The Patient's Impact on the Analyst

Judy L. Kantrowitz

• Publisher: Routledge
• Year: 2013
• ISBN:
  9781134892297
• Edition: 1
• Topic: Psychologie
• Subtopic: Relations interpersonnelles en psychologie

The question of how psychoanalysts are affected by their patients is of perennial interest. Edward Glover posed the question in an informal survey in 1940, but little came of his efforts. Now, more than half a century later, Judy Kantrowitz rigorously explores this issue on the basis of a unique research project that obtained data from 399 fully trained analysts. These survey responses included 194 reported clinical examples and 26 extended case commentaries on analyst change. Kantrowitz begins The Patient's Impact on the Analyst by documenting how the process of analysis fosters an interactional process out of which patient and analyst alike experience therapeutic effects. Then, drawing on the clinical examples provided by her survey respondents, she offers a detailed exploration of the ways in which clinically triggered self-reflection represents a continuation of the analyst's own personal understanding and growth. Finally, she incorporates these research findings into theoretical reflections on how analysts obtain and integrate self-knowledge in the course of their ongoing clinical work.This book is a pioneering effort to understand the therapeutic process from the perspective of its impact on the analyst. It provides an enlarged framework of comprehension for recent discussions of self-analysis, countertransference, interaction, and mutuality in the analytic process. Combining a wealth of experiential insight with thoughtful commentary and synthesis, it will sharpen analysts' awareness of how they work and how they are affected by their work.

PART I

Prologue

CHAPTER 1

The Project

Over the last 15 years, there has been a shift in the way analysts view the analytic process. While many analysts have always seen analytic work as interactional, for several decades ego psychology, the dominant school of thought in America, considered analysts as “blank screens” on whom patients could project their conflicts. The analysts were thought to be relatively interchangeable, and their contribution was primarily the offering of interpretations. In this context, counter-transference reactions were seen as intrusions to be analyzed by the analyst and controlled or a reason to go back into analysis. Countertransference was regarded as not providing the data for exploration that offered the opportunity for a greater understanding of the patient through a greater understanding of what had been evoked in the analyst in the interaction. Increasingly, analysts have recognized that they are active participants in the process who influence, and are influenced by, what occurs with their patients (Gill, 1982; Hoffman, 1983).

A belief about personal change resulting from work with patients seems consistent with psychoanalysts' current way of thinking. Analysts now pay greater attention to the impact of the patient on the analyst's functioning to provide more information about the patient (Dorpat, 1974; Gill, 1982; Greenberg, 1986; Modell, 1986; Stolorow, Brandchaft, and Atwood, 1987; Stolorow and Lachmann, 1988; Dorpat and Miller, 1992; Stolorow and Atwood, 1992; Hoffman, 1993; Mitchell, 1993; Skolnikoff, 1993; Goldberg, 1994). The belief that the personal characteristics and conflicts of another person with whom one has been intensely engaged have had an influence on the other has a commonsense face validity. The bidirectionality of this influence also has a commonsense logic.

Once psychoanalysis is viewed as a process influenced by, and impacting on, both participants, it would seem expectable that the analyst, as well as the patient, would be affected by participating in it. Yet, analysts often resist openly discussing and describing such changes in themselves and how they come about. There are, of course, notable exceptions in which analysts openly describe their countertransferences and elaborate their self-analytic process (Kramer, 1959; Calder, 1980; McLaughlin, 1981; Gardner, 1983; Poland, 1984; Eifermann, 1987, 1993; Jacobs, 1991; Sonnenberg, 1991; Margulies, 1993; Natterson and Friedman, 1995; Silber, in press). Nonetheless, when analysts discuss among themselves this phenomenon of their continuing personal change, there seems an uncertainty about how representative or how unique their own experiences are.

Personal change remains a general and abstract concept. It may mean very different things to each analyst. Gaining some new intellectual information and potentially new insight may frequently occur; however, it is not inevitable that these new understandings actually result in psychological shifts. Analysts, like patients, can idealize their own changes. Most statements by analysts about personal change remain general and undocumented (Smith, 1993; Goldberg, 1994).

This project studies how analysts perceive changes in themselves emerging from their work with their patients. It provides a new vantage point for assessing the impact of the analytic process over time on a group of people who have devoted themselves to this process as their life's work. An interactional view of psychoanalysis contains a latent presupposition that analysts change as a result of participating in the process, but this assumption has not been systematically explored or demonstrated. I hope to show how the particular match of patient and analyst may enable the analyst to attain new or deeper understanding; rework specific conflicts or distress or modify characterological adaptations and attitudes. This process can occur when overlapping conflicts or characteristics of the participants become the focus of analytic scrutiny.

For most analysts, the psychological issues that they explored in their personal treatment are not rerepressed, as they might be following termination, but rather are kept actively alive by their work with patients. As a result, the analyst has the continuing opportunity to rework these issues on a different and potentially deeper level. Every analysis is potentially a reanalysis for himself or herself. The questions are: How often does this actually occur? Under what circumstances does it occur? How do analysts think about, and describe, this phenomenon?

In studying the impact of the patient-analyst match on the outcome of psychoanalysis in the Boston longitudinal project (Kantrowitz et al., 1989, 1990c), it became apparent that analysts frequently believed that they, as well as their patients, changed during the process of analysis. The observations about analysts' personal and professional change were not the focus of this earlier project; in terms of the formal study, the only systematically documented reflections about psychological change were made about the patients. Many of the analysts, however, spontaneously commented how much they thought they had learned and changed as a consequence of their work with these patients. Sometimes their reflections were specific; for example, one analyst described how humbling it had been to be confronted by the limits of his ability to get another person to change. Most comments were more general and less self-revealing; they indicated the analysts' belief that they had been personally affected by their work with their patients but did not detail the area in which this impact had occurred.

One analysand, not formally part of this project, who was interviewed about her views about the impact of the patient-analyst match spontaneously elaborated the ways in which she believed her analyst had changed as a result of their analytic work (Kantrowitz, 1987b). In this instance, the patient believed that her analyst had become more flexible and spontaneous over the years in response to the patient's pain and distress at experiencing her analyst as distanced and formal.

Increasingly in recent years, analysts have openly described their countertransferences and elaborated their self-analytic process (McLaughlin, 1981, 1988, 1993; Boesky, 1982; Gardner, 1983; Spruiell, 1984; Eifermann, 1987a, b; Chused, 1991; Jacobs, 1991; Sonnenberg, 1991, 1993; Schwaber, 1992; Margulies, 1993; Poland, 1993; Renik, 1994; Smith, 1993; Weinshel, 1993; Hoffman, 1994; Natterson, and Friedman, 1995; Silber, in press). Most of these analysts focus on the awareness of affective reactions that are stirred or memories that are reawakened by their patients and their patients' transferences to them. Yet, while there is the suggestion that such reactions lead to psychological changes, with the exception of McLaughlin (1981, 1988, 1991, 1993, 1995) and, less explicitly, Tansey (1994), few analysts openly discuss or describe, at least in print, actual changes in themselves or how they come about.

McLaughlin details the impact of his work with patients on the transformation of his stance toward his work, his personal belief system, and changes in his own comfort. He documents how his failure effectively to reach certain patients and the personal distress aroused in him in the course of these treatments led him to increased self-reflection and led him to return at one time for a reanalysis and at later times to seek consultation on his work. The discoveries that emerged from his intensive self-explorations caused him to reevaluate and then change his relative silent stance in his work. He also relinquished his belief in the analyst's authoritative knowledge, which he came to view as undermining the patient's sense of psychic reality. Specific attention to similarities and differences between his patients and himself served as the stimulus for mutative insights leading him to a new perspective on himself and accompanying shifts in his affect state. The changes that resulted in his actual behavior as a consequence of his shift in outlook were subtle, but he believes they had profound ramifications on his patients' experience in the treatment and on the analytic work. He validates his belief in shifts in himself through observations of the short-term and long-term effects on patients. He confirms his subjective sense of change through the recognition of these changes by his family and long-term friends.

In order to obtain data more extensive than personal anecdotal information, a national survey was undertaken. Questionnaires were sent to 1,100 psychoanalysts who were members of the American Psychoanalytic Association. All 550 training and supervising analysts and a comparable number of graduate analysts from each institute were selected as the sample. The training and supervising analyst group was selected because certain comparability in the rigor of their assessment, if not their actual work, could be presumed; they had all been graduates for at least five years, had seen, at a minimum, four patients in analysis over those years, and had been certified by the American Psychoanalytic Association's Board on Professional Standards. In addition, their clinical work had been reviewed by their local institutes prior to their appointments as training and supervising analysts. The second group was a random sample stratified for age, institute position, and gender.

The purpose of this survey was to explore, first, whether or not and to what extent analysts believe that their analytic work with patients had led to personal change for themselves. When analysts did believe that personal changes had come about as a result of their work with patients, the survey explored what in the patient-analyst interaction triggered this change for the analysts, what method, if any, analysts employed to continue their personal work, and what changes, if any, they believed had occurred.

Some analysts may object to this focus on the analyst as a subject of study. They worry that attention has been turned away from the patient, who, after all, should be the analyst's central concern. Studying changes in analysts, however, opens up another way in which we may learn how psychological change comes about. While analysts' subjective appraisals of how they learn and change have the disadvantage of being self-reports, limited by the subjectivity and blind spots of the particular individuals and lacking any form of external verification, there are also advantages. Analysts were all themselves once analytic patients. They experienced the analytic process and then learned how to provide this experience for others. They learned how to describe what occurs between patient and analyst with a perspective derived from having been in both positions.

Having analysts report on themselves obviates the concerns about confidentiality we have when we report material about our analysands. Full descriptions of what transpires for a patient may sometimes seem an intrusion on privacy and potentially disrupt the solutions that the former analysand has achieved. Many analysts are reluctant to write about their patients for this reason. They want neither to risk disturbing a treatment process to ask permission to publish some aspect of the work nor to chance disrupting the synthesis the analysand achieved after termination (Stein, 1988a, b). When analysts voluntarily describe their own psychological processes and their changes, no such constraints apply.

Many analysts who would be reluctant to self-disclose, nevertheless, admire others who do so. The myth of the perfectly analyzed analyst is fading, but many still hold onto this ideal for themselves and feel shame about not living up to this model. Yet, to the extent to which psychoanalysts have reconceptualized the analytic enterprise as an interactional endeavor, they no longer exclude considerations of their contributions from descriptions of their analytic work. Once a joint contribution is accepted, analysts must then conclude that each analyst's character and residual conflicts, as well as skill and experience, affect his or her patients and the analytic process that develops.

If analysts believe in the codetermination of the analytic process, then they must examine and expose themselves in order to understand the nature of the evolving therapeutic interaction. The analyst's position is then dramatically reversed from its historical one. Not only is the analyst no longer a “blank screen” whose anonymity is desired to facilitate patients' fantasies, but now the analyst needs to be scrutinized in order to understand the analyst's contribution to the development of patient's fantasies.¹ Analysts have, of course, always been the focus of patients' intense interest as transferences develop and deepen, but the shift of attention is to the factors introduced by the particular characteristics of the analyst. While this reorientation involves a loss of comfort and potentially of some privacy for analysts, the benefits come from the potential increase in self-awareness and self-knowledge and the possibility to continue to rework personal issues; however, not all analysts who believe that their patients have an impact on them necessarily subscribe to exploring their patients' perception of their counter-transference. Exploration of the patient's perception of the countertransference is only one of the possible stimuli for the analyst's self-reflections.

All retrospective evaluations of the analyst's own contribution to treatment stalemates or transference-countertransference enactments are based on what the analyst remembers and conveys after the fact. Readers should keep in mind that analysts have presented the material from the point of view of what they have come to understand. Although it may seem as if what became understandable over time should have been recognized at the outset, it is important to remember that the analysts have selected data that support the conclusions they later reached. In the midst of their struggles and confusion, no such clear-sighted perspective existed.

Analysts who respond to a survey that presumes that their patients have had an impact on them are not necessarily the same as analysts who do not respond. The survey was designed so that analysts were able to provide responses that disagreed with the premise of the study; however, the underlying assumption of the project, that analysts are affected by their work with their patients, was made explicit. It could not have been concealed, since analysts familiar with my work would have been clear about my perspective. The questionnaire provided an opportunity for analysts to indicate how they thought about, and worked on, this issue. While there may have been other reasons for answering the survey, most analysts who did so likely agreed with an interactional point of view that presumes that the analyst is affected by participating in the process, or they would not take the time to reply. The analysts who answer, then, cannot be taken to be representative of analysts in general.

Although this survey was sent only to analysts who were trained in American Psychoanalytic Association institutes in order to have a relatively homogeneous population, the fact is that even within the American Psychoanalytic Association, there are great variations in its members' training experiences, attitudes, beliefs, and actual manner of practicing psychoanalysis. Some of these differences are related to the personal histories and characteristics of the individual analysts. Other factors are related to the decade in which the analysts were trained and to the analytic atmosphere in particular geographic locations. For example, analysts trained in the 1950s and 1960s in Washington, D.C., were heavily influenced by Harry Stack Sullivan and Frieda Fromm-Reichmann, who subscribed to an interpersonal perspective on analysis. These analysts long ago have accepted the importance of the personal characteristics of the analyst as having an impact on analytic work and have at least some appreciation of the patient's impact on the analyst. In contrast, and possibly in reaction to these influences in an adjacent city, analysts trained in the Baltimore Institute during the same period held to a strict, “classical” stance and viewed analysts as interchangeable.² These analysts would be less likely to think of their doing psychoanalysis as a source for their self-exploration. Considerations of the representativeness of the sample of respondents to this study for analysts in general are taken up later in the chapter.

A written survey, of course, is not the ideal form to obtain in-depth data. Many will object that it is schematic, open to misinterpretation and misrepresentation, lacks verifiability, and is subject to all the other limitations of self-reported data (Schuman and Kalton, 1985). Nonetheless, a survey is a good place to begin. The value of the study undertaken here is that it provides an overview of the perspective of a large number of people. As Schuman and Kalton (p. 639) point out, a survey is the only method of investigation that can provide information about a large population. Psychoanalysis has perhaps relied too heavily on single case anecdotal reports for most of its data. A good reason for focusing on individual case studies is that in-depth exploration of psychological experience and organization can be obtained only in this way. Yet, the question of how generalizable the findings are persists. A survey gives an opportunity to compare experiences more systematically. It also allows people to reveal personal experiences more readily, since they are guaranteed anonymity.

The present survey suffers from the difficulty of not separating general experiences from specific examples. The questionnaire, however, was intended to offer an open-ended format for analysts to describe their views, their manner of undertaking self-exploration if they engaged in this activity, and their belief in changes in themselves if they thought they had occurred, rather than limiting the nature of their responses. The survey did not provide an operational definition of personal change for a similar reason; if the analyst believed that change occurred, such a definitive description might have set a constraint on how change might be construed. Instead, the questionnaire provided specific items that could be checked indicating if the analyst believed intrapsychic and interpersonal changes had taken place. It was left as optional for the respondent to offer a brief example that illustrated this pr...