In Pursuit of Psychic Change

The Betty Joseph Workshop

Edith Hargreaves, Arturo Varchevker, Edith Hargreaves, Arturo Varchevker

• Publisher: Routledge
• Year: 2004
• Print ISBN: 9781583918227
• eBook ISBN: 9781135447380
• Topic: Psychology
• Subtopic: Mental Health in Psychology
• Index: Psychology

The members of the Betty Joseph Workshop have provided major contributions to psychoanalytic thinking since the meeting's inception in 1962. This book is a celebration of Betty Joseph's work, and the work of a group of analysts who have joined her to discuss obstacles to psychic change in psychoanalytic treatment.

A prestigious line up of contributors present clinical material for discussion on a range of topics including:

• Supporting psychic change
• Complacency in analysis and everyday life
• Containment, enactment and communication.

The history of psychoanalysis is one of an ongoing struggle to reach a new understanding of the human psyche and develop more effective methods of treatment. In Pursuit of Psychic Change reflects this tradition - discussions of each contribution by other members of the group provide an in-depth exploration of the merits and limitations of a developing analytic technique, in the hope of achieving true psychic change.

All psychoanalysts will benefit from the insights provided into the original and stimulating work of the members of the Betty Joseph Workshop.

1

SUPPORTING PSYCHIC CHANGE: BETTY JOSEPH

Michael Feldman

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James Strachey (1934) wrote his great paper on the therapeutic action of psychoanalysis at a time when many of Freud's fundamental ideas had already become established, and Klein's further research work was emerging. He quotes the passage from Freud's introductory lecture (published in 1917) where Freud suggests that psychic change

is made possible by the alteration of the ego which is accomplished under the influence of the doctor's suggestion. By means of the work of interpretation, which transforms what is unconscious into what is conscious, the ego is enlarged at the cost of this unconscious; by means of instruction, it is made conciliatory towards the libido and inclined to grant it some satisfaction, and its repugnance to the claims of the libido is diminished. … The more closely events in the treatment coincide with this ideal description, the greater will be the success of the psycho-analytic therapy.

(Freud 1917: 455)

Strachey observed that in the seventeen years since he wrote that passage, Freud produced very little that bears directly on the subject, and that little goes to show that he had not altered his views of the main principles involved.

Many of the subsequent formulations concerning psychic change incorporate two of the elements Freud presented in 1917. First, the ‘geographical’ model — the notion of the ego being enlarged, or more recently the notion of lost parts of the ego being recovered, reincorporated. Second, he considers the development of a different relationship between two parts of the psyche — the ego becoming more accepting of the claims of the libido. Sandler and Sandler (1994) formulate this in a more contemporary form as follows:

We aim at freeing what has become, during the course of development, unacceptable in the present, in such a way that it is not acted out but is tolerated within the patient's psychic life without having to be defended against, by virtue of being viewed from a more mature and tolerant perspective.

(Sandler and Sandler 1994: 438, original emphasis)

However, in 1933 Freud offered a formulation of the intentions of the therapeutic efforts of psychoanalysis that I find subtly different, stronger and more interesting. He said ‘Its intention is, indeed, to strengthen the ego, to make it more independent of the super-ego, to widen its field of perception and enlarge its organisation’, although he did add that this was ‘So that it can appropriate fresh portions of the id’ (Freud 1933: 80). Freud (1937) returned to some of these issues in ‘Analysis terminable and interminable’. He was primarily interested in those factors which influenced the success or otherwise of analytic treatment, and identified the effects of trauma, and the role of the constitutional strength of the instincts. He also argued that the outcome of treatment depended on the extent to which the ego of the person under treatment was able to form a co-operative alliance with the analyst, in order to subdue portions of his id which are uncontrolled — that is to say to include them in the synthesis of his ego. In a schematic description of the process of treatment, he referred to the therapeutic work constantly swinging backwards and forwards like a pendulum, between a piece of id-analysis and a piece of ego-analysis. In the one case we want to make something from the id conscious, in the other we want to correct something in the ego. Finally, as is well known, in this paper he addresses the fact that in the course of the work of analysis, one may become aware of ‘a force which is defending itself by every possible means against recovery and which is absolutely resolved to hold on to illness and suffering’ (Freud 1937: 238). He concluded that the phenomena of masochism, the negative therapeutic reaction and the sense of guilt provide unmistakable indications of the presence of a power in mental life which could be described as the instinct of destruction.

Returning for a moment to Strachey's (1934) paper, the issue he raises is that in contrast to the rich and powerful model of the mental apparatus, the understanding of the neuroses, of defences and resistances which had been developed, the explanatory descriptions or theories concerning the actual process of therapeutic change, and how the analyst's interventions can promote such change seemed limited and unsatisfactory. He then tried to address some of the crucial issues himself— what kinds of interpretations promote psychic change, through what mechanisms do they operate, what is their impact on the patient, and what difficulties does the analyst have in making such mutative interventions? In the model he proposed, he not only recognised the way the analyst became identified with elements of the archaic object projected into him, but also suggested that therapeutic change comes about when the patient is able to re-introject the archaic superego, modified by the analyst's understanding.

I want to focus on that aspect of Joseph's (1989) work that follows directly in this fascinating, difficult and important tradition. Her thinking clearly embodies the theoretical and clinical model which Klein developed, elaborated and enriched by Rosenfeld, Segal and Bion. Her outstanding contribution lies in her capacity to focus sensitively and thoughtfully on fine clinical and technical issues. Thus, embedded in Joseph's work, is a complex and subtle theory of psychic change, which I propose to explore.

In a recent example of her work which I am going to examine in some detail, Joseph elaborates her understanding of these drives towards or away from development, by means of her study of the use the patient makes of the analyst and her interpretations on the one hand, and her own mental capacities, on the other. These capacities are sometimes used constructively, but the patient will also misuse understanding in a defensive way — to attack herself or her objects, to create a false compliance or collusion, or to whip up sadomasochistic excitement. Joseph illustrates the importance of attending not only to the symbolic content of the patient's communications, but also to the tone, the atmosphere that is created, and the responses elicited in the analyst. The patient not only uses projection into the analyst in phantasy, but also uses language and non-verbal behaviour to have an actual effect on the analyst, who may become drawn into various defensive enactments. By giving detailed attention to these processes in patients, in him or herself, and the interaction between them, the analyst can begin to build up a sense of the way that patients are using their own mind and the analyst's interpretations. Joseph refers to the way in which the analyst can thus, over time, build up a picture of the patients' inner worlds. What I wish to focus on is the fact that embedded in Joseph's understanding of these processes, and the use she makes of this understanding, lies a complex and subtle theory of psychic change.

In an unpublished paper ‘The pursuit of insight and psychic change’ Joseph (1997) begins with Freud's dictum ‘Where id was ego shall be’, which, she suggests, takes us to the core of our problem, namely ‘Psychic structure and its inner objects and their possibility of change’. Our aim, she says, is to enable the personality to contain and be responsible for more aspects of itself, thus enlarging the ego and modifying its structure, and to increase its capacity for thinking, reality testing etc. As a step towards achieving this, she emphasises the need to attend closely to the way that patients hear the analyst's interpretations at a given moment, and to try to discover how they use them. The way that patients use the relationship with the analyst, and specifically their interpretation, provides us with crucial information about the internal dynamics of our patients' minds. We need to follow not only what happens to the interpretation itself, but also what has happened to that part of the personality that may, however briefly, have had insight. Does it, for example, get swallowed up or attacked by another part; does it arouse too much anxiety, become split off and projected into the analyst?

This perspective leads Joseph to focus not only her observations but also her interpretations on the way that patients are using their own mind, their own understanding and insight, how an interpretation was experienced, and what they have done with it. She stresses the importance of concentrating these observations on the manifestations of these processes in the detailed interactions of the session, generally avoiding interpretations that refer to phenomena that are not immediately accessible to the patient. She also believes it is important to avoid attaching explanatory or causal formulations to the interpretation before the patient has been able to recognise what it is that one is attempting to account for.

The theory of projective identification implicit in this perspective has been elaborated by Rosenfeld, Segal and others, and Bion has described his model of the way the patient's projections are received and modified by the analyst's capacity to tolerate and eventually to understand their contents. While Joseph also emphasises the need for the analyst to be able to cope with periods of anxiety, uncertainty and not-understanding, one of her distinctive contributions has been to recognise the way the patient's projections constitute a constant pressure towards enactment by the analyst in the session. Her recognition of the presence of this force, and the way it affects the analyst in the session leads her also to focus very closely on the analyst's experience, and the complex interactions which occur from moment to moment, which are an important source of understanding of the patient's internal world, as well as the basis for interpretations of such processes, which the analyst hopes will promote greater insight and psychic change.

This is then part of the process, which Joseph describes, of ‘enlarging the ego’ increasing its capacity for thinking, reality testing, etc. She argues that this is brought about in part through helping patients to internalise and identify with the analyst's thoughtful and containing functions, and their capacity to face reality, so that patients come to be able to observe and interest themselves more in the workings of their own minds. This is facilitated through the analyst's continuing efforts to clarify and formulate the experience that is actually available to patients at that moment, which they can recognise and acknowledge. Such clarification may, of course, involve the recognition of mechanisms that interfere with understanding. It is often necessary to go over this process repeatedly, taking into account the nature of the patient's responses to the analyst's interventions, in order for the analyst to clarify and refine the understanding of the situation both for him or herself and for the patient. Joseph argues that only when this vital descriptive and containing step has been achieved, is it useful to move to the gradual elucidation of the motives or reasons, continuing to focus mainly on the way these express themselves in the interaction in the session. If the analyst makes a more complex interpretation, which includes both the description and an explanatory formulation, the patient is liable, for defensive reasons, to lose contact with the reality of what is immediately present and available, and focus instead on the ‘explanation’ offered. It is sometimes evident that premature, broad explanatory interpretations are given partly to relieve anxiety both in the analyst and the patient, since the attempt really to clarify and to understand the immediate processes and interactions imposes considerable demands on both.

While formulations such as expanding or strengthening the ego provide a broad explanatory formulation, we still have to refine our understanding of the way in which the analyst's understanding and clarification contributes to the therapeutic process. We do, of course, encounter patients who seem to be capable of observing the workings of their own minds (as well as the analyst's) in a way that is not helpful. In these cases, we find the motivation for such observation is primarily envious or rivalrous, to demonstrate superiority and defend against any dependency. Thus although there may be partial understanding, there is also a powerful enactment of an omnipotent, narcissistic process which is hostile to any constructive interaction. On the contrary, the analyst's role in this process is attacked, devalued or ignored.There must therefore be other aspects of introjective identification which do truly contribute to the ‘enlargement of the ego’, the capacity to tolerate anxiety and conflict, etc. I hope the more detailed discussion of clinical material that follows may throw some light on these difficult issues.

We assume that the patient's experience of the analyst and the analyst's interpretations evokes an unconscious phantasy in the patient, based upon an archaic object relationship. Although the analyst may know this theoretically, it is often difficult to recognise the particular phantasy evoked in the patient at a given point in the session. On the contrary, the way the analyst addresses the patient is influenced by the analyst's assumptions about the patient's state of mind at that moment. These assumptions are, of course, subject to distortions based on the limitations of the analyst's understanding, and the way the patient's projections resonate with unconscious anxieties and needs. However, if the analyst is able to pay close attention to the patient's responses to his or her intervention they can alert the analyst to the nature of the object relationship which is actually present and alive, the unconscious phantasy which it embodies, and the meaning that the intervention had for the patient. This may then enable the analyst (at the time, or subsequently) to focus more directly on the patient's actual phantasies and experience, which can be taken account of in subsequent interpretations.

To give a brief example of my own, a patient who had been missing sessions and coming late to others began a session speaking in a fluent, assertive way, insisting that the fact that he had missed sessions was not an attack on the analysis. He thought it was an expression of his needs and his problems, which he went on to elaborate in a familiar way. After a pause, he said he didn't want to do anything he was supposed to do, including an important project at work. In part he took this as a good sign: he hoped he was less compliant, and a healthy rebelliousness was emerging. Later in the session he said he and his girlfriend had started eating special healthy foods, and had taken up Tai-chi. He actually felt very healthy at the moment, and indeed he sounded vigorous and alert.

The patient thus presents himself as a vigorous, healthy person, with his own understanding of the nature of his problems, and his own methods of treatment. Although he alluded to needs and problems, and I recognised elements of my own formulations in his explanations, he seemed neither in touch with these, nor any discomfort, guilt or concern about his lateness and the missed sessions. From my knowledge of this patient's propensity to identify with and take posses-sion of his objects, as well as the way he actually conducted himself in this session, I attempted to describe the situation, in particular the way he seemed to have assumed the role and functions of the analyst. The patient disagreed immediately, with some vehemence. He said that on the contrary, he felt he was speaking for himself, expressing his own views, which he often finds difficult to do, and he was pleased about that.

What became evident was that the patient had not experienced my intervention as a description or interpretation which enabled him to recognise or understand something more about his own mind and the way it worked, or as the basis for further exploration or clarification. The interpretation thus did not provide him with anything he might use to think about or with. On the contrary, he construed the intervention primarily as the expression of an object relationship embodying his archaic experiences, to which he responded in a characteristic fashion. He assumed that the analyst was trying to undermine his confidence and health, and wanted a compliant, dependent patient. I was aware of this patient's insubstantial sense of his own personality, and how prone he was both to use and suffer from invasive and seductive invasions. On this occasion, I had failed to register properly the significance of his emphasis on what he thought, how he understood the situation, his concern with being less compliant. My interpretation, and the unconscious phantasy it evoked, was evidently felt as a threat to rob him of this achievement, and assert that he had merely assumed my role and function. He believed my main purpose in speaking to him was to try to reclaim the functions I had been robbed of, reverse the situation, and reduce him to a pathetic and dependent figure. His only way of countering this, as ever, was to assert himself in an angry, argumentative fashion, demonstrating the failure and inadequacy of my intervention.

In this example, in addition to my conscious attempt at descriptive explanation, I may well have felt it necessary to assert myself in a way which the patient was very sensitive to, and which he immediately responded to. It often only seems possible to recognise and understand these complex interactions after we have been drawn into such misunderstandings, or enactments. Joseph's work has helped to alert us to these recurrent situations, the necessity to recognise and recover from them, and in due course to show the patient some elements of what one comes to recognise has been going on. Thus once I could realise what I had not properly attended to, and the extent to which I might in fact have felt driven to try to reassert my role, I could perhaps provide the patient with a more accurate description of his experience, and interpret the way he had perceived my response. Furthermore, if I had sufficiently understood the responses the patient had evoked in me, and considered perhaps why he might need to evoke such responses, I might also have been able to make such an interpretation with less need unconsciously to assert myself.

One of the fundamental aims which Joseph articulates is to enable the patient increasingly to hear our interpretations as interpretations, as the communication of understanding. This must involve the diminution in the extent and force of the projective identification which the patient needs to employ, as Segal (1957, 1977) has described, so the interpretations can acquire new symbolic meaning, and are not primarily experienced as concrete manifestations of earlier object relationships. The crucial question which Joseph tries to address is how we can achieve this aim. One familiar way of enlarging the capacities and functions of the ego is of course to make interpretations which attempt to demonstrate the (unconscious) links between the patient's responses to the analyst, and his early object relationships. I believe Joseph has come to believe that while the analyst's recognition and understanding of such links in their broader historical context remains crucial, it is more therapeutically valuable to focus on the detailed expression of thes...

Table of contents

• Cover Page
• Half-Title Page
• Other Page
• Title Page
• Copyright Page
• Table of Contents
• Contributors
• Preface
• Acknowledgements
• Introduction
• 1 Supporting psychic change: Betty Joseph
• 2 Containment, enactment and communication
• 3 Who’s who? Notes on pathological identifications
• 4 Complacency in analysis and everyday life
• 5 Mapping the landscape: levels of transference interpretation
• 6 A phantasy of murder and its consequen
• 7 Luxuriating in stupefaction: the analysis of a narcissistic fetish
• 8 Beyond learning theory
• 9 Talking makes things happen: a contribution to the understanding of patients’ use of speech in the clinical situation
• 10 A projective identification with Frankenstein: some questions about psychic limits
• 11 To defy the fates: doubt as an expression of envy
• Epilogue
• Index