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The Analyst's Equilibrium, Countertransferential Management
Four months after beginning my analytic training, I stumbled into my supervisor's office for our weekly appointment. Collapsing into his leather chair, I began to shake. I had just come from being with (or, in retrospect, I should say, struggling to be with) Sarah, a 31-year-old chronic schizophrenic, a tragic, tormented, hopeless, and bizarre woman. At the end of the session, after rambling in her characteristic style for 45-minutes about the injustices she suffered at the hands of doormen, the butcher, conductors on the subway, and mailmen, she looked toward me for the first time in our two months together, and said that she had a dream last night. With no apparent affect (also characteristic for her) she continued, "There was an enormous all-encompassing penis. And then, it loudly and violently exploded." Profoundly distressed, but saved by my watch, I informed Sarah that our time was up. My first analytic supervisor, after hearing Sarah's dream, (I'm sure aware of my discomfort) suggested an interpretation. He said that the patient was clearly telling me that she needed to borrow my power. While later in my training, I became aware that the supervisor's interpretation reflected only a partial understanding of Sarah's dream, (and the least intense piece, overlooking the dream representation of primitive rage and sexuality, fragmentation, confusion of self and object, of core gender identity, and her profound paranoid anxiety) I did stop shaking, went on to discuss the pre-dream content of the session, and most significant and miraculous, was able to face my patient two days later with an attitude of benevolent involvement. What happened in that long-ago supervisory session that allowed me to regain my psychic equilibrium with this patient? Is there any lesson imbedded in this experience that informs the treatment of other patients with fewer globally-significant disturbances? This article is an attempt to address these questions. The Challenges to the Analyst's Psychic Equilibrium Lawrence Friedman (1988) states that there are two facts that emerge from his experience with psychotherapists and the literature they write and read, "Therapists function in a sea of trouble, and they talk as if they don't." (p. 5) Friedman goes on to describe the identifying truth about our clinical work as, "an uncivil, threatening, even brutal struggle initiated by gently reflective intellectuals dedicated to delicate speculation." (p. 5) In a similar vein, many psychoanalytic theorists argue that the analyst enters the analysand's life as a familiar bad object (for example, Bollas, 1987; Fromm-Reichmann, 1960; Ogden, 1989, 1991; McDougall, 1989, 1991; Racker, 1968; Searles, 1986; Volkan & Searles, 1981). Stephen Mitchell (1988) expresses this point of view most clearly and dramatically when he writes, "The analyst discovers himself as a co-actor in a passionate drama involving love and hate, sexuality and murder, intrusion and abandonment, victims and executioners." (p. 295) It is interesting to attend to what Merton Gill (1982) points out, that Freud's metaphor, of the "playground of the transference" would have captured more of the German connotation if the phrase were translated, instead, as "wrestling arena." (pp. 29-30) Although the overwhelming bulk of the clinical literature is as Friedman describes, generally misleading as to the turmoil sometimes confronted and experienced in the analytic dyad--fostering a delusion on the part of those in analytic training that, once they become experienced, the "sea of trouble" will be transformed into a calm harbor--there does exist some articulate exceptions (for example, Bollas, 1987; Little, 1980; Searles, 1966, 1979, 1986; Spotnitz, 1985; Spotnitz & Meadow, 1976). These tend to be texts concerning specific psychopathology that explore the related countertransference. Some examples: Both Kernberg (1975) and Giovacchini (1975) state that the more disturbed the patient, the more stressful the experience of analysis is for the analyst. According to Kernberg (1975), primitive rage directed toward the patient, the temporary loss of the analyst's ego boundaries and the analyst's need to exert omnipotent control over the patient are each characteristic of this countertransference. (See especially pp. 60-63.) Giovacchini (1975) states that it is the patient's defenses and how these compromise the analyst's role, that make the treatment of patients with ego defects, "arduous, if not impossible." (p. 453) With the borderline patient, common toxic countertransferences involve (a) masochistic submission to the patient's aggression and exaggerated doubts relating to the analyst's competence (Kernberg, 1975, pp. 61 and 71); (b) a sense of failing the patient as a soothing self-object causing the analyst to feel as hopeless, helpless, desperate and angry as the patient (Adler, 1984, p. 125); and (c) a chronic state of confused helplessness--the patient and analyst both feeling that the analyst's interventions are neither hurtful nor wrong, but just irrelevant (Giovacchini, 1979, pp. 194-198). For Winnicott (1960), the treatment of the psychotic and borderline patient is "irksome," mostly because the patient demands primitive merger and breaks through the analyst's professional attitude. Hatred is a common analyst response (Winnicott, 1947). Kernberg (1975) writes that the narcissistic patient, who only barely "tolerates the analyst in a satellite existence," also engenders intense reactions--feelings within the analyst of worthlessness, irrelevance and defeat. (pp. 310-312) In addition, in most analyses, with neurotic, psychotic or character-disordered patients, the analyst, during certain phases of the work, has to tolerate what seems like interminable periods of intractable hopelessness within the patient, clinical ambiguity within him or herself, chronic distortions and constrictions by the patient of the analyst's real motives and characteristics, and the guilt that he or she did not already cure the patient. According to Szasz (1963), it is the intensity of the analyst's feelings, stimulated by the analytic situation, that causes him or her to offer transference interpretations that often serve a defensive function--protecting the analyst from the full impact of the patient's personality, and thereby, keeping the patient at "arm's length." Skolnick (1998), citing Freud, Fairbairn and Goldberg, argues that the couch can be used in this way as well. Given the extraordinary challenges that treatment sometimes poses for the analyst, what techniques do we have access to that will help us regain our psychic balance? How do we effectively comfort ourselves in the face of the discomfort sometimes-intensively experienced in the treatment situation? The classical answer to these questions, derived from a one-person intrapsychic resistance model of the countertransference, involves diagnosis and overcoming of the undesired emotional reaction by either self-analysis or additional treatment. (See especially Freud, 1910; Reich, 1951.) The post-classical answer involves the immersion into the transference-countertransference matrix. Regaining one's psychic balance requires the analyst's commitment to exploring both aspects of this matrix, so that it could be "stretched" to accommodate new experiences. (For a detailed description of this point of view, see especially Mitchell, 1988, 1990.) Each of these two approaches has merit. In this paper, a third complementary approach is developed. When the analyst is feeling threatened, uncomfortable and off-balance, in order to regain the psychic equilibrium required for our work, we use theory. The formulations we construct to explain the patient to ourselves, and the interpretations we offer to our patients that flow from these concepts are both over-determined, invariably serving multiple functions and meanings, some defensive, and some adaptive. An important function of clinical theory, actually the most important adaptive function of clinical theorizing, especially during one of these periods of strain, is to offer the analyst comfort. Our psychodynamic theorizing, and the interventions that are its results, therefore, may not, in the main, serve the function of capturing the essence of the patient, but rather is in the primary service of "managing the countertransference." It is this countertransferential management, operating on a mostly preconscious level of awareness, that allows us to re-establish psychic balance in the face of the myriad challenges confronted. Two clinical examples follow: The Motive for the Analysis of the Transference Resistance: Otto Kernberg Kernberg (1975) writes, "A patient with narcissistic character structure spent hour after hour over many months of treatment telling me how monotonous and boring analysis had become ... that treatment was definitely a hopeless enterprise." He stated that his life outside of analysis was quite good, although he did not understand this. "I pointed out to him that implicit in his description of his psychoanalysis was a description of me as a provider of useless and silly treatment." The patient denied this. Kernberg then further interpreted the patient's devaluation as a defense against his intense repressed envy. Then, the patient "became aware that he really thought it was entirely my fault that his analysis was, according to him, a failure. He now felt surprised that he was so satisfied to continue his treatment while considering me so insufficient. I pointed out to him how much satisfaction it gave him for me to be a failure while he was a success in his life ... as if I had become the worthless self of him, while he had taken over the admired self of me." (p. 244) What are the multiple functions of Kernberg's understanding of this patient implied in his interventions? Do the dynamic conceptualizations of the patient and interpretations he offers serve the primary function of capturing the essence of the patient? Or, could it be that the primary function of Kernberg's analysis and interpretations of this patient help the analyst establish boundaries? Could they provide for the analyst a context for comprehending the patient's chronic perception of the analysis and the analyst as a failure? Could they help the analyst shift from feeling irrelevant, worthless and controlled, to potently central in the patient's experience? Could it be that the interpretive direction that Kernberg chooses in this passage serves the primary function of offering the analyst comfort in the face of the strain that this patient's personality and pathology exert on the analyst? The Motive for Understanding Sadism as Vulnerability: Heinz Kohut Kohut (1977) writes (describing one of his supervisee's patients), "Mr. M., who worked as a writer in what he described as a dependable, but limiting job, sought analysis when he was in his early thirties, when his wife of six years left him. Ostensibly, he wanted to undertake analysis in order to find out how he might have contributed to the failure of his marriage ... His apathy and lack of initiative made him feel only 'half alive,' and he attempted to overcome this sense of inner emptiness with the aid of emotionally highly charged fantasies, in particular, sexual fantasies having a strong sadistic cast. These fantasies of sadistic control over women (of tying them up) he also occasionally acted out. He had done this with his wife, who condemned his behavior 'sick.' (In theoretical terms, these fantasies and enactments were attempts to cover a primary defect with the aid of defensive structures.) ... The genetic matrix of the primary defect--stunted development of the grandiose-exhibitionistic aspects of the self--was insufficient mirroring from the side of the mother." (pp. 6-7) What are the multiple functions of this analyst's understanding of the patient? Do the dynamic conceptualizations of the patient and interpretations offered serve the primary function of capturing the essence of the patient? Or, could it be that the primary function of Kohut's analysis and interpretations of this patient help the analyst establish an emotionally-necessary sense of safety. I would assume that the analyst (Kohut's supervisee) also experienced her patient's sadism unfolding in the analytic relationship, as it did in the failed marriage--the patient's need to control his analyst, to humiliate her, to force himself on this new unwilling victim. Could it be that the understanding/translation of the patient's sadism into terms that remind us and the analyst that this adult patient is a needy and vulnerable child (with deep emotional wounds resulting from faulty mirroring) is a way by which this analyst can maintain psychic equilibrium in the face of the extraordinary Countertransferential challenges? Could it be that the primary function of the interpretive direction that Kohut implies in this passage offers the analyst comfort in the face of the strain that this patient's personality and pathology exert on the analyst? The Conclusion: The Multiple Functions of Interpretation Classical analysts, on the whole, position the interpretation in the center of the technique of treatment, and as the major factor involved in the therapeutic action of psychoanalysis (Arlow and Brenner, 1964; Greenson, 1967). For a classical analyst, the interpretation alters the balance of the psychic forces of the patient, releasing the patient from ties to instinctual fixations and undoing repression. Freud wrote in 1933, "Our ultimate dynamic aim is the strengthening of the ego through the addition of instinctual energy, which has hitherto belonged to the unconscious. There can be no doubt that interpretation is our main pump in the draining of the therapeutic Zeider Zee." (p. 106) Within this theory ofinterpretation, the analytic relationship is important, but primarily as a means to an end. It is via the relationship through the working alliance that interpretations can be registered by the patient, and via the relationship through the transference that deeper insight, more complete interpretations, can be achieved. Winnicott (as quoted in Giovacchini, 1975, p. XI), in contrast to this one-person view, said that he offered interpretations to prove to his patients that he was still alive, and that he could make mistakes. In his humor, Winnicott captured the essence of a different way of looking at the association between interpretation and the analytic dyad. Most proponents of object relations theories and self psychology do not view the relationship primarily as a means to an end. On the contrary, it is the interpretation that is the means to an end--the end (or therapeutic goal) described by various metaphors, as the patient's experience, within the analytic relationship, of being held (Winnicott, 1963), of empathic attunement and mirroring (Kohut, 1984), of a new relational experience (Fosshage, 1990; 1998), of ingesting good milk (Klein, 1957), of a transformational experience (Bollas, 1987), of what kind of relatedness is possible (Mitchell, 1988), of being contained (Bion, 1962), or of symbiotic merger (Mahler, 1967). In these models, it is not the interpretation that is, for the most part, in the center of the therapeutic action of treatment, but what the interpretation, and other clinical interventions, allow the patient to experience within the relationship with the analyst. What I am suggesting is that the interpretation serves a third useful therapeutic purpose, not only fostering changes in the psychic economy of the patient, or offering the patient a new experience of profound understanding, but, in addition, and most importantly, as a steadying device that the analyst uses in order to regain psychic equilibrium in the face of the challenges experienced through the countertransference. Therefore, the analyst's theoretical formulations, and the interpretations that are their most palpable results, regardless of whether these comprehensively capture the phenomenological experience or unconscious motivations of the patient, do serve to protect the relational experience of the analysand, but indirectly, by allowing the analyst to stay emotionally with his or her patient, even when (and perhaps, especially) the transference-countertransference becomes a tumultuous, confused, and treacherous "sea of trouble." I return now to answer the question of how psychoanalysis works. I believe the essence of the therapeutic action of psychoanalysis, the core of how therapy actually works, the irreplaceable ingredient that constitutes the necessary and sufficient condition for human growth within the therapeutic dyad, can be simply stated; but achieved by the analyst only with great emotional and intellectual hardship. Most simply put, The theory holds the analyst, so that the analyst can hold the patient. And, for the most part, the rest is commentary. References
Other sample published articles by Dr. Shulman:
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