Creative Engagement in Psychoanalytic Practice

Henry Markman

• Publisher: Routledge
• Year: 2021
• Print ISBN: 9781032077246
• eBook ISBN: 9781000470987
• Topic: Psychology
• Subtopic: Mental Health in Psychology
• Index: Psychology

Creative Engagement in Psychoanalytic Practice fills the gaps in current clinical training and theory by highlighting the importance of the analyst's unique voice, creativity, and embodied awareness in authentically being with and relating to patients. In this original and personal account, Henry Markman provides an integrated approach toward analytic work that focuses on engaged embodied dialogue between analyst and patient, where emotional states are shared in an open circuit of communication as the route to self-discovery and growth. The involvement of the analyst's singular and spontaneous self is crucial.

In integrated and illuminating chapters, Markman emphasizes the therapeutic importance of the analyst's embodied presence and openness, improvisational accompaniment, and love within the analytic framework. Vivid clinical vignettes illustrate the emotional work of the analyst that is necessary to be openly engaged in a mutual yet asymmetric relationship. From over 30 years of clinical practice and teaching, Markman has synthesized a variety of contemporary theories in an approachable and alive way.

This book will appeal to psychoanalytically oriented clinicians, ranging from those beginning training to the most seasoned practitioners.

Chapter 1

Creative engagement: an overture

DOI: 10.4324/9781003208518-1

I must however make it clear that what I am asserting is that this technique is the only one suited to my individuality; I do not venture to deny that a physician quite differently constituted might find himself driven to adopt a different attitude to his patients and to the task before him.

Freud, Recommendations to Physicians Practicing Psychoanalysis, 1912

In this chapter, I introduce the overarching approach of creative engagement and touch on its essential elements. It is an overture, a broad view, that hits some main themes that subsequent chapters will take up in more depth. In order to give you a vivid sense of these ideas, I will illustrate what creative engagement looks like by a detailed clinical example.

As I mentioned in the introduction, this approach (echoing Freud above) is my way of working. In the next section, I will say something about how I found my way to this approach. I’m not claiming it is the best way but one that may be of use to you in grounding your practice in essential, emotional ways of being with and relating to your patients. I see my approach as a starting point, a ground floor in our work.

By “creative engagement”, I mean the personal, originative, and non-formulaic ways we meet patients, emotionally connect, and create an environment for their emotional growth. We do this through improvisation, playfulness, and spontaneity. By “personal” I mean that we find unique ways to participate with each person—to attune, accompany, and strive for openness to receive what they communicate in all registers (verbal, unsymbolized, and embodied). This is what Freud had in mind—personal as in singular to us. But I also mean it this way: we are personally involved in the relationship with our patients in an intimate way that matters. Our emotions and vulnerabilities are a part of the communication.

Our engagement aims to give another a safe place to express dissociated and repressed parts of their personality, to feel recognized and understood, and to find a (potential) space to creatively explore and experiment as well. My engagement is meant to foster an “open circuit of communication”¹ where emotional states are shared as the basic mode of communication, building common ground between us. This sharing is intrinsically therapeutic; it occurs in words and-or in enactments and action. In this open circuit, I am sensing the way I affect the patient while self-sensing my internal state—how patients are affecting me and my openness to them.

In engaging creatively I am also offering the patient an emotional experience to find their own creative ways of being and living and authentic self-expression, in the session and in their life. As Winnicott (1971) writes, creativity comes from an authentic and unique part of us. He emphasizes the feeling of surprise as a hallmark of being creative. I have found this to be so. But surprise can be both energizing and disruptive—for both participants—as we will see in the following clinical example and the many others that follow in this book.

“Coming from afar”:² the first session with Edwin

Some time ago I received this message on my phone: “I’m in bad shape. I need to talk to you soon … I’ve never done this before, never turned to anyone”, spoken in a desperate, deep, raspy voice. I imagined a frail, older man.

When I went to gather Edwin from the waiting a few days later, I was surprised to meet an energetic man in his early 40s, grinning widely at me. Excitedly bounding up the stairs to my office, his behavior was so at odds with his voice and message—his urgent call, and now, his giddy, coiled-up energy. He plunged into his narrative at a dizzying pace—the way he spoke carried with it an urgent appeal from a young and vulnerable part of him that touched me. This part of him seemed to say, “Don’t hurt me—please like me and take care of me”. Where was that appeal coming from in him?

There were other incongruities in the way Edwin communicated. Though he was born in a non-English speaking country, he spoke English perfectly. More than perfectly. I don’t think I’ve encountered anyone with more command of the English language. His vocabulary, grammar, jargon, and vast literary allusions were astonishing. While describing bone-crushing depression, self-torment, and intrusive suicidal images, he seamlessly inserted quotes by Victor Jarra, Borges, and Neruda to get his emotions across. He lacked his own language for what was happening inside him. At one point I interrupted: “I’m sorry but these quotes are a bit distracting to me. Can you try to use your own words?” He looked blankly back at me, confused and at a loss how to comply with my request. He apparently had no words of his own for his emotional state. Instead, another literary allusion poured forth: “I guess I’m ‘tangled up in blue’,” he said with a smile.

At other moments when his emotional situation was not expressed through references to literature, movies, and music, he expressed himself vividly in pantomime by acting out emotions with grunts, exaggerated facial expressions, and extreme gestures. He had a real talent. His bodily expressions perfectly captured a particular emotion. This might be acting but there was a sincerity too, in trying to communicate something real the only way he knew how. Though he did not have words for his feelings, I viscerally felt them and tried to translate these gestures into words. The emotional impact of his gestures pulled me along, powerfully, like catching a wave that’s too big for one’s surfing skills. Hang on!

I had disturbing and conflicting reactions to Edwin: fascination, pleasure, irritation, confusion, and feelings of genuine warmth—especially when I sensed the frightened and vulnerable young boy peering out from behind the curtain of the performance going on stage. The disturbing part was that in spite of him telling me unbidden, ruminative images of shooting himself in the head (and the relief he would feel in going through this), I had no idea really what was torturing him so. I struggled to feel more directly into his suffering, a suffering without words or context. It was such a strange mixture of agony and theater—but theater with an urgent purpose. I worked to get to, in myself, the seriousness of the situation—to take him very seriously—because there was something slightly off and unreal about his way of speaking. There were moments when he conveyed terrible feelings through bodily expression. Then I fell in touch with something fearful and traumatic.

I told him that I could see he wanted to gain my interest and feel comfortable with me because he was frightened and desperately needed help. I said I wanted to help him. He calmed down a bit and was silent for the first time in our meeting. We then made plans to begin our work together at several times a week.

Entering into creative engagement with Edwin

At the moment I explicitly invite Edwin on this emotional journey, the passage and destination are uncertain, and my responsibility feels unmistakable and weighty. Though I am filled with all sorts of feelings and hypotheses, I am well aware how much I don’t know and understand. Because of this uncertainty, crucial clinical issues come into greater relief, issues that need attention and that will pertain well beyond this first meeting. Edwin and I are each “coming from afar”, to use Borgogno’s (2014) phrase, from different, at times distant, worlds that are determined by childhood experiences, as well as socio-cultural and historical contexts. All of this shapes our unique ways of being. These differences count. There will hopefully be important areas of overlap, some basis of communication and understanding, but that will take time, and the way these overlaps occur is unconscious and unpredictable. When we first meet each other, the space between us is real and palpable and the possibility for learning is always at hand. This sense will (it is hoped) persist throughout the analytic relationship if the analyst and patient don’t become trapped in habit, routine, and other forms of collapse or symbiosis that block evolution. It is a delicate balance to maintain, one of keeping space open while building emotional bridges between us.

Personal and clinical questions that energize and challenge my way of working follow from the sense of uncertainty and space between us. I’ve asked these same questions many times over the years. They gathered and formed my approach. They concern how I will embody the responsibility of inviting Edwin into a relationship of struggle and pain, tumult, perhaps mourning, and ultimately, I hope, greater freedom and a more meaningful and creative way of living. What will be the quality and range of my empathic imagination? Will I be able to make contact with the vulnerable, younger part of him in a meaningful way that matters? How willing will I be to face new, uncharted areas of my own personality that will inevitably come up? As this work may entail sharing an emotional world of trauma and dissociation, will this extend beyond the reach of what I can bear? When we inevitably become embroiled with each other in uncomfortable, conflictual interactions, in entangled transferences, how will we sort that out? Will we be able to?

Then clinical questions come up that pertain to my intention and actions. What ethos will guide me? What position of relating, caring, and responding will I adhere to? Where will I direct my attention and participation in a situation that is often indeterminate and in flux, in which there will be periods of uncertainty and confusion and discomfort and times of real interpersonal stress? How will I interpret and make use of my emotional to benefit the patient reactions—especially those that are disturbing? How will I respond to and make use of my failures?

From these questions that I have asked myself again and again with my patients, striving to a get deeper understanding each time, I arrived at “creative engagement” as my over-arching sensibility and way of analytic relating. How did I come to think of my work as creative engagement? In conceptualizing how I work, “technique” seemed distant from the emotional immediacy of encountering the world and mind of another and trying to understand, emotionally connect, and help. “Technique” concerns important preconceived actions, such as establishing a frame, maintaining a nonintrusive analytic stance, interpreting the unconscious transference in the here-and-now. I searched for other words and ideas that go more to the heart of what I intend and do. “Creative” emphasizes—as Freud’s quote at the beginning of this chapter, indicates the singularity of each analyst’s sensibility and voice, how each analyst makes use of his or her “individuality” to foster intimacy and a unique relationship that allows for the sort of deep experiences that help another person. Because this is personal, there is no blueprint for how a therapist does this. However, there are principles that free the therapist to use his or her creativity and empathy to ground the work emotionally, which I will describe. There are also ethical horizons. “Engagement” suggests an ethical commitment. The etymology of “engagement” is a “binding pledge or commitment”. Our engagement involves an ethically asymmetric responsibility and commitment when we take someone into analysis who then continues under our care.

Elements of creative engagement

Love in the Analytic Framework

First of all, creative engagement has to do with our unique ways of loving within the analytic framework. Love is expressed in our desire to know, understand, and recognize the singularity of a patient in a deep way that fosters intimacy. We express in action our abiding care for the welfare and emotional growth of the patient. This involves communicating in various modes—words, rhythms, gestures, provisions—our understanding of the patient’s world of struggles and needs.

I am guided here by Nacht’s (1962) seminal article where he affirms that the “final result of analysis”, the “reparative gift” the analyst gives, depends on his “inner state of being”, “a real deep attitude” toward the patient (p. 211, author’s ital.). He states emphatically, “No one can cure another if he has not a genuine desire to help him; and no one can have the desire to help unless he loves, in the deepest sense of the word (p. 210, author’s ital.)”. This care and love manifests in our desire to know the patient as fully as we can and communicate that recognition in understandable ways, in the patient’s idiom. In this process of communicating, we learn to speak the language of the patient, whether that is through words, gestures, or embodied rhythm. Ultimately, this expression creates a place in us and in the potential space between us, for the patient to be and find the deeper layers of his or herself. It is an offer of freedom.

One might be tempted to minimize this as something like, “Love is all you need”. In fact, ongoing serious emotional work and self-interrogation are needed by the analyst (for example, how does the patient live in us and what are our real intentions?) in order to develop and maintain this “real deep attitude” that gives a quality of real care and authenticity to the interaction. Edwin may come, I hope, to feel and rely on my abiding care, concern, and love. This takes time, as the patient tests in many ways the reality of our intentions. As Nacht states, this is fundamental and necessary for cure.

Presence

Related to love is what I call embodied presence. Presence is our spirit of openness and welcoming and emotional availability. Presence is offering a place for another within us, opening a door in us for the patient to come in. We allow for an influx of the patient’s emotional states. Presence opens us to live with and within the patient’s world, by allowing for influx and interpenetration. The patient can sense our availability.

Presence makes us available to contain emotional states within the dyad, by making emotional links between our emotional experience and the patient’s. By taking in the patient and allowing for the range of experiences that arise in us, healing can occur. We make contact with our own early difficult experiences and connect this with the patient’s suffering. Our identificatory-empathic responses resonate in the patient, as we work through our own difficult past in the presence of the patient—not necessarily explicitly communicated but communicated by the quality of understanding and recognition.

While a loving “real deep attitude” may endure over an extended period, our presence is momentary and in flux and takes emotional work to maintain. We are willing to work toward it because of our attitude of love. What is this work?

As I show in Chapter 4, to make oneself available and present, involves the emotional work of surrender and mourning. We let go of constraints in us: our transferences, and our attachments to theory and analytic identity, to ways of feeling stable in order to offer a place for the patient in us. We take on their world. I think Edwin will depend on my presence in the immediacy of the moment, in real time, in order for him to bring in the split-off parts of himself and difficult past experiences. He may then sense that his vulnerability—up to now a liability and dangerous condition—can be made safe and meaningful, and that may give a greater sense of reality to his existence. I must be present for this to happen, but this takes ongoing work.

So, the path to presence is not always easy for me. This active work is sensed by the patient. Edwin will eventually experience the way I am strugglin...

Table of contents

• Cover
• Half Title
• Series Page
• Title Page
• Copyright Page
• Dedication
• Contents
• Acknowledgments
• Introduction
• 1 Creative engagement: an overture
• 2 The development of analytic authenticity
• 3 Embodied presence: the analyst's home base
• 4 The analyst's emotional work of surrender and mourning
• 5 Embodied attunement and participation
• 6 The analyst as improvisational accompanist
• 7 “One-sided analysis is no longer possible”: “mutual analysis” as the analysis of mutuality
• 8 The radical uncertainty of psychoanalytic practice
• 9 Modes of therapeutic time
• 10 Moments of transformation and beauty
• 11 Process and non-process
• 12 Creative engagement in these times
• References
• Index