Psychoanalysis from the Inside Out

Developing and Sustaining an Analytic Identity and Practice

Lena Ehrlich, Lena Theodorou Ehrlich

• Publisher: Routledge
• Year: 2020
• eBook ISBN: 9781000089950
• Topic: Psychology
• Subtopic: Clinical Psychology
• Index: Psychology

In the face of considerable scepticism over the function and effectiveness of psychoanalysis, Lena Ehrlich demonstrates how analysis is unique in its potential to transform patients at an emotionally cellular level by helping them access and process long-standing conflicts and traumatic experiences.

Using detailed clinical vignettes, the author illustrates that when analysts practice from the inside out, i.e. consider that external obstacles to initiating and deepening an analysis inevitably reflect analysts' fears of their internal world and of intimacy, they become better able to speak to patients' long-term suffering.

This book, free from psychoanalytic jargon, stands out in its ability to help readers feel more effective, confident, and optimistic about practicing psychoanalysis by providing insights and recommendations about beginning and deepening analysis and sustaining oneself as an analyst over time. It will appeal to both beginners and experienced analysts, as well as supervisors, educators, and those interested in the workings of their minds and in building more intimate relationships.

Part One

Finding Ourselves as Analysts

Chapter 1

The analyst’s reluctance to begin a new analysis

At present in the United States we practice less analysis per analyst than ever before. The last full report (Brauer and Brauer 1996) from a survey conducted by the Committee on Psychoanalytic Practice of the American Psychoanalytic Association presents the following findings: the number of patients in analysis per analyst has been steadily diminishing over the last twenty-five years, at a rate of roughly one per cent a year. At the time of the last survey, certified or active members who had patients in analysis saw on average three analytic cases. The reported morale and level of satisfaction of those who practiced less analysis was low in comparison to that of those practicing more analysis. Troubled by these findings, psychoanalysts have been searching for an explanation of why psychoanalysis is practiced less. Widely accepted reasons include the public’s negative attitude toward psychoanalysis, the current socioeconomic climate, and the public’s expectation of a quick cure.

While useful to consider at the organizational level, these realities can’t of themselves fully illuminate the factors affecting the individual analyst’s practice. The analyst’s interest, experience, confidence, energy level, skill, unconscious conflicts, personality style, social and professional affiliations, locale, attitude, and conviction are among the many variables that can affect an analyst’s practice. My primary interest in what follows is to explore how one variable, the analyst’s reluctance to begin an analysis, affects analytic practice. I don’t intend to negate the role of external realities; instead I suggest that analysts can use adverse external realities to obscure this reluctance.

Psychoanalytic training, demanding as it sometimes was, helpfully cushioned me from fully realizing the implications of being an analyst. During training, my anxiety about analytic work was mediated by the support that an analyst-in-training receives as a candidate (Kantrowitz et al. 1989). My analysis and work in close supervision tempered some of my conflicts and insecurities about practicing independently, provided narcissistic support, afforded me the illusion of sharing the responsibility for the work, and offered me a fantasy of protection. I immersed myself in studying and practicing analysis and focused on becoming an analyst. The more I experienced the healing possibilities of the method, the more unwavering I became in my commitment to practicing analysis, or so I thought. While in training, I’d been able to find analytic patients easily and speedily in order to fulfill the requirements of my institute. I had one low-fee, one moderate-fee, and one full-fee patient. Nonetheless, as I approached graduation, I began to question whether it would be possible to develop an analytic practice. I listened anxiously to reports that the number of patients in analysis was decreasing. I worried about rumors that there were no patients willing to engage in a time-consuming, expensive, and out-of-favor endeavor—at least not with a beginning analyst.

For a few months after my graduation, I thought my worry was justified by external reality. Gradually, however, I realized that I was failing to take into account my own experience: I’d been able to find analytic patients in the recent past (I’d begun my last control case within the last year). I then started to question whether the obstacle was indeed patient availability. Reassessing my practice, I realized that during the initial consultations with several patients who might benefit from more intensive work I’d accepted too readily that they were unavailable for analysis. This puzzled me further. Reluctantly, I turned my attention to the possibility that, despite my conscious eagerness to practice as an analyst, I was hesitant to recommend and engage in analysis.

The analyst’s reluctance

Starting with Freud (1912a, 1912b, 1913), analysts have portrayed analytic beginnings as predictable, grounded in reasonable considerations, and leading to objectively determined recommendations. Efforts to determine analyzability (Bachrach 1990; Erle and Goldberg 2003) and proper beginning technique (Lichtenberg and Auchincloss 1989; Busch 1995) dominated these discussions. This emphasis reflected the prevailing assumptions of the time that treatment outcome depends primarily on the patient’s ability to participate in the analytic process (Kantrowitz 1993) and the analyst’s capacity to apply correct technique. Analysts’ participation was portrayed as technically neutral, comparable, and uniform (Bachrach 1983).

In recent years, we’ve expanded our understanding of analytic process to include not only the patient’s conflicts and resistances but also the analyst’s inadvertent participation. Boesky (1990), in a seminal paper on psychoanalytic process, discusses the analyst’s unconscious contribution to the patient’s resistance: “If there can be no analysis without resistance by the patient, then it is equally true that there can be no treatment conducted by any analyst without counter-resistance or countertransference, sooner or later” (p. 573). Smith (1993) writes about the analyst’s reluctance to engage in analytic work as a manifestation of resistance to self-analysis. He proposes that all analysts in the course of their work face, and at the same time avoid facing, our own character difficulties. As the patient resists engagement, so too does the analyst.

Given my present task, the central questions are: How do the analyst’s counter-resistances manifest themselves at the beginning of treatment? And, more specifically, how do they bear on the analyst’s recommendations?

Jacobs (1988) is among the few analysts who have identified “internal factors” in the analyst as a critical variable affecting the practice of analysis. As chair of the American Psychoanalytic Association’s Committee on Psychoanalytic Practice, he suggested, based on information collected from seventy-one analysts from several institutes, including training analysts, senior non-training analysts, and recent graduates, that the number of referrals didn’t determine the size of an analyst’s practice. According to Jacobs, the way the analyst conducted the consultation and the opening phase of treatment was more decisive. Jacobs concluded his report by stressing “that internal factors operating in the analyst seem to be as important as such external conditions as the state of the economy, the intellectual climate, the kind of insurance coverage available and the prevailing attitude toward analysis in any given locale. Not surprisingly, ambivalence toward recommending analysis to patients is not uncommon in analysts. What feeds this ambivalence is not clear at this point and in any case is an issue beyond the scope of this report” (pp. 101–102).

Some writers have suggested that the analyst’s ambivalence is a reaction to the intense affect generated in the analytic situation. Friedman (1988) speaks to powerful feelings engendered by the therapeutic situation and to the discomfort that is a constant companion to clinical work. He suggests that therapists don’t acknowledge that they “function in a sea of trouble” or that treatment is “an uncivil, threatening, even brutal struggle, instigated by gently reflective intellectuals dedicated to delicate speculations” (p. 6). Elaborating on Friedman’s ideas, Greenberg (2002) suggests that analysts at work are in a constant state of tension between our natural inclination to respond to the patient in a personal and unreflective manner and our professional inclination to analyze.

In an address to the Board on Professional Standards, Orgel (1989) also attended to the turmoil of analysis and the defensiveness that it evokes. He referred specifically to the emotional challenge of practicing as an analyst while simultaneously wishing not to analyze. Orgel described having witnessed analysts and candidates who, in parallel with their patients, defend against “terrifying and/or forbidden drives” by resisting doing analysis. In another contribution, Orgel (1990) relates this resistance to doing analysis to analysts’ unrecognized feelings toward their own analysts. He suggests that analysts must become well acquainted with their idealizations and aggression regarding their training analysts in order to function effectively as analysts. “I have speculated that some candidates’ difficulty in keeping patients, and their anxiety about losing them, are the results of unanalyzed fears of losing or destroying their training analysts, displaced into their patients” (p. 735). Orgel further maintains that some analysts’ lack of conviction about the therapeutic value of analysis reflects disappointment in aspects of their training analysis.

Observing the analyst’s reluctance, Gabbard (2003) proposes that the analyst’s love of analysis is continuously in jeopardy because of a countervailing unconscious hatred of it. As a result of that hatred, he suggests, we might be too quick to abandon the analytic method and impulsively resort to harmful actions; often the hatred is linked, in part, to envy of the patient for receiving the intensive and undivided analytic attention that we unconsciously crave.

Many authors address specifically the analyst’s anxiety and defensiveness at the beginning of treatment. Referring to the initial phase, Friedman (1988) proposes that the tension that characterizes treatment can be witnessed most dramatically at the beginning. Yet, he observes, therapists tend to consider beginnings as less tumultuous than the rest of the treatment. Orgel (1989) suggests that not recommending analysis, or not analyzing resistance in the months following a recommendation, can be a manifestation of the analyst’s defense against aggression: “An underside of our therapeutic ambitions” can be seen in “contrary wishes—not to cure, not to help, not to understand, but to overthrow and defeat, sadistic wishes which are both satisfied and defended against by failing in the therapeutic task” (p. 534).

Poland (2001) speaks to the fear that attends analytic work and how it affects his every analytic beginning: “So my career-long eagerness to have a new analytic patient is now accompanied by a hesitant fear, a small reluctance to start a new analysis. For as much as I want to do my work, as much as I enjoy doing my work, as much as I believe that the likelihood of success justifies the pains ahead, still there is something else I also know. And that is that whatever else happens this new analysis is going to go into areas I don’t want to enter, into fears I would rather keep hidden away.”

Ogden (1992) examines the sense of danger and fear associated with initial consultation sessions. Like Poland, he attributes this feeling to the anticipation of becoming aware of his and his patient’s inner life. Ogden suggests that beginning analysts misapprehend their own fear. While consciously they worry that patients will leave, unconsciously they’re afraid that patients will stay. Chused (in Jordan 2002) discusses how uncertainty influences analytic work. She focuses on how her doubts about whether she’d been helpful to a small number of patients—who claimed they weren’t helped—make her fearful about the value of analysis. Bernstein (1990) is another who explores this uncertainty. He describes analysts who recommend analysis tentatively and in a manner that reveals their reservations about their motives for recommending analysis or about its usefulness. Bernstein suggests that analysts often manifest their reluctance by failing to interpret patients’ resistances following a recommendation for analysis.

Bassen (1989) suggests that recommendations for analysis made during psychotherapy aren’t as simple or non-conflictual as they often appear. She regards such recommendations as possible enactments of transference-countertransference wishes or fears mobilized in the therapy. Similar considerations, she suggests, might apply to the recommendation process at the beginning of treatment.

Of all analysts, Rothstein has written most extensively about the analyst’s reluctance during the consultation phase. He proposes that the analyst’s emphasis on analyzability (1994, 1998) and diagnosis (2002) can serve a defensive function. If taken at face value, this focus can obscure useful transference-countertransference manifestations. Rothstein (1998) proposes that “there are many patients who are particularly disturbing to analysts both during the consultation and/or in the course of their analyses. It is not uncommon for analysts to respond to their own disturbances by deciding the patient is not suitable for standard analysis …” (p. 541). Rothstein considers the analyst’s optimistic attitude (about a patient’s capacity to work analytically and benefit from analysis) and conviction (about the usefulness of analysis) as critical variables affecting whether a patient will accept the analyst’s recommendation for analysis (1994) and stresses how little able we are to predict at the outset who can benefit from analysis (1994, 1998). He recommends that most patients who consult an analyst should be considered analysands and be seen in a trial analysis.

Rothstein maintains that analysts don’t consider or recommend analysis as often as it’s indicated, either because patients don’t fit some strict criterion about analyzability or because they’re disturbing to the analyst. He considers the analyst’s inhibition, pessimism, and lack of conviction to be the result of a misguided educational focus (a focus on the selection of patients who will respond primarily to interpretation of conflict and a focus on outcome) or the result of conflict evoked by a particular patient. Rothstein postulates that the analyst’s attitude and sense of conviction about the therapeutic value of analysis is determined to a great extent by an “unconscious bias” for or against analysis.

Whether referring to a “hesitant fear” to begin a new analysis (Poland) or “wishes not to cure, not to help, not to understand” (Orgel) or a fear that the patient will stay in treatment (Ogden), several analysts have explored the analyst’s reluctance to analyze. Ogden implies that beginners are particularly unaware of their hesitancy to start an analysis. Orgel, however, suggests that students and graduate analysts can be identical in their lack of awareness and hesitancy. Many analysts propose that analysts’ reluctance is related to their fear of affects (Gabbard, Ogden, Orgel, Poland, Rothstein). Some authors view the analysts’ reluctance as a momentary hesitation to begin (Ogden, Poland), while others suggest that it interferes with its actual beginning (Jacobs, Orgel, Rothstein). Several authors point to a lack of certainty about the efficacy of analysis as a critical variable affecting the manner in which analysts deal with recommendations for analysis (Bernstein, Chused, Jacobs, Rothstein).

To my knowledge, no detailed clinical contribution has demonstrated in detail the analyst’s reluctance as it manifests itself during the consultation or the opening phases of a treatment. In what follows, I offer detailed clinical material from my work with two patients who eventually settled into productive psychoanalyses. I focus specifically on the initial phase of treatment: the consultation with Mr. A and the early psychotherapy with Ms. B. I examine my developing awareness of my reluctance to engage these patients deeply, which bore directly on my recommendations for psychoanalysis. I describe the various manifestations of my reluctance, my understanding of its sources, and its effect on the work. In the discussion that follows, I examine how my own findings and understanding add to existing views on the analyst’s reluctance to begin an analysis.

Clinical material

Mr. A

Mr. A, a senior at a loc...

Table of contents

• Cover
• Half Title
• Endorsements
• Title Page
• Copyright Page
• Dedication
• Table of Contents
• Acknowledgments
• Introduction: Why practice psychoanalysis?
• PART ONE: Finding Ourselves as Analysts
• PART TWO: Developing the Capacity to Deepen an Analysis
• PART THREE: Sustaining the Capacity to Listen and Intervene Analytically
• Afterword: Looking inward and forward
• Index