Where the action is: the enacted dimension of analytic process

The Spectrum of Analytic Interaction: A Contemporary Freudian Perspective

The authors set forth a contemporary Freudian perspective proposing that enacted interaction be viewed as a spectrum of distinct yet overlapping clinical phenomena: acting in/acting out, transference actualization, enactment, countertransference actualization, and boundary violation. At the center of this spectrum are enactments proper, interactions in which both parties construct and sustain a process that embodies a crucial aspect of their affective relationship. By conceptualizing these interactions as a continuum that is patient-focused at one end and analyst-focused at the other, the authors delineate a range of modalities for analytic intervention. They contend that an oscillation between monadic and dyadic perspectives is integral to grappling with the interactive dimension of the analytic process.

Repressed ghosts and dissociated vampires in the enacted dimension of psychoanalytic treatment

One of the most evocative uses of the metaphor of a ghost in psychoanalytic writing was crafted by Hans Loewald in "On the Therapeutic Action of Psycho-Analysis" (1960). In this seminal work, Loewald likened the process of psychoanalytic change to that of transforming psychic ghosts into ancestors. In the present paper, the author supplements the metaphor of ghosts that haunt with the metaphor of vampires that menace, and links these two alien experiences to two psychological processes: repression and dissociation. Descriptions of ghosts and vampires in folklore, and the ways they are experienced in analytic treatment, are followed by an explication of the enacted dimension of analytic process-the arena of treatment in which all demons are inevitably revivified, "recognized," and ultimately laid to rest. The paper includes a clinical illustration of a dissociated vampire: a Holocaust trauma transmitted across three generations of survivors.

Enactment and the emergence of new relational organization

Enactments are investigated from the process-oriented focus of our therapeutic approach. By embedding their occurrence within the on-going flow of nonlinear dyadic process, we focus on the subtle back-and-forth between patient and analyst, as well as the importance of what we call now moments. An alternative to the dissociative self-state model is offered that emphasizes implicit memory processes in bodily comportment and style of relating with others. We suggest that change occurs through the emergence of new relational (i.e., procedural) skills within a therapeutic relationship that is self-organizing at more inclusive levels. Treating enactment as an emergent property of the dyad means not concentrating on the level of the individual components of a system. Rather, it means regarding enactment as a property of the entire system, without which there would be no emergent property. Going forward, we suggest use of the term relational apprehension in referring to the complex process of grasping a gestalt of relational meaning as an integration of perceptions, feelings, images and imaginings, sensations, fantasies, thoughts, and intuitions. Two brief case vignettes from the literature are discussed in order to illustrate this view.

The waiting room as boundary and bridge between self-States and unformulated experience

For both patient and analyst, the waiting room serves containing and expressive functions. The waiting room may serve as both a boundary between the analytic couple and a bridge to engagement. At times it can provide a means of titrating the intensity and duration of the affects activated by immersion in the analytic process: it can also serve to extend the boundaries of the analytic frame by providing a holding environment to facilitate metabolizing the impact of comings and goings. It also may be viewed as a membrane between self-states through which oscillating facets of dissociated or unformulated experience are enacted. Clinical material from the analysis of an adolescent girl illustrates these ideas.

Neediness and narcissistic defensive action

Action-prone patients are difficult for most analysts to treat. The author describes patients who act in treatment by pressuring themselves and the analyst to get rid of what is wrong, to change the imperative, life-and-death qualities of need into something else. Viewing neediness in treatment as narcissistic defensive action helps the analyst address the patient's pressured flight away from focusing on the need of the analyst and toward action aimed at riddance. Ghent's (1992, 1993) views on neediness are discussed and seen to be complemented by a view of action as protection against narcissistic vulnerability. Analysts' intolerance, vulnerabilities, and needs with such patients are considered.

Supervision and self-disclosure: modes of supervisory interaction

A conceptual framework is presented for thinking about supervisory issues raised by candidate self-disclosure. The process of dealing with self-disclosure in supervision brings into bold relief certain dynamics that operate in all supervisory encounters. In responding to these and other tensions stirred by analyst self-disclosure, the supervisory dyad moves in and out of various configurations, or "modes of supervisory interaction." Why these dynamics are intensified when the focus of supervision is on an instance of candidate self-disclosure is explored. To illustrate these ideas, a supervisory hour that dealt with the issue of self-disclosure is presented. A nonjudgmental awareness of the various modes of supervisory interaction enriches the supervisory process.

Slippery when wet: the imperfect art of interpretation

When pursuing a line of psychoanalytic interpretation, there are many factors that need to be considered. Interpretation is always a provisional exercise in which the analyst's proposes something to the patient to consider and then wait to see his or reaction. Whether or not the interpretation is correct is not as important as the patient's reaction to it. Does it cultivate insight, does it spur defensive reactions, does it feel helpful, does it leave the patient hurt or misunderstood, or does it aid the patient in facing their anxieties and exploring them in a way that might facilitate change? These are just some of the possibilities when analysts voice their opinions about what might be happening at an unconscious level in a patient's immediate experience. Interpretations may be correct and address the patient's phantasies and transference state, but they can also be part of a pathological projective identification system. In other words, it can be a collusive acting out that not only helps patients to grow but also serves their defensive structure and thus helps them to retreat at the same time. The author explores clinical moments in which interpretive enactment or interpretive acting out occur. The constantly shifting emotional states produced by transference, countertransference, and the dynamics of projective identification make the interpretive process prone to instability, fallibility, and uncertainty. The unavoidable pros and cons of interpretive acting out are examined through the lens of one complex psychoanalytic treatment.

The upward slope: a study of psychoanalytic transformations

In an examination of twelve audiotaped psychoanalytic sessions, the authors, using both quantitative and qualitative methods, observed a stepwise progression in mental organization, which they term the upward slope. Its constituents include a phase of regression (desymbolization and the agony of equivalence), a phase of transition (disruptive enactment leading to transitional space), and a phase of reorganization (triangulation leading to symbolic synthesis). The hypothesis of a phase-specific progression is advanced, wherein different forms of mental functioning evoke distinct dynamic processes of psychic repair The authors present detailed clinical summaries of the sessions they examined, as well as their own observational comments, to illustrate these ideas.

What is medical ethics consultation?

What happens when the field of ethics consultation meets the hermeneutics of suspicion.

To coerce and be coerced

Coercion is a way of forcibly influencing others. While one's core conflicts may contribute to an experience of being coerced in any interaction, specific situations or circumstances commonly encountered in clinical practice set the stage for analyst or patient to feel forced or manipulated. The interaction that develops in these instances is conceptualized as a coercive enactment. Conditions that increase the susceptibility to coercing and being coerced may develop at any stage in the psychoanalytic process. Supervision and conversion from psychotherapy to psychoanalysis are examined as situations that predispose to coercion. Silences and other difficulties in maintaining the analytic frame, as well as crises in the life of the analyst, may also lead to coercive enactments. Pertinent literature is reviewed and illustrative clinical cases are presented.

The Analytic Pair in Action

The case of a musician/performer whose disposition and identity involved action as a privileged modality and whose initial presentation included the absence of a palpable mental life is used to show how the analyst's urge to disclose/to fill in what was unknown was midwife to the development of a symbolizing capacity and an articulated mental life. The patient at first could only tell her story by showing and doing and so the analyst's participation in the actualization of the narrative was vital to its discovery. Relationships between the patient's unusual mental structure, including her proclivity for action, the use of projective mechanisms, and an ease with the concretization of fantasy are discussed with reference to her endowment as a gifted musical composer; and her identity as an "artist. " Technical strategies and difficulties in arriving at a 'best' technique are discussed as the analyst struggled to locate the patient developmentally, and to contain and permit difficult transference/countertransference enactments to unfold. Reflections on parallels to child/adolescent developmental necessities enabled the evolution of a viable technique.

Action as ejection

The systematic analysis of acting-out episodes can be used in assessing analytic progress. Variables to be considered are the nature of the wish, the type of defense, and the degree of concreteness (versus symbolization) of the mental processes used in attempting actualization (as distinct from the resort to action). Two acting-out episodes of a borderline patient who acted out as a character trait, both occurring outside the analytic setting, are presented as illustrations. In the first one, occurring relatively early in the analysis, when split-off negative and positive self-images had to be rigidly maintained, ejection of the negative self-image was actualized via the regressive use of a symbolic equation and the mechanism of displacement, obliterating the distinction between an internal feeling and an external thing that here was literally thrown out. The later episode, occurring after the split was healed and within the context of a frustrating heterosexual involvement, contained an acted-out allusion to identification and competition with the mother. As in a dream, via associations, an unconscious wish for oedipal victory was revealed. Whereas in the first episode the goal of ejection was central, with splitting and denial the underlying defenses, it was absent from the second, in which an attempt was made to actualize a repressed infantile wish and made greater use of symbolization. It is concluded that acting-out episodes at different periods of the analysis, when systematically analyzed, can serve in assessing a patient's progress.

Psychoanalytic controversies contextualized

Psychoanalytic disagreements are famously heated, polarized, and prolonged. These controversies are often the reflection of a shared agreement by the participants to engage in debate at an abstract level far removed from the clinical context in which the disagreement first arose. As a specimen example of such disputes, a case report by Patrick Casement is examined, together with a series of polemical discussions it inspired concerning physical contact suddenly demanded by an analysand in session. Over two dozen authors were almost evenly divided on whether to agree with Casement's technical conclusions, but showed a disquieting indifference to the detailed information available in his report regarding how this clinical crisis developed. The substantive merits of the contending arguments are not at issue; rather, the point is to demonstrate the crucial need to refine a methodology of contextualization to clarify inferential assumptions in clinical discussions. Premature truth claims might then give way to a more rational comparison of the clinical sources of divergent opinions. The term contextual horizon is introduced to facilitate an understanding of how the psychoanalyst makes inferences from the patient's associations.

A note on transference and alliance: I. Transference--variations on a theme

Conceptual and pragmatic difficulties are encountered in relating and differentiating transference from alliance. Transference and alliance, along with the real relationship, are component elements of the analytic relationship, and are mutually involved in intermingling and interaction at all points of the analytic process. Variants of transference are discussed with an eye to distinguishing their differentiation from and relationship to alliance components and functions. Forms of transference differentiated are classical transferences (libidinal and aggressive), transference neuroses, transference psychoses, narcissistic transferences, selfobject transferences, transitional relatedness, transferences as psychic reality, and relational or intersubjective transferences. Transference mechanisms--specifically displacement, projection, and projective identification--and their role in transference development are discussed. Differences in the concept of transference conceived classically as opposed to relationally or intersubjectively are explored. Therapeutic advantages and limits of these differentiations are considered.

Are we losing our mind?

The individual mind of the patient, and how it works, are the central topics of this plenary address. In psychoanalysis we are always dealing with a mind--a mind with its own particular structure--and this is a fact of singular importance in how we listen to, understand, and communicate with patients. Techniques geared to this view are presented. The author reflects on and challenges some contrasting current views of psychoanalysis as primarily coconstructed or as a relational matrix. Technique according to this view highlights the analyst's subjectivity and actions as central to treatment.

The interpersonal and Freudian traditions: convergences and divergences

The traditional Freudian and interpersonal schools of psychoanalysis diverged during the psychoanalytic wars in New York in the 1940s. Each has developed from a different set of assumptions concerning the mind, especially the role of structure and the role of interaction. Recent developments in both schools in the last twenty years suggest a convergence and overlap in theory and technique. The relevant history of the divergence is examined and the work of three contemporary interpersonal writers explored in depth. That work is contrasted with contemporary developments in traditional Freudian psychoanalysis.

The wish to regress in patient and analyst

The analyst's wish to regress is used as a paradigm of the "forbidden" topic of what analysts want from their analysands. The aim is to expand the subjective domain of analysts' awareness so that they can analyze better by grasping more of their temptations with patients before enactment can occur. Clinical examples illustrate how the author temporarily joined patients in wish-fulfilling mutual regression. Analytic process is disrupted when the analyst wishes to relinquish the more differentiated role of the containing and interpreting analyst in favor of more childlike relatedness both with the patient and with the analyst's internal objects. The author, expecting a more typical counter-transference, had not anticipated that he might temporarily join these nonpsychotic patients in mutual regression. It is suggested that in the face of analytic impasse analysts should consider whether they might temporarily have joined the patient in mutually regressive wishes that have taken them away from more responsible analytic functioning.