The Process of Psychoanalytic Therapy

Models and Strategies

Emanuel Peterfreund

• Publisher: Routledge
• Year: 2020
• Print ISBN: 9780881630039
• eBook ISBN: 9781000148985
• Edition: 1
• Topic: Psychology
• Subtopic: Mental Health in Psychology
• Index: Psychology

In his extensive description of the heuristic approach to psychoanalytic therapy, Peterfreund discusses the strategies used by both patient and therapist as they move toward discovery and deeper understanding.

PART ONE

STEREOTYPED APPROACHES TO PSYCHOANALYTIC THERAPY

1	Stereotyped Approaches: Examples from Personal Experience

Mrs. A.

Mrs. A. was one of my early cases, one conducted under supervision. Her case typifies the many experiences that led me to begin to question the scientific basis of much of clinical psychoanalysis and the validity of many widely accepted clinical generalizations. Also, it was cases such as Mrs. A. which led me to begin to specify the nature of acceptable psychoanalytic clinical thinking.

Mrs. A. was a young woman who sought analysis for a host of symptoms including intense anxiety, depression, and episodes of tachycardia. Inexplicably, her pulse rate would often exceed 160 per minute, accompanied by difficulties in breathing. She suffered from severe and crippling hypochondriacal preoccupations and fears of death. Especially prominent were fears of breast cancer, fears of imminent heart attack, and fears of aging. Her anxiety had become so great that she was taking barbiturates around the clock to calm herself. She decided that treatment was urgently needed when her agoraphobia increased to such a point that she was not able to leave home alone.

Her initial history revealed that she had had serious difficulties throughout her life, fears of getting a mastoid infection when young, ever-present fears of death. She became nauseated when out on dates. When she first began to work, in her teens, her anxiety was so intense that she had to be accompanied by her mother to and from work. In general, she felt friendless, alone, ugly, and unloved. She felt that she was never able to “connect” with people. Psychological testing confirmed that she was profoundly disturbed, and possible hospitalization was advised. She was nonetheless accepted for low-cost psychoanalysis at the Treatment Center of the New York Psychoanalytic Institute, after having been initially turned down. It is important to emphasize that Mrs. A.’s treatment started before modern psychotropic drugs were in use.

The patient was the older of two children; she had a brother 3 years her junior. The mother was portrayed as chronically irritable, angry, paranoid, lacking any affection or warmth. She had had several major depressive episodes during the patient’s life. One occurred after the birth of the patient; one, which lasted about 6 months, occurred after the birth of the younger brother. The most recent episode began on the very day that the patient started treatment.

The beginning of the analysis was hardly auspicious—a desperate patient clinging to analysis as her only chance for life, feeling lucky to have finally been accepted for a low-cost analysis. And here was her analyst, 3 years her junior, obviously inexperienced, and exactly the age of her despised brother. The situation was an explosive one as the patient tried desperately to hang on to the analysis while simultaneously trying to deal with her highly ambivalent feelings toward me. In the very first hours before beginning supervision, I found it necessary to deal with the transference. I interpreted almost immediately that she was afraid of being overwhelmed by her feelings, was afraid that she might break down and cry, and thought that I was too inexperienced to handle her. The patient agreed with me completely and elaborated on these anxieties. My supervisor, however, was critical of what I said to the patient. She felt that it was much too early for the patient to be dealing with the transference, too early for her to be preoccupied with me. The supervisor felt that the patient should be talking about her husband, since he, according to the supervisor, was probably the cause of the patient’s difficulties. The supervisor told me she had a hunch that the patient was ill because her husband was “making her do a perversion.”

It should be emphasized that I had been taught that Freudian analysts worked from the surface, worked with the immediate experience that patients present. Mrs. A’s feelings about me were at the forefront from the moment the analysis began. Indeed, they seemed to be at the forefront in a most explosive way. But the supervisor was telling me to disregard the presenting material. Furthermore, my early interpretations, though accepted and elaborated upon by the patient, were deemed to be serious errors. Finally, when I repeatedly asked the supervisor about the evidence for her inferences made about the patient’s husband, the answer was always “Experience.” The supervisor had had 20 years of experience and therefore understood what was going on.

Having no immediate alternative, I had to go along with my supervisor. Under the guise of interpretations, I suggested ideas to Mrs. A according to the instructions given me, especially ideas related to the husband. Actually, these efforts were in great part attempts to organize the chaos presented by the patient. Because of her desperate need to hang on to the analysis and not be thrown out, the patient picked up my suggestions and tried to deal with them. When, at the supervisor’s insistence I said to Mrs. A., “You are preoccupied with me as a way of avoiding your real problem, namely, your husband,” Mrs. A. would dutifully tell me something about her husband, and then say, “Now what?” Actually, she was only dancing to our tune.

As could be predicted, the analysis went downhill very rapidly. The main issue, the transference, was not being dealt with. The patient was principally concerned with how a beginner and so young a man could handle someone who felt as ill as she did, literally ready to fall apart. She felt that I was her only link to life, but she feared her own internal chaos, feared breaking down and becoming totally out of control, feared being able to overwhelm me completely and even sexually seduce me. She felt that only a God-like, very experienced, senior, special person could help her and bring the external controls that she felt were necessary to organize her.

After a few months, the supervisor decided that the case was not analyzable, because of a “persistent, unresolvable, brother transference,” and suggested that I discontinue treatment. I disregarded this advice, left the supervisor, and radically changed my approach to the patient. When on my own, and before acquiring a more congenial supervisor, I stopped giving Mrs. A. subjects to deal with under the guise of interpretations. I asked for “free associations” and tried to deal with whatever came up spontaneously. I stayed very close to the surface and dealt actively with the explosive transference. Naturally, she was puzzled and bewildered by the change in technique. I was now trying to analyze her need for cues about what to talk about, whereas until now, I had been giving her such cues. Mrs. A. reacted to the marked change in technique with the following dream: “I am on a stage giving a performance, but I cannot go on because the prompter is gone.” She then told of a performance at age 7 when she had trouble speaking because she could only perform on cue. Indeed, the “prompter”—the supervisor—had gone, and I think that the dream gave convincing evidence for the idea that the patient had been merely a puppet, acting a role in response to the totally artificial format imposed on her.

Although the treatment was very stormy, the situation turned out to be relatively salvageable, and I was able to work with this patient for about 9 years. However, I was able to achieve only limited success.

As time went on it became increasingly clear how ill the patient truly was. Indeed, in retrospect, in all of my years of experience I have rarely seen, outside of a hospital setting, a patient so anxious, so constantly in terror, so unable to find a moment of peace. She lived in a constant nightmare; death, destruction, cancer, heart disease, abandonment, and consequent total helplessness—all were either always happening or were just about to happen. She lived in a tenuous world, one that was constantly changing, an unreliable, unstable, unpredictable world, one that could not be trusted. She had to be ever on guard to detect the changes in the outer world in order to protect herself. Terrible things could suddenly happen for no obvious reason—someone could get violently upset and angry over the slightest offense and abandon her. She often saw herself as a rat scurrying around, trying to survive in a terrorizing world. “Survival” was the theme of her life and one of the main themes of the analytic treatment.

Mrs. A. saw herself as totally vulnerable, utterly helpless; inner urges could engulf and overwhelm her. She saw herself as a total “zero,” and her body as nothing but debris or “flotsam.” Indeed, she saw her body as made up of totally disorganized, disconnected parts with no apparent central regulatory mechanism. She felt that her body parts were only loosely joined together, and each part could go off on its own, totally out of control. The reality of having extra-systoles and attacks of tachycardia served as living proof to her of her disorganized, malfunctioning, bankrupt image of herself. She feared orgasm because then her body could literally “burst and fly apart.” She never knew how to predict what might happen to her. She feared, for example, that she might become ill in a crowded department store, faint, and then be trampled upon and destroyed by a deaf and oblivious world.

An inner image of death and stagnation permeated her life. Her mind, she felt, was basically “dead and stagnant.” She could not think, she felt; she was too inept to communicate with or contact the outer world, which could only turn away from her with “glazed and unseeing eyes.” Her bowels were dead, she felt, and so were her genitals. She felt that she was empty and dead and that life for her had actually never begun. She was born a defective and born into darkness. Mrs. A. saw herself as a dazed, glassy-eyed child, living in a bombed-out world. She once said to me, “I am nothing; I offer nothing; I am just tolerated; I interfere with people; I am a bother and a nuisance; I intrude on the peace of people; I am tolerated only out of charity. I am all dead; I must create a superstructure, a façade to conceal the nothingness. I always copy and become like others. I don’t know who the real me is.”

I felt from the beginning that much about this patient could be understood by recognizing how ill her mother was and how traumatic were the patient’s early life experiences. In addition to her multiple depressive episodes, the mother, according to the patient, “could not hear,” and was intolerant of any opposition. “Bad” behavior “killed” her, and she constantly threatened abandonment. She was subject to very rapid mood changes, and very early in life the patient learned to be attuned to these moods, always alert for any sign of a breakdown. She had vivid memories from age 3 of a weeping, depressed, dejected, sad mother, with dull, glassy, unseeing eyes. She once described her early life as, “This dead mother, this dead house, this dead city.”

The patient’s early life was fraught with anxiety. At age 4 to 5 she would frequently awaken at night feeling that something was in her throat, that she might choke, and that she might not be able to open her mouth. In later years these fears took on the specific form of a fear of lockjaw. At age 5 to 6, she fantasied that she could make her dolls come alive and transform them into real living babies. The early years were characterized by violent quarrels with the mother, “white rages” over everything, especially over toilet training. Apparently the patient was chronically constipated as a child, received frequent enemas, and was constantly threatened with their use.

From the history and from what I learned as the analysis progressed, I had every reason to believe that Mrs. A.’s anxiety was unusually total and primitive and had to be dealt with accordingly. I was struck by the illness of the mother and the massive and overwhelming rage, anger, frustration, deprivation, and helplessness that probably characterized the patient’s early years. Her anxiety was not that of a simple hysteric, and, if any sort of therapeutic process was to be established, I felt very strongly that she could not be treated as one. Certain reassurances and gratifications had to be allowed, and certain frustrations avoided. To have frustrated her when she needed to hear my voice to reassure herself of my benign presence would have been to duplicate what her depressed mother undoubtedly had done.

Several years after the beginning of this patient’s treatment, I presented all of the foregoing material plus a great deal more at a case conference. After reading my extensive case report, one discussant, a young analyst of about my level of experience, concluded that I had completely misunderstood the patient. It was clear to him that she was only trying to seduce me through her anxiety, and he felt that she had succeeded in doing so, judging by my response to her. He informed me in no uncertain terms that he would have repeatedly interpreted her sexually seductive efforts regardless of how she replied and no matter how long she continued to resist.

A second discussant, a prominent senior training analyst, also viewed the material from the standpoint of late infantile sexuality. He reasoned that, inasmuch as Mrs. A. had mouth and throat symptoms beginning at age 4, she was obviously struggling with fantasies of devouring her father’s phallus, and her interest in dolls and babies undoubtedly had to do with her wish to have a baby from her father. He did not understand why oedipal issues were not discussed in my case report.

A third discussant, a young analyst who was trained with me, responded to the same clinical presentation differently. He suggested that the patient’s symptoms at age 4 might have been related to her mother’s depressive episode during the previous year, following the brother’s birth. He wondered if the mother had been closed-mouthed and unable to respond during this depressive episode.

In general, as is probably clear, my own understanding of the case was quite consistent with the ideas of the third discussant. It seemed probable that at age 4 the patient had been struggling with violent aggressive feelings toward her very ill, psychotic, depressed, silent mother. Throughout her life, she tended to develop mouth and throat symptoms when confronted with similar conflicts. It was also my understanding that her interest in dolls and babies probably had to do with fantasies of making her “dead” depressed, silent mother wake up and come alive. It also apparently had much to do with her attempts to wake up and restore her own “dead” withdrawn self.

What we have here, then, is a veritable Rashomon situation. Five “Freudian” analysts coming from the same psychoanalytic institute have almost as many understandings of the same data. It cannot be said of the supervisor that she was working with a stereotyped approach. Indeed, it is not easy to find a label for her approach; I can only call it idiosyncratic. She saw a totally unworkable case, and I never did find out the source of her inferences about the patient. Certainly, her suggestions about the patient’s husband, the supposed cause of the patient’s illness, did not come from any existing clinical theory. Equally certainly, these ideas had no obvious relationship to the patient’s life. Indeed, years later when the patient was finally able to talk about her sex life, she said she felt that her husband was far too inhibited, not free or “perverse” enough to arouse her. Furthermore, the supervisor had abandoned one of the basic principles of Freudian analytic technique which we are all taught, namely, that one works from the surface with whatever the patient brings up.

In contrast to the supervisor’s idiosyncratic approach, the first and second discussants approached the case in what I am calling a “stereotyped” way. Both disregarded the early traumatic history, the mother’s psychotic depressions, and the ominous clinical picture. Both reasoned directly from existing clinical theory based on genital-oedipal themes, disregarding everything that did not fit these ideas. Both viewed the patient as though she were essentially a well-functioning simple hysteric and not profoundly ill. For the first discussant, everything was “sexual” and therefore the patient’s anxiety represented merely her sexual seductiveness. The second discussant understood the clinical material from the standpoint of theoretical stages of development, all, of course, sexual and oedipal in nature. Both discussants worked with very limited models of development and psychopathology. Neither one thought about the patient from within the unique and specific case material she presented. The first discussant even suggested that I pay no attention to whether or not the patient understood and accepted the sexual interpretations that he advised; he saw lack of understanding or failure to accept interpretations as...

Table of contents

• Cover
• Half Title
• Title Page
• Copyright Page
• Dedication
• Table of Contents
• Preface
• Introduction
• Part One Stereotyped Approaches to Psychoanalytic Therapy
• Part Two A Heuristic Approach to Psychoanalytic Therapy
• Part Three Case Illustrations of the Heuristic Approach
• Part Four Strategies Used in the Therapeutic Process
• Part Five Evidence, Explanation, and Effectiveness
• References
• Index