Impasse and Innovation in Psychoanalysis

Clinical Case Seminars

John E. Gedo, Mark J. Gehrie, John E. Gedo, Mark J. Gehrie

• Publisher: Routledge
• Year: 2013
• ISBN:
  9781134886418
• Edition: 1
• Topic: Psicologia
• Subtopic: Psicologia applicata

Impasse and Innovation in Psychoanalysis offers a rare perspective on the technical difficulties and creative responses to them that typify clinical psychoanalysis. The four seminars at the heart of this volume are not case reports in the usual sense. Rather, each seminar revolves around the challenges of translating an understanding of difficult process issues into an effective therapeutic response. What emerges in each case is a vivid picture of an analyst's subjective experience in conceptualizing and managing a particularly demanding treatment, supplemented by data about the patient's history and free associations and enlivened by seminar leader John Gedo's challenging questions and clinical commentary.

Each seminar is framed by Mark Gehrie's introduction and commentary, the latter addressing the interplay of theory and technique in the preceding case. Gehrie's commentary is then followed by Gedo's notes, which are keyed to specific points in the seminar transcript. Gedo not only clarifies issues left in doubt by the original discussion but offers his own second thoughts about the clinical material and its technical handling.

The uniquely dialogic format of this volume brings different voices to bear on issues at the forefront of the evolution of clinical psychoanalysis. Edifying reading for practicing analysts and analytic therapists, Impasse and Innovation in Psychoanalysis is a wonderful teaching tool, introducing candidates, residents, and students to the demands of coping with stressful transferences and enactments and sparkling, throughout, with Gedo's wit and wisdom.

—1—

Questions of Basic Psychoanalytic Technique

Among the cases presented in our seminar, few lent themselves to the application of the basic technique of psychoanalysis as has been described in the standard references of the past generation (for instance, in Stone, 1965). Because every presentation involved some impasse or crisis in treatment, the analyses that did not call for any departure from basic technique were necessarily instances of mismanagement, which have not been included here.

From this series of presentations, it has been possible to single out a number of technical issues that contributed to the unsatisfactory course of many analyses. In this chapter, we review these questions in what we hope is a logical sequence; insofar as possible, we use excerpts from the relevant seminars as part of this discussion.

Diagnosis, Nosology, and the Strategy of Treatment

Inexperienced analytic candidates tend to fall back on their prior experiences as psychotherapists to master the uncertainties of embarking on their initial efforts to perform psychoanalysis. This unacknowledged resort to nonanalytic ideas about psychopathology and its treatment often determines in advance the outcome of the analytic attempt—particularly if the supervisor colludes in focusing on questions of psychiatric nosology (often dressed in the language of psychoanalysis, for instance, “Is this an oedipal neurosis or a narcissistic personality disturbance?”) instead of calling attention to issues of transference and the defenses against its emergence. About one instance of this kind, the seminar proceeded as follows:

“GEDO: This case is an important prototypical example…. What I am about to say applies to many, many cases. The understanding of the material that you convey—apparently with your supervisor's approval— assumes too much. You are both too fast [in reaching closure]. You thought you knew what things meant just because similar things mean that to the majority of people. You assume that [your patient] is like everybody else. You offer this interpretation to the patient, and the patient says there's something to it. The patient doesn't reject it, won't reject it, can't reject it, because in fact it's more or less true, except—it's utterly unimportant. The trouble is, this is not where this woman lives.

“The [screen memory you recounted] can have umpteen meanings, and the oedipal meaning is probably there. The fact that she had the fantasy that her parents never had intercourse after—whenever—may not be used to substantiate the contention that either positive or negative oedipal configurations are the crux of the matter. Unusual people have unusual reasons for everything they do, and think, and feel.”

“QUESTION: Do you have a sense of what may be more central?”

“GEDO: There is no knowing. Once again: one must proceed from the surface downward. That's the surface. You pushed through! You reached into the pie and you pulled out a plum—the oedipal plum. You worked with it; it was there. She improved. And you have the fruits of the work you have done. But you have done the work in an unsystematic, disorderly way, by going too deep too soon. The character defenses are still there. One doesn't know what's underneath.

“When I have done second, third, and fourth analyses with people who look like this to begin with, what has generally come out is that some plum was pulled out and though [the interpretation] wasn't untrue, the issue was not central. It wasn't as important as many other matters—of some importance, but the importance has to be contextualized. [There] is a system of many problems that are tied together. You pull out one and you create internal chaos. You have to work from the surface down!

“The nature of this defensive organization—it would be better to think of it as an adaptive organization—[was determined sometime during] adolescence. That is what you have to investigate very carefully at the beginning of the analysis, and underneath you may find anything. How about a sadistic perversion, for instance? Why not? Or a masochistic one. Or a fetish. If this [unusual] adaptation is really a defense against some pathology, it's scarcely going to be a defense against [what you diagnosed as] an oedipal victory. [That is] inherently not likely.”

“PRESENTER: There is a sadistic perversion.”

“GEDO: NOW you're talking. You should have told us that in the first place. So how much does that have to do with the Oedipus complex? Of course, anything is possible, but that's not the horse I would bet on in this race! Has the perversion entered the transference? No wonder [this analysis cannot be finished]. These are very, very difficult cases, and they take a terribly long time. But one can't be too careful; slow, easy, don't shoot till you see the whites of their eyes! Don't say anything until you are 200% sure.”

Because a diagnosis based on behavioral phenomena gives the therapist an illusion of understanding the patient's personality structure and inner life, it will generally predetermine the nature of the analytic interventions. The outcome might be called a manualized, template-oriented approach to analysis, lacking the inductive flexibility required (in our view) to deal with this highly complex undertaking. This technical error leads to an overcommitment to specific formulations—what one might also call a technique of omniscience. Hence this procedure amounts to “wild analysis” (Freud, 1910), the use of a technique based on the assumption that the analyst's formulations of the meanings of the patient's behavior are unfailingly accurate. The resulting confusion creates iatrogenic problems subsequently easily misdiagnosed as part of the psychopathology.

In several instances presented at the seminar, a putative diagnosis was actually made on the basis of historical data alone. In these cases, the Clinic Committee of the Institute, the candidate, and the supervisor concurred in using the evaluation process to arrive at a tentative formulation of a psychiatric diagnosis. Such practices are extremely widespread, in spite of innumerable caveats in the literature (e.g., Kohut, 1971) about the impossibility of making valid distinctions of this kind on the basis of historical data alone. Kantrowitz (1987) has documented the lack of reliability of initial assessments even about the question of analyzability—a matter of less complexity than that of deciding which developmental phase contributed most to pathogenesis.

Commitment to a Favored Clinical Theory

In many cases that reached an impasse, this stalemate was a result of unchecked reliance on a favored clinical theory. Although such theories are relevant in a broad spectrum of circumstances, they are not actually intended to illuminate any particular analysand's inner life. By reducing human complexity to relatively simple schemata, the use of theories to make deductive inferences about patients misses the overriding importance of the individual's own hierarchy of meanings, his or her core experience of life.

One example of this kind of neglect occurred in a stalemated analysis presented in the course of its tenth year. The candidate reported that early in the treatment her patient (an intellectual blue-stocking and a spinster) had attempted to present her with a gift of personal historical significance. When asked what this enactment had meant to the analysand, the candidate could only say that she did not accept the patient's offer when it was first made. She later relented, although not because she had learned the significance of the proposed gift. (In all probability, the change in tack had to do with the adoption of some ideas about self psychology as the candidate's orienting clinical theory.) At the time of her presentation, she still had no idea about the meaning of this transaction.

Another way to put this matter is to say that some of the candidates who presented in the seminar were unable to grasp the meaning of the patient's communications precisely because they were thinking solely about theory-laden categories of meaning, and not about the experience of the patient. They had a need to remain anchored within a focused template of “psychoanalytic” reasoning about the patient's experience. Such schemata lead to certain assumptions about the meaning for the patient of various events, but without adequate data to substantiate these claims thoroughly.

Complexity is added to the muddle by the fact that the interpretations are often partially correct, leading to the inability of the patient to refute them convincingly and, worse, to the analyst's reinforced conviction that the “plum” that was “pulled out of the pie” contains all the significant meanings that exist. To state this in still another way, the psychoanalytic view requires that the uniqueness of every analysand be regarded as fundamental from the very beginning; it is ignored in favor of nosological “plums” only at great peril.

Failure to Agree on Rational Goals for the Treatment

In their eagerness to fulfull training requirements, candidates all too often failed to look into the prospective analysand's reasons for seeking treatment. Consequently, there was seldom an explicit agreement about rational goals to be pursued through the analytic effort, and in several cases the participants agreed to collaborate although they had radically different notions about the aims of the procedure. In one seminar, Gedo commented, “And so the great analytic machine swallowed her up, processed her, and she came out at the other end as an analysand.”

If one is not overly concerned about ultimate prognosis, it may be feasible to overlook these issues of motivation for treatment, at least at the beginning of the analysis. Candidates are, however, usually desperately eager to score a success with their supervised cases, so that they cannot really afford to take them into analysis on the basis of some mutual misunderstanding. Impasses that develop as a result of such a disparity of goals among the participants amount to a clash of Weltanschauungen. (For a report of several analytic failures caused by false consensus about treatment goals, see Gedo, 1981a, chap. 3.)

Although it has been customary to disavow that analysis has therapeutic aims beyond the fulfillment of process criteria for reaching a natural termination, Lawrence Friedman (1988) has convincingly shown that the analyst “as operator” cannot avoid commitment to the improvement of the analysand's adaptation. At the same time, the particulars of that adaptive change must be acceptable to the patient if treatment is to avoid becoming a power struggle.

The subculture of the psychoanalytic community, extraordinarily resistant to change over the past century, has clung to prejudices about the pathological import of religious faith, the overriding importance of sexual activity for adaptive equilibrium, and some of Freud's other personal hobby-horses of the 1890s. In this sense, psychoanalysis misused becomes an ideology, promulgated under the guise of a quasi-medical procedure; in this debased version, our work parallels that of C.G. Jung, who finally revealed his psychology as the carrier of a message of that kind in the autobiography he wrote in old age (Jung, 1963). A generation ago, Philip Rieff (1966) predicted the coming triumph of such therapeutic cults (see also Gedo, 1986, chap. 14).

In performing so-called analyses in the service of proselytizing for a new, secular creed, it is unnecessary to pay heed to the patient's goals and values; to the contrary, it is incumbent on the analyst-shaman to ritualize the analytic procedure, to convey a catechism limited to certain familiar verities—in other words, to conform to a template.

In the foregoing sense, the psychoanalytic community constitutes a unique subculture within society as a whole, and every encounter between an analyst and a patient from “the outside” has to overcome the problem of a severe cultural gap.

The Problem of a Cultural Gap

The deck is stacked against an analyst's treating someone from an entirely different cultural background with no knowledge of that background. An analyst relies heavily on shared cultural meanings in any analysis, as in any sort of intimate communication. Possibilities for misunderstanding are so broad as to be endless and are not correctable solely by reliance on empathy; an empathic position requires some context for shared experiences in the absence of which others will of necessity be substituted, experiences that may or may not have anything to do with the experience of the patient.

Beyond such a “confusion of tongues” in the analytic situation, the analyst's failure to appreciate the extent of mutual misunderstanding transforms the transaction into a tug-of-war about the “correct” perception of reality. As Modell (1990) has discussed in detail, such an impasse is likely to be experienced in the transference as an attempt at brainwashing, which, on the deepest level, is bound to be resisted. When such situations go unrecognized, many patients are likely to lapse into hopelessness and silences, or compliance with the “program.”

The cultural differences between most prospective patients and their analysts-to-be are not so great as to predetermine the failure of any therapeutic couple to attain a “shared language” (see Gedo, 1984, chap. 8)—or, as Modell (1990) put it, a “shared reality.” To put the matter somewhat differently, a doctrinaire analyst's inattention to a patient's individuality, an unrelenting focus on the patient's putative illness (to the exclusion of healthy aspects of the personality), merely repeats the errors Freud (1905) made with one of his earliest analytic cases, the celebrated Dora—yet, in the literal sense, Freud and his patient shared a common cultural background.

Cultural differences, particularly the difference between the analytic subculture and its surround, become a major obstacle to therapeutic progress if they cause analysts to fail to allow patients to be truly different from themselves. This is particularly likely to occur when the analyst projects his or her own psychology onto a more complex personality—a situation that is a mirror image of the ones Kleinians call “projective identification.” Freud's assumption that an adolescent girl should be willing to welcome sexual advances from a man whose wife is her father's mistress constitutes a similar misattribution of behavioral imperatives in his treatment of Dora.

To illustrate the ubiquity of psychoanalytic prejudices of this kind, Gedo relates the following anecdote:

“Once I presented a case to Margaret Mahler, 20-odd years ago, what I considered to be a very successful analysis of a woman who came to me after a psychotherapy in which she had been sexually abused, with the connivance of her husband, who had referred her to this therapist. Not to make this story too long, she got out of this marriage and became a college teacher, an independent person. She was a woman of 45 when we finished. Margaret Mahler said, ‘And did she get remarried?’ I was stunned! And I said, ‘No. She lived in a very conservative suburb, she didn't have much opportunity for that sort of thing.’ Mahler said, ‘Well, does she have affairs?’ I said, ‘This is an upper-class lady, that's not the way it's done.’ And Mahler said, ‘Let's hear another case.’ Literally. Such are the prejudices within psychoanalysis.”

Countertransference Issues

It may surprise some readers that, as far as the presenters were concerned, countertransference issues did not appear to play any major role in producing the difficulties described in the seminar presentations. In only one case did a presenter indicate that the therapeutic impasse was, in large measure, created by her inability to master her countertransference. According to her, this was the sense of being excessively burdened by her intractable analysand—as the latter's mother had presumably been burdened in the past. Operating at this time within a self-psychological framework, the analyst implied that her aversive reaction was grossly unempathic and created a traumatic situation (presumably within a “mirror transference,” although the presenter was consistently unable to state generalizations of this kind in any of the alternative technical vocabularies available). She labeled the behavioral consequences of this trauma “tension states,” probably in deference to Gedo's terminology in Models of the Mind (Gedo and Goldberg, 1973).

It has become acceptable to refer to the analyst's emotional responsiveness to the transference as “countertransference,” thereby eliminating the vital distinction between appropriate reactions (which the analyst should be able to contain and turn to account in discerning the nature of the transference constellation) and those leading to dyadic enactments (see Gedo, 1988, chap. 9) of the kind reported in the case under discussion.

Since it is by no means clear that the real obstacle to progress was the analyst's inability to avoid repeating the mother's failures with her formidable child (as the patient herself is reported to have stated, she was ready to forgive those who were merely defeated by her intransigence!), the analyst may have been off the mark in blaming herself for creating difficulties through countertransference reactions. It is equally likely that her affective reaction should merely have alerted her to the operation of a hostile mother transference.

Transference in the Here and Now Versus Reconstruction of the Past

In response to inquiry about the manner in which phase-specific material appeared in the transference, candidates often displayed considerable confusion about the way in which vital unresolved issues are relived within the psychoanalytic situation. Instead of relating the relevant vicissitudes of the patient-analyst relationship, they tended to summarize a series of reconstructions about the childhood past. What is worse, often they did not specify whether those conclusions were reached on the basis of the unrolling of a sequence of transference reactions or whether they were the kinds of “dynamic formulations” demanded of participants in psychoanalytic training programs, that is, essentially speculative. (The clinical details sometimes provided, such as transactions between patients and their parents in the recent past, suggested that the issues did not enter the transference.)

The presenters’ inability to answer this question in a coherent manner convinced us that, if any organized process supervened in the treatment, the analyst remained ignorant of it. For all intents and purposes, such therapies had been chaotic because neither participant was able to attribute a meaningful gestalt to its manifold vicissitudes. As the case mentioned in the discussion of countertransference issues illustrates, candidates were often unable to distinguish their affective compliance in reliving a childhood transaction as transference from inappropriate counterresponses. Whatever the cause of their confusion, some of these beginners tried to resolve it by assigning their analysand to membership in one or another nosological category, as if a “diagnosis” would resolve their uncertainties and relieve them of the task of monitoring transference developments.

The Problem of Superego Analysis

We found it particularly striking that many candidates in the seminar appeared not to grasp the concept that superego contents require careful scrutiny, as does any other compromise formation. Occasionally one or another student gave voice to the notion that these internal guidelines constituted psychopathology whenever they differed from the candidate's own standard of conduct. In one presentation, the a...