; Hirsch, 1996, 1998a; Jacobs, 1986; Levenson, 1972, 1981, 1992; McLaughlin, 1991; Mitchell, 1988, 1993; Poland, 1992; Renik, 1993; Sandler, 1976; Stern, 2003, 2004; Varga, 2005; Wachtel, 1980). The issues addressed here, however, focus on analysts’ conscious disinclination to assert the effort to put these interactions (unwitting enactments) into words, choosing instead to remain in a comfortable moment, or in a long-standing equilibrium of what may perhaps be either free of anxiety for the analyst singularly or a familiar and therefore comfortable mutual enactment for both analytic participants. Implicit in this exegesis are the ideas that analysts often fail to use countertransference productively and that the thorough-going embrace of countertransference experience in much of contemporary two-person psychology theorizing may not be sufficiently thought out. A more genuine two-person relational psychology cannot assume optimistically that each unique analyst will engage countertransference experience to good end. Analysts’ idiosyncrasies dictate that each individual analyst will at times indulge his or her countertransference, and that patients will be the worse for this. If the examination of the experience and participation of both parties in the dyad is to be as thorough as interpersonal and relational writers suggest it should be, there will have to be added a focus on how often patients’ progress is limited by analysts’ failures to translate what they know about their countertransference experience into helpful shifts in analytic relatedness. That is, the inclination to pursue self-interest must be included as a feature in any conception of a mutually subjective (Aron, 1991, 1996; Benjamin, 1995; Hirsch, 1990; Levenson, 1972, 1981, 1992; Renik, 1993, 1995; Singer, 1977; Stern, 1997; Wolstein, 1954, 1977, 1997), two-person psychology of psychoanalysis. Though I do believe that analysts’ unwitting participation is inevitable and virtually always potentially productive, I also believe that analysts too often are willing to coast with comfortable modes of participation after they become witting. What Buechler (2002, 2004) has called “effort fullness” reflects her recognition of how counterintuitive it is for anyone to choose discomfort and disequilibrium in preference to their opposite states (Slavin & Kriegman, 1992, 1998). Theories of therapeutic action are based on ideals and on analysts behaving ideally, though each individual analyst is, indeed, a flawed human being who operates selfishly and falls short of analytic ideals very often.

In what follows throughout this volume, I will address a variety of ways and contexts that reflect analysts’ at least somewhat conscious choices to maintain self-interest, or to coast, and to make less than optimum effort to use immediate experience to help patients progress to satisfactory termination (Renik, 2006). Though, as noted, I will try to separate these pursuits of self-interest and personal equilibrium into discrete categories, inevitably there is much overlap between categories, and they are not at all independent of one another. In the remainder of this chapter I address the particular theme of analysts’ lapses of involvement and attention, and the often selfish way analysts structure their workday and integrate their range of professional commitments. Implicit throughout all chapters is the concept that analysts need to tolerate disequilibrium and to personally change in relation to patients, if patients themselves are expected to change (Buechler, 2002; Mendelsohn, 2002; Slavin & Kriegman, 1992, 1998; Wolstein, 1954, 1959).

The Analysts’ Lapses

It is worth restating Slochower’s (2003, 2006) obvious but rarely addressed acknowledgment of how difficult it is to suspend attention to one’s own concerns, and intently listen to another person for 45 or 50 minutes, much less do this repeatedly over the course of an entire workday. Indeed, this seems to me quite impossible, and I believe every analyst has lapses in attention for some fractions of time in every session. When these periods of inattentiveness occur, of course, are crucial data, because analysts’ boredom or affective withdrawal is usually related to the patients’ participation and to elements of the analytic interaction. As well, the content of analysts’ ideation during periods of inattentiveness may be highly informative about patients and about the analytic interaction. Ogden (1994) and Wilner (2000), from very different analytic perspectives, both suggested that all of analysts’ fantasies or reveries are related to the analytic interaction not only in form, but in content as well. In a sense, they imply that analysts never really withdraw from patients, because every withdrawal and how it is spent are actually just other forms of being involved with patients.

Though I agree that this often is the case, this conception seems to me somewhat idealistic, and a denial of the flawed humanity of all of us who practice analysis. It suggests that analysts never retreat into privacy and self-involvement for reasons that are largely narcissistic and selfish, and that are more often than acknowledged independent of patients’ participation. I do believe that every act, when with another person, indeed does have some interpersonal meaning. However, this meaning could be far secondary, for instance, to an analyst’s communication of the wish for privacy or respite, or a statement, for example, of analysts’ fatigue, preoccupation, worry, or looking forward to what lies ahead in the day or evening. Most analysts will acknowledge privately that boredom is an occupational hazard, and that this experience is not always primarily related to a particular interaction with a given patient. I will say more about this later in this chapter, but boredom is often related to how many patients are seen in a day, how they are spaced, the time of the day, and competing activities. I suggest that although analysts are, of course, more likely to withdraw into boredom and self-involvement with some patients more than with others (and that this is always of informational value), the reverie involved in these withdrawals sometimes reflects exclusively analysts’ narcissistic concerns (Bach, 1995; Blechner, 2005b; Fiscalini & Grey, 1993; Hirsch, 1993), and may not at all be of informational value in understanding patients.

Although some analysts are better able than others at suspending attention to their own concerns during sessions, and most analysts can do this best when not especially busy or fatigued, or when their personal lives are relatively smooth, I do not believe that anyone does not use his or her workday, in some degree, to retreat into privacy. Indeed, the structure of the analytic situation lends itself to this. Psychoanalysts are expected to be quiet and reflective, and patients quickly learn not to expect very much verbal interaction. When patients lie on the couch, they face away from the analyst, and the analyst probably speaks less often, so that both visual and auditory cues about the analyst’s experience are less available to patients than when they sit up. I am not sure, though, that patients on the couch know as little about the analyst’s ongoing experience as analysts often seem to think. I have always believed that patients are able to read our sentiments, attitudes, and levels of engagement despite even lengthy silence and/or not seeing us. However, because analysts’ roles, even in current times, are defined by at least reserved or infrequent verbal and nonverbal expressiveness, it is difficult for patients to entirely trust their perceptions about analysts’ momentary, or sometimes even long-term, disengagements. Indeed, analysts often do not encourage patients to challenge them about their withdrawals, preferring instead to remain in such states, often protected by patients’ unwillingness to be overly critical and to lose analysts’ affections. Because analysts’ work is defined more by listening than by speaking (we are supposed to be “good” listeners), we can usually get away with brief or even extended periods of listening to ourselves more than to our patients. Obviously, this is more likely with patients who do not expect and/or demand a great deal from us, or from relationships in general. Independent of particular transference–countertransference interactions, I believe that the use of the analytic couch lends itself to analysts’ taking selfish leave from patients. Designed to minimize analytic influence on patients and to provide analysts optimal freedom to use creative reverie in the service of helping patients, this freedom, unfortunately, extends to greater latitude to be absent without detection—to be self-involved, and “missing in action.” Slochower (2003, 2006), with some self-effacing humor, cited a variety of ways that she and/or her colleagues have taken leave from patients, aided by the absence of visual cues afforded by the couch or, even more extremely, in the context of telephone sessions. Indeed, this latter phenomenon has become more common in recent years (Richards, 1999). Slochower’s examples include making shopping lists and schedules, paying bills, scanning the Internet, and looking at personal photographs. The humor involved in noting such unabashedly selfish pursuits is the humor of recognition—each analyst feeling some personal exposure to what Slochower called analytic “crimes and misdemeanors.” In face-to-face analyses, one must learn to be more subtle, to scan the Internet of our mind, so to speak. Paying attention to oneself and not to patients will never be eliminated by any of us—it will only at best be controlled when analysts fully acknowledge this to themselves and encourage patients to make us uncomfortable by expressing, not containing, their transference-related perceptions of us (Aron, 1991, 1999; Blechner, 1992; Fiscalini, 1988; Gill, 1982, 1983, 1984, 1994; Goldstein, n.d.; Greenberg, 1986; Hirsch, 1998a; Hoffman, 1983, 1987; Singer, 1968; Stern, 1987; Wachtel, 1982).

Later in this chapter I refer to circumstances that make analytic disengagement more likely, independent of particular transference–countertransference configurations. Nonetheless, as noted earlier, analysts’ boredom, retreat into privacy, and the like are usually related to the person of the patient, and to the nature of the interaction at any given moment. I want to emphasize that I do not consider experiences like boredom, lapses in attentive listening, and affective retreat and isolation as unmediated expressions of the analyst’s character or personality, and therefore as countertransference in the one-person sense described by writers such as Reich (1951). Instead, I view such states as intrinsic to any interpersonal situation that endures for even a modest period of time. What is problematic (albeit universal), and reflects my emphasis throughout, is analysts consciously choosing to remain in these states because this represents the most comfortable place to be situated at any given moment for the analyst, and often for the patient as well. Analysts’ failures to make the effort to return from lapses in attention and pursuit of personal reverie, and/or to use these retreats for therapeutic ends in order to expose mutual enactments, comprise the countertransference theme most unaddressed in our literature. Here is a brief illustration.

Hillary* has been in analysis for some time, and has made only modest gains in her original presentation of herself as depressed in a “low-grade” (her words) way and passionless in both her marriage and career pursuits. She reports “the blahs” and, indeed, relates to me with a flatness and absence of verve or of urgency, virtually regardless of the seeming importance of the issue she brings to me. This was so when she told me of uncovering her husband’s sexual infidelity, as it was true of her recent report of the acute mental collapse of her elderly mother. Our interaction follows a pattern. I usually tell her that she is speaking in a flat and disinterested tone about something I know that she has strong feelings about. She takes note, though continues in the same vein. I begin to become bored and retreat into my own private world, and then mobilize, and convey to Hillary that she still sounds like she’s deadening her feelings. Hillary agrees, yet continues true to form. I resort to interpretive comments, reminding her of the origins of her retreat. In capsule, the origins to which I refer are largely the loss, in her early teens, of her romantic fantasies with, and strong sense of being special to, both her father and her brother, a loss brought on by her mother’s success in “stealing back” her father, and the beginning of her brother’s relationship with a girl who eventually became his wife. Until her acquiescent father withdrew profoundly, Hillary describes herself as having felt special to him and, as well, felt vivacious and excited about life. Subsequent to this period, she usually chose safety, including a marriage to a man she knew she was not in love with, but whom she perceived as steady a...

Table of contents

• Cover
• Halftitle
• Title
• Copyright
• Contents
• Acknowledgments
• Foreword
• 1 Coasting in the Countertransference
• 2 The Influence of Situational Factors, in Analysts’ Lives and Analysts’ Preferred Relational States, on Analytic Participation
• 3 Analysts’ Character Structure and the Wish for Emotional Equilibrium
• 4 Preferred Patients, Preferred Relational Configurations
• 5 Psychoanalytic Theory and Its Unexamined Comforts
• 6 Baldness
• 7 Money and the Therapeutic Frame
• 8 Money and the Ongoing Therapeutic Relationship
• References
• Footnotes
• Index