The Concept of Analytic Contact

The Kleinian Approach to Reaching the Hard to Reach Patient

Robert Waska

• Publisher: Routledge
• Year: 2007
• Print ISBN: 9780415422925
• eBook ISBN: 9781134099924
• Topic: Psychology
• Subtopic: Mental Health in Psychology
• Index: Psychology

The Concept of Analytic Contact presents practitioners with new ways to assist the often severely disturbed patients that come to see them in both private and institutional settings. In this book Robert Waska outlines the use of psychoanalysis as a method of engagement that can be utilised with or without the addition of multiple weekly visits and the analytic couch.

The chapters in this book follow a wide spectrum of cases and clinical situations where hard to reach patients are provided with the best opportunity for health and healing through the establishment of analytic contact. Divided into four parts, this book covers:

• the concept of analytic contact
• caution and reluctance concerning psychological engagement
• drugs, mutilation, and psychic fragmentation
• clinical reality, psychoanalysis and the utility of analytic contact.

Analytic contact is demonstrated to be a valuable clinical approach to working analytically with a complicated group of patients in a successful manner. It will be of great interest to all practitioners in the field of psychoanalysis and psychotherapy.

Part I
The concept of analytic contact

Chapter 1
Defining psychoanalytic treatment

ORGANIZATIONAL ISSUES

Kernberg (1996) has explored the many ways psychoanalytic training institutes prevent, punish, and work against the creativity and individuality of candidates. He points to the abuse of power, political rigidity, pathological narcissism, competitiveness, and the general need of the institutional authority to control the candidate’s contribution to the point of making sure there is no contribution, only unquestioning allegiance.

Kernberg has explored the ways psychoanalysis manages to sabotage itself within the training society atmosphere. In a similar manner, I notice the psychoanalytic community as a whole managing to work against its own identity, growth, and potential by conducting a self-destructive debate about what is analytic. Without covering the long history and the many contributions in the debate, this struggle to define what constitutes “true psychoanalysis” has been going on for decades, while the integrity and strength of the field crumbles. In many varied ways, the field of psychoanalysis seems to be in conflict about how to interact with society, with its own members, and with the patients who should be at the heart of Freud’s invention rather than part of theoretical debates on analyzability. In this chapter, I will touch on these self-defeating manners of relating to the public and relating to its own professional identity and suggest an alternative focus that realigns the profession to a more therapeutic standard. Specifically, there needs to be a rededication to the clinical process that we all call psychoanalysis, rather than competitive, academic debates taking the place of our mission as clinicians helping the sick and troubled.

The almost religious battleground that the field of psychoanalysis has created over what constitutes true, authentic, proper analytic treatment can be understood as a primitive, self-destructive act. I will examine a few aspects of this problem, but mainly concentrate on why the theoretical and political battle that alienates candidates, the public at large, and the prospective patients who need the help a trained analyst can provide is very much out of touch with and overshadows what actually occurs in the clinical setting.

Most of the general public has no idea what the difference is between a counselor, a psychologist, a psychiatrist, or a psychoanalyst. What the analytic profession fails to realize is that analytic training enables the psychotherapist, from whatever background, to provide the best psychodynamic, therapeutic encounter possible to every patient that comes to them for help. The bickering, backbiting, and territorial squabbling between analysts blinds them to the value of what we have to offer. Therefore, the importance of educating the public about the unique and skillful therapy we have to provide is lost.

The dramatic posturing, the arrogant debates, and the devaluing of anything that doesn’t fit the idealistic notion that rarely exists in clinical reality demeans the valuable work all psychoanalysts do and the special expertise we provide to our troubled patients. The obsessional focus on frequency and use of couch, the fear of sibling rivals in forms of counselors, medications, and managed care companies, the need to appear superior and omnipotent, and the religious worship of theoretical ideals that fly in the face of clinical data leave the psychoanalytic profession adrift.

Twenty-five years ago, Der Leeuw (1980) stated, “Anyone who is familiar with the practice of psychoanalysis and psychotherapy today can distinguish two trends: a steady decline in the number of psychoanalysts engaged in full-time psychoanalytic practice” and “a diminished demand, or social need, for psychoanalytic treatment. Young psychoanalysts complain that it is difficult to get patients.” He goes on to note the reasons for this that include “the many kinds of psychotherapy that have been developed since psychoanalysis began, the high costs, the long duration of treatment, the time required daily for therapy, and the difficulty in predicting and testing the results in a reliable way” (pp. 137-8).

This lament is still with us three decades later. Many in the profession would say it has merely gotten worse.

The American Psychoanalytic Association has pondered how to generate new members especially when the average age of current members is now in the seventies. Many mental health professionals seek psychoanalytic training in some capacity, but when exploring the official routes, they often are met with off-putting arrogance and rigidity.

On the internet discussion group of the International Psychoanalytic Association, the audience’s reaction to Kernberg’s (1999) article on the differences between psychoanalysis, psychoanalytic psychotherapy, and supportive psychotherapy brought out many voices within the analytic community. Many of these reactions illustrate the changing tide within the profession to what has been a restrictive, rigid, and idealistic vision of psychoanalysis and an overfocus on politics, territoriality, and theory rather than the clinical outcome of psychoanalytic work with patients.

Galatariotou (2000) has summarized in his review many of these responses to Kernberg’s article and the more contemporary views of what psychoanalysis really is in its modern practice. Jose Silberstein sees the debate as mostly political and points out that most patients suffer rather severe pathology and don’t attend sessions with the frequency usually considered “analytic” for financial and cultural reasons. Ray Poggi clarifies that psychoanalysis and psychoanalytic psychotherapy both aim for structural change and use expressive means to do so. Poggi thinks psychotherapy is merely a modified form of psychoanalysis that is much more applicable to the usual patients whom analysts treat. Echoing the political aspect of Kernberg’s debate, Poggi notes that the profession’s need to find organizational clarity and alleviate professional anxieties hinders more important clinical issues. In the same article by Galatariotou, Howard Levine noted how a debate about psychoanalysis versus psychoanalytic psychotherapy seems to come up every twenty years or so because of a perceived threat by whatever the latest wave of innovative thinking brings to the theoretical and clinical stage, such as the Sullivanians, Self Psychology, Relational Analysis, and the Kleinian Movement. Leo Goldberg, in the same article, points out that the distinctions Kernberg and others make between psychoanalysis and psychoanalytic psychotherapy are artificial and break down when the clinical process is examined.

I think this is at the heart of the problem. Goldberg sees psychoanalysis as the analysis and interpretation of psychic phenomena, with couch and frequency not a defining factor. She believes psychoanalysts should serve all patients, not just the rapidly vanishing mild neurotic sector of the population. This brings us back to Freud’s mission, healing the wounded psyche.

The debates over frequency of sessions, acceptable patients, and the differences between psychoanalytic psychotherapy and “true” analysis all destroy the efforts to demonstrate to the public and to our own community how we actually help people in distress.

At a conference in 2003, Otto Kernberg talked about this matter. He told the audience that he had been on a committee several decades earlier that had voted on the specific number of sessions per week which were to be deemed proper for a “true” psychoanalysis. He said he now regrets being a part of something that became so religiously deified and rigid to the point of dismissing the actual clinical work of psychoanalysis and to focusing on numbers instead. Also, he pointed out that these now unmoving frequency rules were invented only as a standard of training, not as a standard of actual practice. This has obviously been lost in the translation. Finally, he said most of the major psychoanalytic organizations today resist any major change, in frequency or any other now sacred rule, out of fear of psychoanalysis being seen as no different than any other therapeutic treatment. All of Kernberg’s comments make sense from a clinical standpoint. Interestingly, they all contradict what he said in his 1999 paper on supposed differences between psychoanalysis and psychoanalytic psychotherapy. I think this is because his paper was formulated from a narrow, theoretical perspective and not within a clinical context.

I believe that one crucial step in changing all of these self-destructive debates that plague the field of psychoanalysis is to study the clinical reality of psychoanalytic work. After graduation, most certified psychoanalysts see an average of one patient four times a week for on the couch treatment. When looking at the research, some analysts simply have no patients that fit that criterion. Cherry (Cherry et al. 2004) has noted that the modal number of analytic cases for graduates of analytic institutes was zero and the mean number was one. Their research showed that newly graduated analysts had a mean of three patients in twice-a-week treatment, with most not using the couch. The most common form of treatment was once-a-week psychotherapy. So, out of a forty-hour work week in private practice, a well-trained psychoanalyst may spend four hours “doing analysis” by textbook criteria and the other thirty-six hours doing “something other than analysis” by that same criterion.

We analysts have put ourselves in a constrictive mindset in which we collectively feel negative and pessimistic about the future of psychoanalysis. Because of this self-inflicted inertia, the profession has blinded itself to the fact that as a result of our psychoanalytic training, we provide a quality of treatment that is unique: the analytic approach. Whether it is in the form of once-a-week couples therapy, four-times-a-week analysis on the couch, or twice-a-week individual analysis face to face, we offer a superior, sophisticated, time-tested psychodynamic therapy for mental conditions.

ANALYTIC CONTACT: THE CLINICAL QUEST

When psychoanalysts engage in the now predictable and tiring debates over the differences between psychoanalysis and psychoanalytic psychotherapy, there is usually a central assumption, either spoken or unspoken. This is the idea that as the doctor and authority, we decide what form of treatment is best to apply to the patient. In one sense, this seems right. We are the professional with the knowledge of what sort of treatment would be best for what sort of ailment. But, this is a view based in medical metaphor rather than a psychological perspective. This skewed view is noticeable in debates over the indications or contraindications of psychoanalysis versus psychoanalytic psychotherapy versus supportive counseling. Various authors propose that certain diagnostic categories are best dealt with by one form of therapy over another. This type of outlook is not only narrow-minded and often flavored by an authoritative stance. Most importantly, it is very removed from the clinical reality of the analytic setting. In previous writing (Waska 2005), I have stated that the bottom line for psychoanalytic theorizing should always be based on what goes on in the room with the patient. Regardless of what we recommend or prescribe, the patient ultimately decides what form of therapy will be administered. This decision occurs through both conscious and unconscious channels and is actualized both interpersonally and intra-psychically. The analyst can attempt to influence this, by means of interpretation and working through of defenses, toward the direction of something more analytic, promoting more analytic contact. Or, the analyst can be pulled by the patient’s transference stance, often with counter-transference acting-out fueling the fire, into something less analytic and away from genuine analytic contact.

In a conscious, reality-based, or situational realm, the patient can take our recommendation regarding the type of treatment, the frequency, the use of couch, and so forth and simply agree or refuse. In other words, we can offer ourselves to the patient as a skilled and trained psychoanalyst and make whatever recommendations we want, but the patient’s conscious, verbal response will shape what the treatment is or becomes. This goes either way. Some patients may not accept the analyst’s recommendation of supportive counseling and instead want to come in more often, bring in dreams, make associations, ask about using the couch, and so forth. Likewise, patients who are told they would benefit from a “full” psychoanalysis can balk, only attending once a week and refusing to use the couch.

Another factor is the external circumstances that a patient brings to the setting. It is common enough that patients who would be suitable for a psychoanalysis cannot partake because they don’t have the funds, don’t have the time, or don’t have third party coverage that will pay for it. Unless we simply refuse to see the patient, we must find a way to still work analytically within these difficult confines. Some would say that is impossible. However, I think it is rare that we are operating under optimal settings and most analytic work is done under duress of one sort or another. So, I see analytic contact as the clinical goal, with the understanding that this may not always be possible.

The main way the patient shapes what clinical treatment is taking place clinically is from their internal world. The patient’s intra-psychic landscape ultimately determines the nature of the treatment. Regardless of how badly we want to conduct a psychoanalysis with a particular patient because we decide they would benefit from it, that patient’s particular phantasies and internal object relations may force that treatment into an interactive, supportive counseling situation. So, I think that it is simple-minded to argue over the differences between psychoanalysis and psychoanalytic psychotherapy if that argument presupposes that we can exert the power to apply whatever aid we wish to the passive entity. This theoretical mistake is perhaps a reliance on the medical model in which the all-knowing doctor applies the bandage of his choosing to the passive finger of his compliant patient. In saying this I don’t mean to say the patient should come up with their own diagnosis and treatment and that somehow analysis should be a completely mutual co-construction. This is not the case. We are the trained professional and should determine what sort of problem is before us and how to proceed. But, I am asserting that as psychoanalysts, we need to believe that the psychoanalytic approach is the best treatment and if we attempt to engage the patient in an analytic exploration, we are trying to foster a comprehensive path toward healing. However, the patient’s internal world will either enhance our attempt to establish analytic contact or seek to distort or destroy it.

I will present various cases in which the transference and sometimes the counter-transference were responsible for shaping the work into either what could be termed psychoanalytic contact or something less than analytic contact. Circumstantial and external environmental factors play a significant role in some of these cases. But ultimately, it was the transference, the phantasies, and the associated defensive structure of the patient that molded the treatment into something either more analytic or less analytic.

The cases I use may seem extreme, too brief, “untraditional”, or even outright failures. I make it a point to use all clinical situations I encounter in my psychoanalytic practice as illustrations in my writing and not just the “classic”, well-running, successful ones that seem to fit the norm because I believe analytic contact, and the struggle to find and maintain that contact, occurs in all our cases. In previous writing (Waska 2005, 2006), I have noted how research shows that actual psychoanalytic practice in the US and internationally consists mostly of stormy, “untraditional”, often brief, and often “unsuccessful” cases with patients suffering severe pathology and rarely achieving any full cure. However, if the psychoanalyst uses the psychoanalytic method to try and establish analytic contact, the same research also shows a great deal of successful work can take place which leads to significant internal and external change for the patient, with subsequent increase in ego integration and functioning.

Case 1.1: An ever so brief analytic contact

John was a middle-aged manager for a software company. He had worked there five years when the company was purchased by a larger entity. John and his company were aware they were facing a period of several months in which there would be an increased workload to bring themselves in line with the larger, new company. For John, this meant some longer hours and increased paperwork. However, when this transition began, John felt overwhelmed, anxious, and unable to sleep. He sought help for this sudden tension and we began meeting regularly, using the analytic couch.

My immediate impression was of an obsessive man wound up in a manic quest to appease and please his object. John talked rapid-fire and kept things very concrete. His goal was “to get back to normal” and “find a way to do all the extra work without feeling so overwhelmed”. His way of relating to me was to use me as a path back to efficiency. I asked him, “Are you curious about why this has thrown you so much?” When I introduced more reflective questions like this, John would first respond reflectively but quickly bring it back to the more concrete.

Answering my question, he said, “I am not sure. I feel like I have to make sure to do everything and make sure I deliver it all exactly on time.” I said, “So, there is a way you make yourself feel pressured and rushed, trying to get it done exactly?” He replied, “Yes, that is right. But, I think it is normal to...

Table of contents

• Cover Page
• Title Page
• Copyright Page
• Acknowledgments
• Introduction
• Part I The concept of analytic contact
• Part II Caution and reluctance concerning psychological engagement
• Part III Drugs, mutilation, and psychic fragmentation: is analytic contact still possible?
• Part IV Clinical reality, psychoanalysis, and the utility of analytic contact
• Summary
• References
• Further reading