The Spectrum of Psychoanalytic Techniques


CHAPTER 6




The Spectrum of Psychoanalytic Techniques


 


 


In Chapter 4 of this book, “The Basic Components of Psychoanalytic Technique and Derivative Psychoanalytic Psychotherapies,” I defined four basic aspects of psychoanalytic technique as the fundament for both standard psychoanalysis and derived psychoanalytic psychotherapies. These four basic components of psychoanalytic technique were interpretation, transference analysis, technical neutrality, and countertransference utilization.


I shall attempt to define and describe a full complement of psychoanalytic techniques that may be considered specific applications of the combined use of these four basic components of technique. The definitions that follow should facilitate the empirical assessment of their respective use in particular treatments, thus constituting a basic manualization of psychoanalytic modalities of treatment, geared both to clinical utilization and research endeavors. These descriptions are addressed to readers with practical experience in carrying out psychoanalytic psychotherapies as well as standard psychoanalysis. Thus, it is hoped that it is sufficiently clear without having to be illustrated by clinical vignettes. The risk is that these definitions may at first appear to be too schematized or abstract. However, the effort of a comprehensive enumeration of psychoanalytic techniques, including their mutual relationships, should facilitate the clarification of each of them. In each case, I shall attempt to define these techniques in their use as part of standard psychoanalytic treatment and then refer to their potential modifications in derived psychoanalytic psychotherapies.


Given the unfortunate fact that we do not have a universally recognized and agreed-upon dictionary of all psychoanalytic techniques or an integrated text of psychoanalytic technique that would be recognized by the different psychoanalytic schools, I have attempted to provide basic definitions that reflect common contemporary views of the respective concept by different psychoanalytic approaches, while spelling out significant differences in their conceptualization and utilization by alternative psychoanalytic models if such differentiations apply. Leading contemporary psychoanalytic dictionaries have provided the background for these definitions (Akhtar 2009; Auchincloss and Samberg 2012; de Mijolla 2002; Etchegoyen 1986; Hinshelwood 1991; Laplanche and Pontalis 1988; Mertens 2014; Skelton et al. 2006; Spillius et al. 2011).


Psychoanalytic technique is based on the availability of a psychotherapeutic relationship that involves work, including a particular attitude, on the part of both analyst and patient. On the part of the analyst, analytic listening involving “evenly suspended attention,” and an implicit simultaneity of alertness to the content of the patient’s free associations, verbal and nonverbal behavior, external reality, countertransference activation, and the implicit use of a particular theoretical view that is expressed in the intuitive application of knowledge and experience. On the part of the patient, the expectation or hope is that the patient will be able and willing to carry out free association and in the process express both emerging thoughts and emotional experiences activated in his or her mind, along with impediments, distortions, and difficulties emerging in the effort to free associate.


During this working situation, the analyst’s focus (i.e., paying attention to what is affectively dominant in their interaction) will lead to specific areas that call for the application of features of psychoanalytic technique. These developments include the emergence of dominant defenses that frequently will present as transference resistances, repetitive characterological defenses that will lead to character analysis, the exploration of dreams, repetition compulsion, and a spectrum of transformations of emotional experiences into somatization or acting out. Acting out, in turn, will have to be differentiated from emotional enactment in the session, and the analytic work involved in an interpretive approach will lead to transformation or insight, resolution of repetition compulsion, or what we know as working through. Complications such as negative therapeutic reaction, treatment disruptions, and termination may require additional technical interventions. This list of the particular areas that will stimulate the focus of an interpretive approach also suggests the specific applications of the four basic components of general psychoanalytic technique, as we shall now examine in detail.


It should be emphasized that affective dominance emerges as the most important feature orienting the clinician to the simultaneous activation of the many aspects of the analyst–patient interaction. Affective dominance is referred to by different terms within different theoretical orientations but appears again and again as the point of departure of the analyst’s orienting attention to the material of the session. What is affectively dominant may be derived from the patient’s verbal or nonverbal communication, in one’s countertransference, in a particular aspect of the analytic field, or in a blocking or an intrusive or bizarre perception, but it is where emotion seems to be concentrated at the moment.


Character Analysis


Character analysis refers to the exploration of the patient’s dynamic organization as exhibited by his or her habitual behavior patterns, idiosyncratic reactive or inhibitory traits, and chaotic or fragmented repertoire of character traits. This approach practically coincides with the analysis of the patient’s dominant defensive mechanisms and his or her mutual reinforcements (Kernberg 1993). In patients with neurotic personality organization, the “classic” cases for psychoanalytic treatment, defense mechanisms tend to emerge as blockings or distortions of free association. In fact, this is how the ego’s mechanisms of defense were discovered and described. The analysis of defensive operations, their manifestations, their motivation, and the unconscious impulses against which they are directed may appear as specific contents of the analytic situation.


Defense analysis coincides with what used to be called resistance analysis—that is, the analysis of clinical manifestations of defense operations. Psychoanalytic technique has evolved to consider “resistances” not as forces to be overcome, but as defensive operations to be understood for their unconscious meanings, motivations, and functions (Busch 1996). Such exploration constitutes a central aspect of interpretive interventions. From the perspective of contemporary object relations theory, these defensive operations may be translated into unconscious, defensively activated object relations (dyadic self and object representations) in the transference, which are directed against opposite, and unconscious, impulsively dominated dyadic units of self and other representations. These defensive and impulsive object relations jointly represent the activation of the presently dominant unconscious conflict (Kernberg 2004).



In the case of severe personality disorders in which identity diffusion and predominance of primitive defensive operations center around splitting rather than repression, these defensive operations may become so dominant that they practically characterize patients’ habitual behavior patterns and, in their overall mutual combinations, coincide with a primitive, severe character pathology. The analysis of these primitive defensive operations, particularly of paranoid-schizoid and depressive defenses, becomes part of the analysis of the patient’s defensive character structure, and what may be called “character defenses” rapidly show as transference resistances. In the case of patients with neurotic personality organization, the fact that the prevalent constellation of higher levels of defensive operations also serves general defensive character patterns usually emerges only more gradually in the treatment. However, in the long run, the systematic analysis of ego defenses also comes to coincide with a systematic analysis of predominant characterological defenses.


The main point of this brief review is to stress that as a practical matter, defense analysis will become concentrated in the analysis of characterological defenses and thus the analysis of the patient’s pathological character structure. This raises the question of when and how such predominant characterological patterns need to be explored. A contemporary consensus indicates that the analysis of the patient’s habitual behavior as it acquires defensive functions in the treatment situation is indicated whenever it becomes affectively dominant. In some patients with severe character pathology, this may appear in the first session so that the treatment will start with analysis of a patient’s characterological structure. In fact, this frequently is the case with severe narcissistic character pathology. In less severe cases involving a circumscribed pathology with specific symptoms relating to oedipal or preoedipal conflicts, these conflicts may dominate the transference situation without being reflected in a dominant character pathology. However, whenever defensive character traits are affectively dominant in the treatment situation, there is an indication for an interpretive approach.


The essential technique of character analysis has been well articulated by Wilhelm Reich (1933). However, given the idiosyncratic complications of Reich’s personality and professional behavior, the term character analysis fell into some disrepute, and his early contributions have not been fully acknowledged. In contemporary psychoanalytic technique, the approach to character analysis may be summarized briefly as follows: 1) draw the patient’s attention to a particular, predominant behavior that becomes central in one or several sessions; 2) raise the patient’s interest in that particular behavior and ask him or her to associate regarding the implications of that behavior; 3) interpret the immediate transferential implications of the activation of that particular behavior; and 4) gradually interpret the defended-against, feared and/or desired relation under the impact of the respective aggressive or libidinal impulse that is being defended against.


Systematic analysis of the transference typically, and dominantly, involves character analysis. Its effect, under optimal circumstances, should bring about significant changes in the patient’s experiences and/or behavior in his or her external life as well as in the analytic situation. In the case of patients with severe character pathology and identity diffusion, the predominance of primitive defenses centered on splitting mechanisms translates into severe dissociation between idealized and persecutory transference developments, and their analysis fosters characterological integration, progressing from a predominance of paranoid-schizoid to depressive transferences in advanced stages of the treatment.


Transference-focused psychotherapy (TFP), indicated for patients with borderline personality organization and the corresponding severe, primitive constellations of personality disorders, involves carrying out characterological analysis in the context of a severe potential for acting out of primitive defensive operations and corresponding object relationships in the sessions and in the patient’s external life. It requires particular attention to the maintenance of the therapeutic frame, with temporary abandonment of technical neutrality, and the development of specific techniques to both limit acting out and restore technical neutrality (Yeomans et al. 2015). In these cases, the therapist’s stress on immediate and external reality as a starting point of an interpretive approach is the counterpart to the limitations of free association as an ongoing work commitment on the part of the patient.


Characterological defenses may include defensive operations that not only reflect ego efforts to maintain characterological “armament” but also may reflect superego defenses and the enactment of profound guilt feelings, as well as the entire characterological structure of obsessive-compulsive, hysterical, masochistic, and narcissistic pathology.


In the application of TFP with neurotic personality organization, character analysis may be limited to a particular segment of the patient’s habitual behavior and linked to the specific area of conflicts regarding which the patient entered into treatment. Here transference analysis is limited to the specific transference reflections of the dominant unconscious conflicts related to the patient’s symptomatology in addition to the ever-relevant indication to analyze manifest negative transference in order to preserve a “workable therapeutic relationship.”



This may be the point to refer to the problematic concept of the therapeutic alliance. This term refers to the alliance of the nonconflictual, “normal” part of the patient’s ego with the work-related aspects of the psychoanalyst’s interventions. There exists, undoubtedly, such a potential for collaborative work in patients with a well-integrated neurotic personality organization, signaling the patient’s capacity to collaborate in the analytic work and to maintain a certain objectivity at points of activation of significant negative transference developments. That potential, which reflects in a deeper sense the availability of a secure positive transference disposition, should not, however, be artificially stimulated by the therapist’s seductive behavior as that would counteract the nature of analytic work. In supportive psychotherapy, the effort to appeal to and strengthen the patient’s wishes to be helped and his or her capacity for trusting the therapist may be part of the supportive repertoire, but it is not an aspect of psychoanalytic technique proper. In the case of severe personality disorders, the therapeutic alliance may be absent for extended periods of the treatment, and the patient’s capacity to collaborate in the treatment situation depends on the systematic analysis and working through of the predominately negative transference.


Dream Analysis


Although dream analysis is no longer considered the exclusive “royal road to the unconscious,” it continues to be an important source of information about unconscious processes and represents a focus of interpretation. Dream analysis also has acquired additional importance in the present time as renewed attention to the consistent psychic activity of daydreaming has gained attention under the heading of “waking dreaming” in Bion’s formulation (Civitarese 2014; Ferro 2009). The neo-Bionian approach tends to treat free associations as equivalent to the manifest content of dreams—that is, it attempts to transform even patients’ talking about aspects of their daily reality as if those aspects represented symbols of unconscious psychological processing. This development has led to a renewed emphasis on the value of dream analysis.


In its classical technical approach, dream analysis deals with the manifest content of dreams as surface material to be divided into meaningful partial segments, inviting the patient to associate to these segments of the dream with the expectation that latent content of each of these segments of the manifest dream would emerge. The interpretive integration of the latent meanings of the manifest segments, explored by means of the patient’s free association and the analyst’s corresponding “reverie,” then would lead to the deeper unconscious meanings of the dream.


This general approach to the technique of dream analysis assumes that the manifest content of dreams is the product of unconscious elaboration, by means of “dream work,” of the original, primarily wishful feeling fantasy expressed in dreams. The elaboration of unconscious dream thoughts involves exploring them as reflecting primary process thinking: logic that ignores the principle of contradiction, collapses time and space, tends to represent ideas visually, and uses condensation and displacement as the dream thoughts are undergoing secondary elaboration by the dream censorship, usually leading to a more rational or representational manifest dream narrative. Dream analysis, therefore, involves deconstructing the manifest content while considering all these distorting elaborations and considers the impact of day residue previous to the dream that may have stimulated unconscious infantile wishes. At the same time, it expresses these wishes in the context of the dominant transference situation. Contemporary stress on the stylistic and communicative aspects of dream narratives and Fairbairn’s (1952) proposals that self and object representations may emerge in split forms and through multiple characters of the dream content add further complexity as well as informative value to dream analysis. Dream contents and other characteristics of dreams may point to specific meanings, such as in anxiety dreams reflecting the incapacity to control threatening unconscious impulses fully, examination dreams, dreams that provide gratification of immediate physiological needs frustrated in reality, and so on.


Important questions involve when and how dreams should be interpreted, to what extent they always or at times reflect an affectively dominant issue, to what extent dream analysis needs to be integrated in the analysis of the presently predominant transference, and so on. Chronically repetitive dreams very often deal with various aspects of an essential conflict of the patient and deserve particular attention, because their modifications in the course of treatment may reflect the transference modifications and elaboration of the corresponding conflict. In general, dreams should be interpreted when they seem affectively dominant in the sessions rather than systematically explored whenever they emerge. Dreams have a seductive quality, and their narrative may serve defensive purposes. Very confused dreams may, in fact, be closer to the possibility of their analytic understanding because they reflect a reduced secondary elaboration, whereas some very clear dreams with ordinarily unconscious content erroneously may convey the impression that repressions have been lifted. Undoubtedly, there also are good dreams, in which a significant conflict is being elaborated in an emotionally meaningful way, profoundly influencing the wake life of the dreamer.


Dream analysis depends on the patient’s capacity to carry out free association and optimally is carried out in the context of standard psychoanalysis. In psychoanalytic psychotherapies, dream analysis also requires the patient’s capacity for free association. In TFP with individuals with severe personality disorders, dreams in the early stages of the treatment tend to be explored in terms of their manifest content, linking the meanings of the manifest content to the presently predominant transference. In the middle stages of TFP treatment, partial analysis of the latent content of dreams may be attempted, and in advanced stages, full-fledged dream analysis may be carried out (Yeomans et al. 2015). Dream analysis is usually contraindicated in supportive psychotherapy, except in the utilization of manifest content in terms of the elaboration of the conscious conflict that is explored at that point.


It is rarely possible to elaborate and analyze fully a complex dream within one session. Sometimes the analysis might stretch over several sessions, because other issues may become affectively dominant during that time. Some patients use dream narratives to escape from a realistic examination of their lives. Narcissistic patients may eagerly “interpret” their own dreams in terms of their assumed knowledge and understanding of the meaning of particular contents, and the effect of such self-analysis in the countertransference reaction of the analyst is usually one of empty speculation.


An essential attitude of the patient that may indicate his or her capacity to participate in the analysis of dreams is an authentic curiosity about the unknown that may emerge in the patient’s mind, in clear contrast to his or her competitive intellectualizing attitudes regarding dream analysis, or transference-related devaluation of dream contents.


Acting Out, Enactment, Repetition Compulsion, Working Through


ACTING OUT


In a strict sense, acting out refers to the behavioral expression of an unconscious conflict bypassing an emotional awareness of a conflict. A general tendency to expand the meaning of the concept to “bad” behavior does injustice to the technical implications of this concept, which requires transformation of the behavior into an emotional awareness of the corresponding conflict against which the patient is defending (Sandler et al. 1973).



Acting out may occur outside the sessions as well as in the session itself. Sometimes it takes unusual, subtle forms such as distortions in free association that lead to the use of language as action, which are intended to influence the analyst rather than to communicate emotional experience. Accretion, a super-condensation of meanings expressed in a brief, almost casual comment that tends to deny the emotional implications of the subject matter that has been evolving gradually in the patient’s mind, is one such form of “mini-acting out.” It may come to the analysts’ awareness only by a sudden disruption of his or her understanding or a sudden loss of attention to what is going on in the session.


In severe personality disorders, such transformation of language into action, geared to control the therapeutic situation and directed against the possibility of cognitive communication with the therapist, may become a prevalent way of expressing transference developments, and the interpretation of this form of acting out practically coincides with systematic working through of transference resistances. In healthier patients with neurotic personality organization, acting out usually emerges more gradually, outside the analytic sessions, and reveals its affective dominance in the sessions by the analyst’s careful attention to the “total transference” (Joseph 1985)—that is, the analyst’s alertness to the expression of the dominant transference disposition in the session and simultaneously in the patient’s external reality. Whereas attention to the transference in the patient’s total emotional experience may alert the analyst to the subtler aspects of acting out, the obvious nature of persistent forms of emotionally charged behavior or acute crises in the patient’s life situation usually becomes quite evident as an affectively dominant content of the sessions. Such material takes the highest priority for interpretive interventions.


There are, however, severe cases in which the nature of splitting operations is so effective that subtle but chronic forms of acting out, seriously affecting the patient’s life in the long run, may remain undetected for a dangerously long time unless the therapist remains specifically alert to that potential in individual cases. Careful exploration of the patient’s total life situation at the beginning of the treatment, and the alertness to his or her potential for the activation of severe, self-destructive acting out, may provide an important preventive therapeutic function (Kernberg 2016).


Long-standing experience has taught us that acting out is always intrinsically linked to the transference, even when it is expressed in behavior patterns that predate the treatment. The analyst’s alertness to this new and now dominant function of “a long history” of acting out becomes an important requirement in the treatment of severe personality disorders.



Standard psychoanalytic technique does not require any technical modifications to deal with severe acting out potential and relies upon the systematic analysis of the unconscious meaning of acting out in the context of transference analysis from a position of technical neutrality. The activation of specific countertransference reactions to acting out—with the important implication of the patient’s effort to unconsciously recreate a primitive object relationship or a particular defense against such a threatening object relationship—may provide important clues to the psychoanalytic understanding of the meanings expressed in this acting-out development. It may be utilized as part of the interpretive working through of acting out, its transformation into emotional experience to be explored during the sessions. In general, André Green’s (1993) recommendation to systematically pay attention to acting out and to somatization as two major channels of defensive avoidance of emotional awareness of unconscious conflicts in the sessions becomes relevant. He recommends consistent work on transformation of acting out and somatization into emotional experience that enriches the available expression of the dominant transference and permits its exploration and working through.


In the case of borderline personality organization with indication for TFP, the prevalence of acting out that threatens the treatment or well-being of the patient requires certain steps before treatment can begin. First, a careful assessment of the total present life situation of the patient will expose potential activities such as suicidal behavior, severe violence, and antisocial behavior. Once potential threats have been identified, based on the patient’s history, a discussion is indicated to agree on how these behaviors and impulses will be managed so that the treatment may proceed with a minimum of disruption. A “contract” will be negotiated (verbally) as to limits and responsibility for safety that the patient accepts. Lastly, the transference implications of the patient’s reactions to the contract setting and restrictions of dangerous behavior must be interpreted from the beginning of treatment. The therapist should be prepared to explicitly grant the patient a second chance after breaking a contractual commitment, and such occurrence should be used to interpret the meaning of the patient’s behavior as representing a destructive part of him or her that is perhaps triumphing over the therapist and risking continuation in the treatment (Yeomans et al. 2015).


Severe acting out may require the abandonment of technical neutrality, but in our experience the combination of limit setting and systematic interpretation of the necessity for such limits, the transference implication of the therapist’s being pulled out of role, and the extent to which this situation reflects deeper transference dispositions constitutes an important technical modification of TFP that has permitted the expansion of this psychoanalytic psychotherapy to a broad segment of severe personality disorders.


Direct control of severe acting out in supportive psychotherapy requires the use of supportive techniques, such as the provision of information and advice giving and the use of external support, to facilitate and reinforce adaptive, protective behavior patterns that counteract the temptation and risk for the corresponding acting-out behavior (Rockland 1989). The exploration of the gratification derived from acting out and of the price paid for it, together with the suggestion of alternative ways to compensate for the loss of this gratification, constitutes important aspects of a supportive psychotherapeutic technique that is an alternative to the possibility of an analytic approach.


ENACTMENT


Enactment is a relatively recent enrichment of psychoanalytic technique highlighting that the activation of a certain transference disposition in the session and of its correspondent countertransference disposition in the analyst contributes to the development of a temporal modification of the analytic relationship under the effect of that specific transference/countertransference bind (Chused 1991). It is the “emotional enactment” of the unconscious conflict in the transference situation that powerfully influences the analyst’s countertransference, often reinforced by what Joseph Sandler called the “role responsiveness” of the analyst, who may be particularly responsive to a particular transference activation (Sandler et al. 1973). For relational school analysts, it provides evidence for their important theoretical assumption that transference not only reflects the unconscious dispositions of the patient but also serves, in part, as a response to the countertransference dispositions of the analyst (Mitchell and Aron 1999).


In more general terms, the implication is that the countertransference influences the transference so that transference and countertransference constitute an interactional dyad that, naturally, is predominantly determined by the patient’s transference. It leads, however, to a new experience of the patient determined not only by the analyst’s interpretive attitude in the context of technical neutrality, but by the analyst’s response to the transference, with his or her personality dispositions, and thus contributes potentially to a new therapeutic life experience in the context of transference development.


Within the Kleinian approach, enactment is conceptualized as the consequence of the activation of projective identification—an important primitive mechanism that tends to induce specific reactions in the analyst, which is unconsciously intended by the patient—that reflects the activation of a specific primitive object relationship of the patient (Spillius et al. 2011). Realistic features that the patient observes in the analyst’s behavior facilitate the focus and the rationalization of projective identification, and the intensity of the corresponding countertransference reaction permits the analyst to experience by concordant or complementary identification in the countertransference the total transference activated in the psychoanalytic situation.


Enactment differs from acting out in that it is a very direct, intense expression of the dominant transference development, in contrast to the primarily defensive function against transference awareness in the case of acting out. Enactment in the analytic situation allows and facilitates transference interpretation and is practically a privileged aspect of systematic transference analysis, with the contribution of the self-analytic function of the analyst exploring his or her countertransference disposition at that point. Betty Joseph (1992) stressed the importance of the analyst’s internal musing as to what the patient might be trying to achieve with his or her particular way of attempting to influence the analyst. Enactments allow a sharp focus on this issue.


For relational analysts, enactments may reflect a dissociated self state that needs to be integrated interpretively with the patient’s dominant self experience. As mentioned previously, this interpretive process, influenced by the analyst’s unconscious contribution to the transference/countertransference bind, contributes to a new object relation as an important therapeutic aspect of psychoanalytic treatment.


REPETITION COMPULSION


Repetition compulsion refers to the unconscious tendency to repeat past conflictual, particularly traumatic, painful experiences regardless of the pleasure principle, but it is also an effort to obtain general satisfaction of particular libidinal or aggressive needs. The compulsive nature of these behaviors is evident in their unremitting persistence despite analytic elaboration (Freud 1920/1955). It used to be described as a defense of the id, rather than a superego or ego defense. In fact, in the light of contemporary psychoanalytic experience, repetition compulsion appears to be linked more typically with significant activation of internal object relationships and the effort to repeat and overcome the unconscious conflicts linked to them.


In the case of severe traumatic experiences, repetition compulsion may involve an unconscious effort to gradually work through traumatic situations, and, in effect, a patient’s working through of these repetitive experiences in the transference gradually may lead to their resolution. Very often, however, there are other important meanings expressed in repetition compulsion that must be considered in the correspondent interpretive approach. A frequent dynamic involves the unconscious reactivation of the relationship with a persecutory object of the past that is projected onto the therapist with the secret hope of turning a bad object into a good one despite one’s consistent effort to destroy or undermine the present transferential relationship. Some sadomasochistic transferences evince such repetition compulsion as reactivation of past experienced traumatization or repeated sadistic assault and may reflect a combination of the projection onto the analyst of the sadistic object and, at the same time, an unconscious identification with that object in an effort to reverse the past relationship and transform the other into the victim. The unconscious envy of the analyst’s not being controlled by such internal hostile forces as the patient is experiencing may be an important related dynamic, particularly in patients with narcissistic personality disorders.


The technical approach to repetition compulsion in standard psychoanalytic treatment is the ongoing reexamination of the behavior, exploring it as a pathological character pattern that reflects an internal pathological object relationship in terms of its different functions under different circumstances and within different moments of transference activation. Under optimal circumstances, such working through permits the resolution of repetition compulsion in consonance with the resolution of pathological character defenses expressed as transference resistances.


In the treatment of severely regressed patients with borderline personality organization by means of TFP, in some cases the impossibility of resolving repetition compulsion with the interpretive approach described may require the exploration of secondary gain possibly obtained by means of the repetition compulsion. Under such circumstances, limit setting to reduce the secondary gain may be indicated, followed by the analysis of the transference implications that necessitated the analyst to deviate from technical neutrality.


In supportive psychotherapeutic technique, the endless repetition of pathological behavior patterns requires a combination of informative and supportive induction of alternative or compensating behavior with adaptive function that reduces the pressure for carrying out the pathological repetitive behavior. A worst-case scenario is provided by patients in whom the repetition compulsion involving severe self-destructive, self-harming, and potentially life-threatening behavior expresses a narcissistic fantasy of being beyond the fear of pain or death, and in whom suicide may reflect an ultimate expression of the patient’s omnipotence. Such developments may correspond to the most severe type of negative therapeutic reaction referred to later in this chapter.


WORKING THROUGH


Working through is an essential therapeutic process that implies joint work of analyst and patient on the activation and resolution of unconscious conflicts, particularly in the elaboration of intense transference resistances derived from the activation of pathological character patterns in the treatment situation. Working through acquires particular importance under conditions of repetition compulsion. Working through, under optimal conditions, also relates to the general work of mourning and refers to the elaboration of the depressive position, the patient’s gradual capacity to resolve the dominance of primitive defensive operations centering around splitting and projective identification. It includes the development of the patient’s capacity for self-observation and insight, conflict tolerance and elaboration of disillusionment about self and others, the gradual desensitization regarding potentially traumatic experiences and memories, and the assumption of autonomous growth. Working through implies, above all, the development of the capacity for insight—that is, the combination of cognitive and emotional understanding of unconscious conflict, concern over the effects of that conflict on the patient’s life and the lives of others, the tolerance of guilt feelings and the strengthening of a sense of personal responsibility, and the wish to overcome the respective limitation to one’s optimal functioning. Working through involves, in essence, a gradual resolution of transference regression as well as the regressive features of the patient’s relationship to self and others in the present and in the reconstruction of his or her past.


Negative Therapeutic Reaction


Negative therapeutic reaction refers to the paradoxical reactions of patients in psychoanalysis and psychoanalytic psychotherapy expressed by worsening of the symptomatology or destructive transference regressions after becoming aware of the helpfulness of the analyst. Patients get worse after clearly having experienced something good coming their way. It typically involves any one of three potential developments in the psychoanalytic situation. First, it may be the expression of unconscious guilt; second, it may be the expression of unconscious envy of the analyst; and third, it may represent an unconscious identification within a primitive sadomasochistic relationship (see Chapter 9 of this book, “An Overview of the Treatment of Severe Narcissistic Pathology”).


The first case, negative therapeutic reaction as an expression of unconscious guilt, frequently can be observed in cases of depressive-masochistic personality as an expression of profound guilt over being helped by the analyst. The patient harbors the unconscious conviction that he or she does not deserve to be helped or that to be helped implies an implicit injustice carried out regarding a third person, or regarding others who would be more deserving of such help. Unconsciously, the patient may fear that the analyst is not aware of the depth of the patient’s unworthiness or the severity of the patient’s unacknowledged aggression. The unconscious fear of the loss of the dependence on the analyst if the patient were to improve sometimes may be involved. Unconscious guilt over the good relationship with the analyst experienced as a forbidden oedipal triumph is another dynamic one may observe in this development.


The second possibility, negative therapeutic reaction from unconscious envy of the analyst, is a typical development in the psychoanalytic treatment of narcissistic pathology. Here, negative therapeutic reaction expresses the need to deny any dependency on the analyst and an effort to avoid the experienced inferiorization and humiliation perceived as part of the analyst’s “triumphant” capability to help the patient. In a deep sense, the patient’s unconscious envious reaction also expresses the intolerable experience of acknowledging the creativity of the analyst, who has been able to continue helping the patient despite the patient’s resistances and negativity. This dynamic unconscious envy is by far the most frequent form of negative therapeutic reaction and replicates narcissistic patients’ difficulties to learn from others as a major cause of their difficulty in learning and progression in work and studies.


The third type of negative therapeutic reaction is relatively rare. It is experienced by patients who have had a chronic, severely sadomasochistic relationship with a parental object and chronically traumatized patients who have developed the conviction that the only way in which a needed object expresses his or her interest in them is by sadistic attacks or mistreatment. The analyst’s interest in the patient cannot be trusted unless it is motivated by rage or resentment. The conviction that only somebody who hates the patient is really interested in him or her tends to evolve hand in hand with severe self-destructiveness as well as a tendency to attack the analyst or therapist with chronic dangerous acting out. These usually are patients for whom psychoanalytic treatment proper is contraindicated but who may respond to TFP if strict control and limitation of self-destructive behavior, and at times careful supervision of the patient’s life outside the sessions, become part of the conditions under which psychotherapy is undertaken. Here, the need to establish strict parameters around the treatment and abandonment of technical neutrality required by the need to protect the continuation of the treatment and the patient’s life may color the essential nature of the transference. Consistent interpretation of the patient’s needs to have the analyst control his or her life as a condition for survival, as well as a confirmation of the patient’s fantasy of the therapist’s sadism, needs to be carried out again and again as varying circumstances reactivate this transference in ever new forms.


The technical approach to negative therapeutic reaction consists in the interpretation of the respective underlying dynamic and, in the most severe type of negative therapeutic reaction, in the establishment of conditions and control that protect the stability of the treatment. Negative therapeutic reaction out of unconscious guilt is the easiest to detect and resolve analytically. Negative therapeutic reaction reflecting unconscious envy usually requires long-term working through and, in the analyst’s countertransference, the tolerance of negative countertransference reactions within which the analyst may experience a sense of revengeful superiority over the patient who envies the life and capability of his or her therapist.


Somatization


Somatization is a broad spectrum of manifestations of physical symptoms related to psychological conflicts. It is important to differentiate the organic manifestations of illnesses that may present a psychological component as part of their etiology, the so-called psychosomatic disorders, from the direct physical manifestations of psychological conflict that emerge in the psychoanalytic situation under conditions of the activation of these conflicts. These latter physical manifestations of psychological conflicts, which may be properly called somatization in the narrower context of transformation of psychological conflict into somatic expression, include 1) the physical manifestations of anxiety and depression; 2) the symbolic expression of psychic conflict in the form of physical symptoms—that is, the broad spectrum of conversion reactions; and 3) the generalized hyperalertness and concern over physical illness in the syndrome of hypochondriasis. I am referring to hypochondriasis as a stable psychiatric syndrome, in contrast to the occasional hypochondriacal manifestations that are part of what are clearly manifestations of anxiety.


These physical manifestations of anxiety and depression, conversion symptoms, and hypochondriacal concern need to be interpreted in the context of the affectively dominant material that is the interpretive focus in the sessions. They need to be interpreted as part of the defensive and impulsive manifestations of the internalized object relations activated in the transference and are of particular importance in combination with the focus on acting out as combined efforts to avoid the emotional awareness of psychological conflict in the session. Physical symptoms as manifestation of anxiety and depression are most easily identified as part of the patient’s total emotional reaction. Conversion symptoms tend to become prominent in the activation of the corresponding conflicts in the transference and, of course, have more complex relations to the unconscious conflict dominant at any particular time.


Chronic hypochondriasis constitutes a relatively rare but extremely difficult and prognostically reserved form of severe personality disorder, usually within the spectrum of borderline personality organization. Hypochondriacal symptoms typically represent the projection of paranoid defenses against aggression onto the interior of the body. These “internal enemies” protect the patient against imaginary external ones. An unstable equilibrium is achieved by fear of illness and magical procedures to control it. Medical professionals who attempt to assure the patient become allies of the internal enemies. The analytic interpretation of hypochondriacal symptoms typically transforms hypochondriacal pathology into severe paranoid transferences, at times to the level of psychotic regression in the transference. In fact, if an interpretive approach to hypochondriasis is attempted, the analyst or therapist needs to be aware of the extent to which the patient will be able to tolerate an analytic approach without a psychotic regression, which quite frequently may require a shift in the treatment approach to a supportive psychotherapeutic modality.


The Psychoanalytic Field


The “psychoanalytic field” is a relatively new addition to the repertoire of technical psychoanalytic concepts. It stems from the original contribution of Baranger and Baranger (1969) about “bastions,” unconsciously conflictual areas that by unconscious mutual collusion of patient and analyst are excluded from analytic exploration in the sessions. This contribution signaled the importance of exploring the intersubjective processes in the treatment situation occurring in parallel and split off from other transference elements, an interest that also was fostered by Winnicott (1971), who pointed to the symbolic importance of the “frame” of the psychoanalytic situation. He stressed the importance of the stability of the analytic setting and its symbolic function in reproducing, particularly in severely regressed patients, the earliest “space” involved in the intersubjective relation between mother and infant. Ogden (1986, 1989), in turn, generalized the concept of the intersubjective space as an “analytic third” and described the intersubjective field, constructed by projective contributions of patient and analyst, asymmetrically insofar as projective identifications stemming from the patient by far predominate over those introduced to the field by the analyst. Ogden suggested a technical approach to this intersubjective field by utilizing the analyst’s reverie, his or her fantasies involving the emotional experiences of this field, to gain access to the co-constructed “third subject” of analysis. The analysis of the intersubjective field was further expanded in relational psychoanalysis by the analyst’s focusing on the importance of the contribution of the analyst’s personality and countertransference to transference developments, so that a two-way street of transference/countertransference dominates the intersubjective space to be explored.


Neo-Bionian analysts, particularly Ferro (2009) and Civitarese (2014), have further developed the concept and analytic utilization of the psychoanalytic field, assigning major importance to the intersubjective creation of a constantly varying field of emotional experience that the analyst should attempt to capture by his or her alertness to the ongoing development in the analyst of “awake life dreaming” reflecting the transference/countertransference situation. The analyst’s reverie or daydreaming becomes an important source of information determining the interpretive process. As mentioned before, the complementary consideration of the patient’s free association as also representing a form of awake life dreaming to be understood as reflecting deeper unconscious thoughts contributes to an atmosphere of mutually induced narratives by patient and analyst that signals the potential for direct, mutual unconscious communication. The analyst’s evocative, nonsaturated interpretive comments would foster this process. It seems fair to say that this theoretical and technical approach may be a significant departure from standard psychoanalytic approach to interpretation and transference analysis, separating from what I have called the psychoanalytic mainstream, including contemporary Kleinian analysis. In any case, as we have seen, both the relational approach and the neo-Bionians have underlined the importance of this analytic approach to the intersubjective field.



It remains an open question to what extent the analyst may or should rely on his or her reverie regarding the intersubjective field in which the analyst’s relation with the patient is operating. Under certain conditions in which free association seems to be leading nowhere, or when it is not clear what the dominant transference relationship is, and there is a sense of disorientation dominating the analyst’s countertransference, attention to the nature of reverie evolving as a “distracted” aspect of the analyst’s reaction to the total situation may provide important information. At the same time, an excessive focus on his or her own reverie on the part of the analyst may distort his or her perception of what is affectively dominant and actively bring both the personality and the theoretical leanings of the analyst into the foreground.


In short, from a technical viewpoint, considering the activation of the intersubjective field as a temporary influence on the analyst’s countertransference as a source of new information may represent an addition to the diagnosis of the presently dominant, workable transference/countertransference bind. At worst, it may lead to the neglect of direct analysis of transference developments and of the activation of character patterns in the transference that reflect important problems in the patient’s interpersonal life outside the sessions.


In TFP of severe personality disorders, chronic distortion of the therapeutic situation by rigid characterological patterns of the patient that constitute a veritable barrier to the establishment of a meaningful active interpersonal contact may bring about a situation of unreality and strangeness in the therapeutic relation that dominates the clinical situation. This situation may rapidly seduce the analyst into a defensive adaptation to that severe, chronic, ego-syntonic distortion of the relationship established by the patient. Here, the attention to the nature of the intersubjective field may be of particular interest, conveying an explanation in terms of object relations reflected in this situation that facilitates the analytic exploration of this severe, pervasive characterological defense. Sometimes the simple reminder to the analyst to question how a “normal” relation with a patient would be in similarly early stages of a psychotherapeutic treatment may bring into sharp focus the specific nature of the distortion of the relationship to be explored through analysis of the intersubjective field.


Termination


The psychoanalytic technical approach to termination deals with two main issues: the first issue is the criteria for the termination of the psychoanalysis, involving resolution of the pathology that brought the patient to treatment, normalization of the patient’s personality functioning in all major areas of his or her life, and the assumption of autonomous growth and development. It has been abundantly documented in the literature that such an ideal goal often may not be achieved, and there are varying degrees to which the patient may obtain a significant improvement of his or her personality structure and functioning (Firestein 1974).


The second issue regarding termination is the process of termination itself. It has particular characteristics that must be evaluated and interpretively approached. Termination activates processes of mourning, the respective conflictual aspects regarding mourning derived from the general dynamic of the evolution of paranoid-schizoid defenses into depressive mechanisms, and the tolerance and elaboration of depressive defenses and related sublimatory functioning. Here, Melanie Klein (1950) has provided essential technical criteria in her proposal that, under conditions of the combined and alternating emergence of paranoid and depressive defenses connected with the analytic process following setting a date for termination, it is important to first analyze in-depth paranoid mechanisms and only later the corresponding or related depressive mechanisms. Premature focus on depressive mechanisms may drive paranoid defenses reactivated in the transference underground, whereas full elaboration of paranoid mechanisms and related unconscious conflicts linked to them permits a full-fledged emergence of the processes of the depressive position.


Ideally, the patient’s capacity for analytic work should be reflected in a self-analytic function after the end of the analysis. The general criteria of symptomatic improvement, characterological change, and satisfactory functioning in love and sex, work and profession, social life, and creativity should become evident in concrete aspects of individual functioning. The tolerance of normal mourning processes; aggressive, sexual, and dependent impulses; anxiety; and conflicts around those impulses should go hand in hand with realistic self-affirmation, predominance of sublimatory mechanisms, affect maturation, and, of course, fully satisfactory object relations in depth.


The technical approach to mourning processes first involves their diagnosis. Psychotic intolerance of mourning—with loss of reality testing and emerging psychotic symptomatology—represents the pathological extreme of a spectrum of mourning reaction that includes, at the most severe but nonpsychotic end of the spectrum, the narcissistic incapacity for mourning reflected in the self-protective devaluation of object relations that must be abandoned, including the analytic one. We see this in narcissistic patients who report having no affective reaction to the ending of the treatment. Patients with borderline pathology (but with no narcissistic pathology) and unresolved mourning processes typically present predominantly paranoid reactions with severe separation anxiety, reflecting the unconscious experience of separation and loss of the analyst by projection, as an attack. They evince paranoid fears regarding the attitude of the analyst toward them.


Under the condition of healthier neurotic personality organization, mourning regarding termination may be present but excessive, with a development of idealization, clinging, and a sense of loss of an ideally needed object combined with feelings of unworthiness. When the patient reaches the capacity for more normal mourning, a more realistic mournful remembering of all the positive experiences of the treatment may be activated under the presence of impending separation and constitute the material that needs to be worked through. Mourning reactions at the end of analysis have already been analyzed preventively in patient’s separation reaction to weekends, vacations, or illness during the treatment. The patient’s affective reaction to separations such as depression, anxiety, or rage needs to be explored during the treatment in terms of the specific object relations activated in them. A patient’s tolerance of normal ambivalence in intimate relations, also experienced in the relation to the analyst, is a good indicator of his or her capacity for working through of the depressive mechanisms of the mourning reaction. The analyst’s corresponding countertransference reactions also indicate the extent to which paranoid-schizoid mechanisms have been shifting into depressive ones.


By setting a date for the end of the analysis within a prudent time period, the reactions of the patients may be observed, and a full-fledged analytic approach to the corresponding mourning processes achieved, in preference to a questionable “tapering off,” or gradual reduction of the sessions of the treatment. The patient’s mourning process will not end with the end of the treatment, and he or she must be prepared that under optimal circumstances a process of 6–12 months may be needed for full completion of the mourning over a successfully terminated analysis.


In psychoanalytic psychotherapy, because of the severity of the reactions to traumatic losses and separation and the severity of the incapacity to tolerate ambivalent feelings toward intensely hated parental objects, who quite often objectively may have presented important sadistic features, pathological mourning is frequently present. Narcissistic rage or paranoid reactions are more intense and frequent than those found with patients presenting neurotic personality organization, and these reactions practically become part of the ordinary treatment situation from the very beginning of the treatment. Paradoxically, then, the working through of the mourning reaction related to termination may offer lesser problems with severely ill inpatients. Traditionally, it used to be thought that very ill patients have greater difficulty to end the treatment than healthier ones, but for the reasons just mentioned—the importance of exploring separation reactions during the treatment, and the treatment of narcissistic pathology—we have found that this is not the case. In clinical practice in which severely ill patients are treated with psychoanalytic psychotherapy by therapists who see them as part of their training experience and as part of rotations and then transfer them to other therapists, the analysis of mourning reactions becomes much more important as part of these periods of transition, and the frequent neglect of such reactions is a major cause that determines these patients to stop treatment.


It is of great interest that contractually time-limited, brief psychoanalytic psychotherapies may permit the specific analysis of mourning reactions to termination as part of the overall approach in such a brief psychotherapy. In fact, there is clinical evidence for the effectiveness of such an approach, which constitutes an important application of present-day knowledge of the technique of dealing with mourning processes applied to termination in such brief therapeutic endeavors.


Conclusion


A broad spectrum of psychoanalytic techniques may be used in the conduct of psychoanalytically informed psychotherapies. There is a clear differentiation of the modification of some of these technical instruments required in the case of psychoanalytic psychotherapy, and an overall conceptual integration of the technical approach in psychoanalytic as well as in supportive psychotherapy based on psychoanalytic principles is needed. The basic components of psychoanalytic technique of interpretation, transference analysis, technical neutrality, and countertransference utilization have an important role in all psychoanalytic modalities of treatment, but they imply a precise awareness of the required modifications, particularly as far as depth of interpretation, degree of technical neutrality, and restrictions of transference analysis are concerned. The potentially contradictory effects of the use of psychoanalytic and supportive techniques are an additional important aspect of these applications of psychoanalytic technique to a broad spectrum of psychoanalytic psychotherapies. A supportive psychotherapy based on psychoanalytic principles may be more effective than a chaotic combination of techniques on an ad hoc basis, which is more prone to significant overrun by countertransference developments and problems in the setting up of indispensable protections for the therapeutic frame.


It is hoped that a clear and comprehensive definition of the instruments that characterize standard psychoanalysis and the modifications employed in psychoanalytic psychotherapies will contribute significantly to the empirical evaluation of the efficacy of the entire field of psychoanalytically based treatments and the possibility of its practical application to a broad spectrum of psychopathology. This chapter is a tentative, modest effort to move in the direction of these objectives.


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Mar 29, 2020 | Posted by in PSYCHIATRY | Comments Off on The Spectrum of Psychoanalytic Techniques
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