It may seem obvious that what we do as analysts has a lot to do with who we are as people as well as what we do as interpreters of our patients' subjective experience. Yet when it comes to the teaching of analytic technique, our literature has not offered much guidance on how to use our unique personalities as “analytic instruments,” despite our appreciation that the analyst is, unavoidably, a direct participant in the construction of the analytic experience. This evolution of perspective on the nature of what we do would seem to call for a revisiting of our ideas about what constitutes analytic technique and how to teach it. The following paper is a beginning effort.
Any discussion of psychoanalytic technique needs to give its due to Freud's original efforts to set down on paper what he actually did with patients. The 5 papers he devoted to this topic (Freud, 1912, 1913, 1914, 1915) were the accumulated wisdom of years of clinical experience with a method that was largely the product of his own creative genius. Yet Freud's own forceful personality probably played as large a role as his genius in all of the endeavors that put psychoanalysis on the map, including his clinical work. He was bold. His own boldness in developing “the analytic situation” allowed him to have the experiences that informed his theorizing about the nature of the mind. And in reciprocal manner, setting the stage for future psychoanalytic generations, his theory informed his technique. Thus, his recommendation that analysis was best done with an attitude of abstinence derived from “Topographic concepts” that he had thus far found most useful in organizing the data that he had obtained clinically. This recommendation suggested that the analyst's personality was something to be, for the most part, suppressed—as if this were possible for a man like Freud, let alone the rest of us.
Freud realized that the technical procedures he endorsed were particularly suited to his own personality, and he said as much (Freud, 1912, p. 111), calling them “recommendations.” Perhaps his recognition of his own forcefulness inclined him toward an emphasis on restraint in accordance with the theory he had developed at that point in his career, a theory in which he clearly had a great personal investment. At the same time, what Freud actually DID with his patients seems to have been a reflection of a personality that was anything but restrained. As Lipton (1977) and others have pointed out, Freud seemed to take for granted that the analytic procedure would be superimposed on a REAL RELATIONSHIP in which the analyst's personality found ample room for expression. This relationship, with all of it's suggestive elements, resided somewhere outside the realm of technique until it was placed center stage by Franz Alexander and Thomas French, with their controversial concept of “The Corrective Emotional Experience.”
The essence of the CEE was the recommendation analysts depart from analytic abstinence and use their own personality characteristics in a manner that might be particularly suited to the needs of each particular patient. (This orientation, if not explicitly stated, had been implied by their analytic predecessors Ferenczi and Rank as early as 1925.) Alexander based this recommendation on his interpretation of classical “structural” psychoanalytic theory, which rooted psychopathology in maladaptive defense mechanisms that had been, at least in part, an ineffective response to a pathogenic emotional environment.
Alexander's work evoked a strong negative reaction among his peers, locally and nationally. He is commonly caricatured as encouraging analysts to present themselves in a fraudulent way by playing a role that was not authentic to them. But looking back on his work, it appears that he was trying to open things up by allowing analysts to use those aspects of their personalities that were authentic, as opposed to hiding them behind the artificial posture of detachment. As summarized by Bacal (1990) Alexander buttressed his thesis by drawing attention to the fact that the usual analytic attitude of objective detachment “is itself an adopted and studied attitude and not a spontaneous reaction to the patient” (p. 94). He made it quite clear that he was not advocating that the
analyst attempt to hide the true nature of his personality from the patient or to play the role of a significant figure of his past in a better way. He was, rather, recommending that the analyst deliberately plan to modify his attitudes according to his understanding of the patient's original conflict situation, in order both to reactivate the patient's early attitudes and to create an interpersonal atmosphere that will provide the patient with emotional experiences in his relationship with the therapist that would “correct,” or alter, reaction patterns that are currently maladaptive (see Alexander & French, , p. 76 and Alexander, , pp. 101–102).
In addition to the accusation of inauthenticity was the criticism that Alexander was advocating an overtly suggestive technique and calling it “psychoanalysis,” a brand that defined itself by it's distance from suggestion and it's proximity to more objective “truth” residing inside the patient and independent of the analyst, whose function was not to influence, but to interpret.
Kurt Eissler was particularly influential in establishing an equivalence between analytic technique and interpretation, making the case—based on his own interpretation of theory—that the analyst's personality and the patient's particular life circumstances were extraneous factors that, while meriting consideration, were not, fundamentally, relevant to what was psychoanalytic in psychoanalytic technique.
As we know, the pendulum has swung far in the other direction. Preceded by Winnicott's work on “the facilitating environment” and Balint's attempts to direct our attention to developmental needs instead of unconscious wishes, Kohut's self psychology led to a new emphasis on the analyst's responsiveness as central to the technique of analyzing. An increasing comfort with discussing countertransference has led to greater clarity in recognizing that the analyst's responses were not always (or seldom) consciously constructed. In other words, as a analyst, no matter how much you try to “sit out”, you can't help but play or expend energy trying to convince yourself and, possibly, your patient, that you are not a player.
While this pendulum swing, like it's countermovement, is rationalized on epistemologic and theoretical considerations (a reaction to positivism, post-modern perspectival thinking, intersubjective theory), the fact remains that it has proved impossible to keep the analyst's personality out of the room. Our multiplicity of contemporary psychoanalytic “theories” appear to find common ground in the space they provide for the emergence of the analyst's personality. Perhaps the very fact of our theoretical pluralism provides a kind of testimony to the irrepressible way in which our personalities find expression in the theories we create to solve the dilemma of what to do with our personalities.
Of particular note is the ascendancy of the interpersonal theory of “Enactments” within the psychoanalytic mainstream (Boston Change Group Panel Report, JAPA 2013) (and, lagging far behind, the eventual incorporation of the WAW Institute into the American Psychoanalytic Association). The idea that patient and analyst are inevitably destined to react to one another according to the dictates of their unconscious, and that useful meaning can be derived from this interplay has come along with a greater readiness to play on the part of the analyst, whose non-interpretive (and often non-verbal!) responses are now well within the scope of technique.
To the extent that analytic technique is a function of the totality of the analyst's responses, a conversation about analytic technique should include a discussion about the analyst's use of his own personality, and his relationship and attitude toward his own responses—conscious and otherwise.
I think that efforts in this direction can be facilitated by the recognition that there are, in fact, two modalities of technique, each necessary but not sufficient to support a psychoanalytic treatment. One is the hermeneutic modality, the modality of interpretation. The other—whether we call it suggestion, provision, parameter, optimal responsiveness, or a corrective emotional experience—has to do with the use of the analyst's unique personality. In the dialectic unfolding of these two aspects of psychoanalytic intervention over our history, they have often appeared as antithetical, while in fact the one is inseparable from the other.
The pursuit of meanings can become a meaningless intellectual exercise if not accompanied by a compelling experience (as Ferenzci, Rank, and Alexander suggested). The pursuit of “connection” can lead away from the reflective distance needed to raise the question “what does this all mean?”
Thus, we may think of necessary and sufficient conditions for analysis. Neither the search for meaning or the striving for relationship is sufficient for generating a fruitful psychoanalytic situation, and the two are both essential ingredients of psychoanalytic technique.
Our discussion of technique is particularly relevant to the field of psychoanalytic education. The “Eitington” educational model which we follow in the United States involves 3 elements—the analyst's analysis, supervision and didactic. Analysis and supervision provide the experiential basis for learning that carry the most weight in the analytic educational process. But in addition to such experience, as stewards of analytic education we should strive to provide our students with a cohesive and contemporary set of principles appropriate to the experience of the analyst who is sitting, listening, thinking, and, at a conscious level, making decisions about what to say.
It seems to me that the best organizing principles here are to think of technique in terms of the cultivation of ATTITUDES. Freud himself suggested this in discussing the “attitude of interest” that was useful in attaching the patient to the analyst—a small throwaway sentence of huge importance (Freud, 1913, p. 139). Years later, Roy Schafer (1983) used this organizing principle to encompass a spectrum of relational and interpretive functions. Schafer was prescient in anticipating the continued shifting sands that would require a new way of thinking about how to keep one's bearings—back in the 1980's, at a time when postmodern sensibilities were starting to take hold.
Schafer recommended that the analyst SUBORDINATE his/her personality in the service of the analytic task—recognizing that it could not be eliminated. He elaborated on this by introducing the idea of the analysts “second self,” characterized by attitude of neutrality, empathy, affirmation and the privileging of interpretation. (Schafer saw this as the
counterpart to a “second self” that the analysand brings to the consulting room. The analyst's second self is the analyst at his best, in contrast to the analysand's, which is often the patient at his worst.)
But, as I am asserting here, despite our best efforts at “subordination,” the analyst's “working ego” or second self is inseparable from those elements of the analyst's personality that inevitably accompany the analyst from one side of the consulting room door to the other. One impact of relational thinking and the general acceptance of “enactments” as a legitimate locus for therapeutic action is that over the last several years we analysts have allowed ourselves to become increasingly entangled in the therapeutic process, and that much more free to be ourselves, in ways that reflect our uniqueness as well as the “analytic ideal” that we strive to achieve. This puts our own knowledge of who were are and how we effect others right up front as something we need to consider. Thus, some additional recommendations may be in order.
The first recommendation goes like this:
1 Be open to learn about yourself from your patients.
In addition to one's own analysis, we can learn a tremendous amount about ourselves from our significant others—those patients who allow us to get to know them over time. They get to know us as well, if we let them. While as analysts we are trained to look at the transference aspects of our patient's communications to us, they provide us with even more information about the non-transference aspects of how we impact on them. (Irwin Hoffman, following Merton Gill, has been pivotal in raising the curtain on this aspect of our work.)
This information is important because it can guide us in discerning what we do that is helpful and what we do that is not as we strive to use the best of who we are to relate (one essential element of technique) in a manner that will permit us to interpret (the other essential element). But our ability to usefully access and employ this information is limited by the degree to which the perceptions of our patients pose a threat to our psychological equilibrium.
The recognition that we might be as visible to our patients as they are to us can be unnerving. Patients are, inevitably, a source of our self esteem
to the extent that they provide us the privilege of allowing us to be their analysts. But the opposite is also true: Patients can hurt our feelings. When they tell us something about ourselves that we might not want to know, it can be just as painful as when we tell patients something about themselves that they would rather not know. This is a threat that can't be eliminated simply by putting them on a couch so they can't see us, or by attributing all that they see to the perceptual distortions of transference.
Freud engaged this difficulty by recommending that the analyst needs an analysis. Our educational tradition has wisely incorporated the personal analysis as the way in which we as analysts can learn as much as we can about ourselves so that we can be effective instruments for our patients. But Freud could not be as specific as we can be in actually characterizing what we need to learn. We have learned, through years of clinical and introspective experience, that self esteem and relatedness are essential dimensions of human psychological experience, and that as analysts we need to manage our need for both in order to be open to the relational needs of our patients and allow for true engagement with them.
Thus, the attitude of “Openness” is predicated on our own self maintenance, and our ability to recognize and satisfy our own relational needs. This expands the domain of technique beyond the confines of the analytic hour, and into the zone where we are who we really are. This is important for us to talk and think about if we are to rise to the challenge implicit in thinking about the role of our unique personalities in analytic technique.
2 Remember The Transference
Back in the early days of analysis, Sterba wrote a seminal paper emphasizing
“…one of the most important processes in analytic therapy, namely, the effecting of a dissociation within the ego by interpretation of the patient's instinctually conditioned conduct and his defensive reaction to it. Perhaps I may say…that the therapeutic dissociation of the ego in analysis is merely an extension, into new fields, of that self-contemplation which from all time has been regarded as the most essential trait of man in distinction to other living beings.” (Sterba, (1934, p. 125.).
While Sterba was speaking in the language of ego psychology, the attitude he was advocating transcends the terms particular to the structural theory, and is key to helping patients develop a perspective on their own subjective world through an appreciation of it's transference dimension. With all of our current emphasis on what is new and transformative in the analytic experience, it is easy to forget what is old.
Regardless of one's theoretical persuasion, analysis has something to do with the past as it lives in the present, and the benefits to be derived from distinguishing the two. It is the analyst's job to keep track of the transferential relevance of the emotional field at any particular moment, and to help the patient become aware of it through interpretation.
It may seem as if this is such a fundamental point that it goes without saying. But as psychoanalysis has evolved to it's present state, the transference implications of the analytic dialogue often recede into the background, especially with patients who present histories of early trauma that inclines us toward an attitude of “deficit repair.” Following Ferenczi, we seem to have learned overall that such patients can be further traumatized by a strictly interpretive approach. That has been a central tenet of this paper. But at the same time, an awareness of the transference dimension is essential in psychoanalytic work, whether we interpret the transference or not. Transference, resistance and the influence of the Unconscious on mental life are what make psychoanalytic work psychoanalytic.
In order to keep the transference in mind, we need to be reflective as well as open, to be able to step backward as well as forward. The ability to shift perspectives—to let ourselves go and to reel ourselves back—is a fundamental and hard won skill that is at the core of analytic technique.
3 Be Bold in Entering Enactments
In his “Technique” papers, Freud described a posture that enabled him to do battle with his patient's transference desires as they collided with the “basic rule” of free association that he had assigned to the those who consciously had solicited his help. As we have come to see, there is nowhere the analyst can sit to avoid being swept up by the pressures of the patient's unconscious and his own, and visa versa. Hence, the focus on what we now call “enactments.”
Varga (2010) and others have helped us understand the usefulness of viewing enactments as a form of “free association,” a co-constructed relational text that offers us a point of entry into the unconscious life of our patients just as they bring us an inevitable encounter with our own unconscious life.
This expanded vision of the analytic field lends itself to another recommendation: as enactments are inevitable and invisibility is not an option, let yourself get swept away by them by simply being yourself.
I am not advocating a disregard for boundaries or a license to engage in a contemporary version of “wild analysis.” What I am advocating is a relaxation of inhibitions that interfere with the authenticity fundamental to establishing good human relationships. This can be as frightening for analysts as it is for our patients. Once we jump into the water of transference and surrender to the emotional currents, how does we avoid getting flipped out of the boat? To translate the metaphor: how does one avoid wrecking the analysis?
Freud's original technique papers can help us here. When Freud recommends that the analyst be like the surgeon, who does his work with a dispassionate attitude, we should keep in mind that surgeons are not only dispassionate—they are bold. The very creation of the psychoanalytic situation was the bold expression of Freud's personality. But along with the boldness required to jump into the water comes the necessity of pulling away from the action and remembering the importance of holding up the mirror—not only to the patient, but to ourselves—and asking “what does it mean?”
4 Analysis Transcends the Room
If we allow ourselves to become emotionally in tune with our patients, we find that that they are with us outside of our sessions. It follows that much of what occurs in sessions is dependent on processing that takes place outside of them, and that an expanded view of technique might encompass a variety of activities that relate to what we do with the emotions stirred up in us by our patients. This demands a great deal of self analysis and emotional processing on our part, that must take place outside of sessions. We could look at this as a matter of keeping ourselves in tune, and as such it belongs in the domain of technique. This runs
counter to the traditional wisdom that thoughts about patients reflect countertransference “problems” within the analyst, just as our current appreciation of “countertransference” is that it is not part of the problem, but part of the solution.
I believe the above recommendations distinguish the psychoanalytic process from other psychotherapies. Along the way of implementation, there are two major types of errors that can corrupt efforts to implement an analytic technique as described above. The first are errors of INHIBITION: our tendency to hold ourselves back from engagement. The theory of abstinence has long served to support such a defensive posture on the part of analysts.
Equally problematic are errors of EXHIBITION, in which the analyst is unrestrained in his intrusion into the therapeutic arena in order to fulfill his own needs at the expense of his patient's. It seems likely that we have gone, as a group, to erring on this side of the equation in reaction to years of erring on the side of holding ourselves back.
What are correctives to these errors? It should go without saying that a respect for BOUNDARIES and a sense of ethics are essential analytic attitudes. But beyond that, our patients themselves are usually very forthright in their diagnosis of us, and who they need us to be . It seems to me that to withhold from a patient a “Corrective Emotional Experience” that we bring with us by virtue of being who we are and who we are not is an unnecessary albatross for us to hang upon our necks. To the extent that we authentically embody the attributes they require, why not be open in employing them on their behalf when we are able to do so?
There is an analogy here, if not an identity, to parenting. As our children get to know us, they tell us who we are and what they need from us using the means of communication at their disposal. Wise parents learn from this.
Last, but certainly not least, comes HUMILITY. Our ability to promote helpful change in our patients is significant, but limited. Such change is more likely to occur, paradoxically, if we are able to maintain a high
degree of humility in our work, despite the grandiose ambitions we often bring with us to this career. And I've got to admit, it takes a fair amount of grandiosity to undertake a career in psychoanalysis, which Freud so aptly described as an impossible profession..
Our own grandiosity can interfere with the recognition of the grandiosity in our patients, which so often conceals vulnerability and hides where the hurt is, for both patient and analyst. An attitude of humility promotes the analytic task of trying to understand our patients within the limits of our capacities.
There is one more way in which an attitude of humility is useful. That has to do with our relationship with the different psychoanalytic theories that compete with each other for a place in our Institute Curricula. When we invite the unconscious into our consulting rooms, it is very tempting to imagine that we know what by definition isn't knowable. Theory may start us off, but thinking that “we know” can be an obstacle to empathy and its operation in the psychoanalytic process.
I have tried in the paragraphs above to make the case that use of The Analyst's unique personality should be recognized as a fundamental aspect of technique, and that the relational elements, once recognized, are coequal in importance to the interpretative activity that is also fundamental to analysis. While the use of the anaIyst's personality encompasses so many responses as to make specific recommendations impossible, Roy Schafer's idea of “analytic attitude” is prescient and seems more important than ever as a way of teaching of students who want to learn how to use themselves as “analytic instruments” in the service of their patients. I believe the above recommendations distinguish the psychoanalytic process from other psychotherapies, and that they may be useful as a contemporary update to Freud's initial “Recommendations to Physicians Beginning Psychoanalysis”.