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When the patient reports atrocities. Specific treatment considerations of the Vietnam veteran.
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Narcissism and the readiness for psychotherapy termination.
The readiness for termination of psychotherapy is considered from the perspective of the importance of the narcissistic features. After a guiding theoretical orientation, several case vignettes are presented that illustrate outstanding changes in the patient's self seen during the terminal phase of psychotherapy. These include the re-experiencing of narcissistic injury, a differert response to interpretation, and a substantial alteration in the reaction to disappointment.
Intensive psychotherapy of a borderline patient.
A detailed case report of the long-term intensive psychotherapy of a borderline patient illustrates my approach to such patients. It also raises questions about the value of interpretations in the early phases of therapy of such patients, regardless of which conflicting theories are chosen as the basis of these interpretations. Stress is placed on the value of empathic attunement to the patient, staying with the patient through the many vicissitudes of long-term treatment, and the developmental use the patient made of a long treatment, reliving certain phases of development in the transference. Acquisition of internalized controls may need to occur in this way before the patient is ready to utilize interpretations. Also illustrated are the difficulties in convincing insurance companies and other third parties to support long-term psychotherapy and the effects of such intensive interaction over the years on the psychotherapist.
Elements of change and cure in psychoanalysis.
Many elements are involved in the process of change and cure in psychoanalysis, some of which are seen as facilitative and others as definitive. I attempted to establish and illustrate the role of the interpersonal interactions between analysand and analyst. As a result of the traditional analytic process, the patient relives at a regressive level some of the unresolved developmental conflicts and crises in the relationship with the analyst. Thus, he has an opportunity to find, through the current experience, a more satisfactory and appropriate developmental resolution of previous psychopathology.
Intensive individual psychotherapy of schizophrenia. A review of techniques.
I reviewed the substantial psychiatric literature on the technical strategies of intensive individual psychotherapy of schizophrenia. Numerous issues were covered: the nature of intensive psychotherapy and the nature of schizophrenia from the psychotherapist's point of view, elements of the treatment situation, general technical attitudes, general technical interventions (establishing a relationship, elucidating, tolerating, integrating, and working through), special technical interventions with specific symptoms and resistances, and a final brief discussion of mutative mechanisms.
Impasses in the psychoanalytic relationship.
In this article, I outline a psychoanalytic perspective on therapeutic impasses based on more recent developments in psychoanalytic therapy and on Winnicott's (1971) work in particular. This perspective suggests that many impasses result from clients' inability to participate in their own experience in a subjectively meaningful and affectively vital way. I argue that, in such cases, the therapeutic task becomes one of helping clients relate to events in a more personal and affectively engaged fashion through a type of therapeutic play in which the boundary between what is real and unreal becomes temporarily ambiguous.
Abusive help-- helping abuse: the psychodynamic impact of severe personality disorder on caring institutions.
Personality-disordered patients have invariably suffered abuse at the hands of carers when young, and they tend to repeat an abusive relationship when they encounter care in later life. The provision of care in psychiatric, forensic, penal and other institutions may degenerate into a form of unconscious abuse perpetrated against those in care. This is almost always unrecognized and the experience of carers is often to mismanage their own frustrated inability to understand what is happening to them, their charges and the institution.
On the question of self-disclosure by the analyst: error or advance in technique?
The question of self-disclosure by the analyst and its uses in treatment is an issue widely debated today. In this paper, the author reviews this controversial technique from historical and contemporary points of view, delineates several forms of self-disclosure, and, by means of several clinical examples, discusses the effects on the patient and the analytic process of utilizing one or another kind of self-disclosure in these particular situations.
Enactments: an intersubjective perspective.
We offer a critique and synthesis of classical and interpersonal views of enactment. From an intersubjective standpoint, the study of enactment leads to a reconsideration of the nature of the psychoanalytic process. And enactment becomes virtually synonymous with the psychoanalytic process. Enactments are interactions of analysand and analyst with communicative and resistive meanings that lead to valuable insight and can constitute corrective emotional experiences. Enactments that are recognized and defined become valuable dramatizing moments that have condensing, clarifying, and intensifying effects upon consciousness. The inevitable participation by the analyst in enactment is compatible with appropriate analytic discipline. A case will demonstrate these points.
What the analyst does not hear.
In the clinical situation, the analyst fails to hear more than he or she hears and spends much time working in the dark. The author raises questions about how we can take cognizance of that state of affairs in our thinking about analytic work. A clinical example illustrates how, in an analytic atmosphere, a patient will correct an analyst's failure to hear. Some ideas are offered about how to maximize the patient's participation in that effort. The author suggests that the problem may not fall precisely under the heading of technique so much as reflecting the analyst's attitude.
Intersubjectivity and interaction in the analytic relationship: a mainstream view.
The authors conceptualize intersubjectivity as a meta-theory that reflects the inherent nature of human relatedness and is conceptually independent of any particular theory of mind or school of psychoanalysis. Their view of intersubjectivity joins the emotional life of the analyst to that of the patient and places the analytic relationship at the center of the analytic process. They contrast intersubjectivity with traditional classical conflict theory so as to clarify the relevance of intersubjectivity for psychoanalytic clinical theory and therapeutic practice. In so doing, they hope to direct analysts more firmly toward the study of the unconscious dyadic contributions to the affective, inactive, and interactive dimensions of the analytic situation and their impact upon the patient's actions within and experience of the analytic relationship. To illustrate their thesis, two hours from an analysis are presented in detail.
From schisms through synthesis to informed oscillation: an attempt at integrating some diverse aspects of psychoanalytic technique.
There exists a conceptual bifurcation at the core of psycho-analysis. It has been viewed from differing vantage points and portrayed as subsuming various dichotomies (oedipal-preoedipal, conflict-deficit, one person-two person, classic-romantic, and so on). While each such conceptual pair has its own heuristic accompaniments, these dichotomies share a profoundly important element. They have divergent effects upon the analyst's mode of listening and the nature of his or her interventions. These and other related technical implications are the topic of this paper. With the help of three clinical vignettes and by coalescing the isolated voices of many distinguished theoreticians, the author attempts to elucidate and heal this split. This paper proposes three levels of increasingly sophisticated resolution of the technical divergence resulting from this schism. The paper recommends an informed oscillation between the two polarities of psychoanalytic technique, an oscillation that must remain in consonance with the patient's shifting ego organization. The paper concludes by highlighting the developmental bases for the proposed technical conceptualizations.
On analytic listening.
Multiple dimensions of the listening process as implemented in the analytic process are discussed. Listening is not the same as hearing; it is done with the mind rather than just the ears. Listening seeks meaning, specifically the meaning in the mind of the patient. The meaning of words is often obscure, ambiguous, and uncertain, and their deeper implications can only be approached over time through uncovering associative linkages. Listening takes place in multiple perspectives--subjective/objective, active/passive, dynamic/genetic, etc. Listening is also contextually related to dimensions of the analytic relation, including transference, alliance, and real relation. Modalities of listening related to each are explored for both analyst and analysand, and aspects of listening empathically and listening to silence are discussed.
Subjective reality, objective reality, modes of relatedness, and therapeutic action.
This paper describes a dialectic believed to be at the heart of therapeutic interaction within a relational model. The dialectic consists of the interrelationship of two modes: the dyadic and the triadic. In the dyadic mode, the analyst responds with aspects of his or her self that singularly reflect the patient's subjectivity. This mode of attunement is uniquely suited to bringing the patient's experience into a place where it can then be seen and known. In the triadic mode, realities are recognized that are important to, but still outside of, the subjectivity of the patient. The analyst invites the patient to see him- or herself not only from inside his or her own space, but also from a point outside, through the perspective of others. The analyst is charged with asymmetric but not exclusive responsibility for negotiating and sustaining a fluid and flexible relationship between these modes. Optimally, this occurs through spontaneous and authentic engagement informed by intuition, empathy, and clinical judgment. However, when this dialectic loses its robust and kinetic quality (as frequently occurs in approaches ranging from the classical to the postmodern), an impermeable dyad is formed by extruding potentially triangulating aspects of reality (and subjectivity). This can result in curiosity and the openness of uncertainty being replaced by closed-mindedness and proclamation.
Reflections on the goals of psychoanalysis, the psychoanalytic process, and the process of change.
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No search or getting down to business?
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The treatment of affects: an interdisciplinary issue.
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