Answering ‘What happens in psychoanalytic treatment?’ is a daring task. This question relates to pointing out the essence of psychoanalysis and psychoanalytic experience, which may lead us to a Platonic discussion similar to answering what makes a chair a chair. What are the necessary and sufficient elements and phenomena a treatment must have to be called ‘psychoanalytic’? What phenomena may transform a psychotherapeutic approach into a ‘non-psychoanalytic’ one? Is a psychoanalytic treatment defined by its structuring elements, purpose, or aims, if any? Is it possible to separate them? Interrogating these topics usually causes division among psychoanalysts, who sometimes engage in heated discussions on how many carats their psychoanalytic gold has. As the jokes say, where there are two psychoanalysts, there are three different ideas, and where there are two Lacanian psychoanalysts, there are three different psychoanalytic training institutes.
After reading her book chapter, I first thought Hall offered a condensed version of her clinical and theoretical views about psychoanalytic treatment, aiming to engage different audiences and connect with them. Then, I reflected on her psychoanalytic training journey, imagining that it was inaugurated by teachings in classical psychoanalysis and her first analysis, then continued through relational psychoanalysis and her second analysis, and now is currently addressing neurosciences. Her journey also seemed to cover object relations theory (Klein, 1946), the importance of real traumatic events during childhood (Ferenczi, 1916–1917), and life trajectories theory. This journey is reflected in her ‘teasing apart and integrating theoretical understandings’ when answering what a psychoanalytic treatment is, which was narrated as if she was free-associating, going back and forth on complex topics such as therapeutic goals, the psychoanalytic frame, therapeutic alliance, deprivation, mental growth, and emotional experiences in the analytic situation. I was left
with the idea that Hall tried to house many topics in her answer, showing her experiences as a psychoanalyst and the wide variety of phenomena that take place during a psychoanalytic treatment.
However, during my reading of her work, I perceived Hall abruptly and consistently changing frameworks during her exposition. I felt myself constantly and swiftly jumping from one theoretical and technical approach to another while following her description of what happens during psychoanalytic therapy. For example, on one occasion, she moved from respecting the role of early defenses in diminishing shame, passing by the internalization of the analyst, to referring to oxytocin's role in positive and erotic transference. Would this have occurred because the author was writing for in-depth psychotherapists as stated in her introduction, and assumed they could follow her? As a traveler, I got dizzy, like when you are in the back seat of a car driving through a downhill slope full of curves.
While trying to understand this sensation, I remembered the words of my first psychoanalytic supervisor. Similar to what Hall mentioned about finding your own analytic voice and ears, Coloma (2011) said psychoanalysts need to rigorously train and study in-depth the theoretical and clinical approaches they want to use to inform their free-floating listening. Only in that way, he said, psychoanalysts would be able to use psychoanalytic authors ‘incorrectly’—they would be free to use different theories beyond their original purpose, as they know their boundaries and elasticity. In my own words, psychoanalytic training and practice mean learning the different ways of playing with psychoanalysis, thoroughly understanding and experiencing the game rules and dynamics of each theory and clinical approach an analyst wants to play with. Doing so would allow analysts to teach their patients how to play and play with them, eventually leading to a way of playing in which the participants can play freely without focusing on how to play. As Hall says, their playing together, their relationship, has become part of themselves.
Nonetheless, unlike the author, Coloma added a precaution: analysts should be coherent and consistent in their listening and understanding of their patients, as the analyst's jumping from one theoretical and clinical framework to another during a session or a treatment may risk using two or more conflicting and opposite clinical interventions and
thus cause confusion in the patient's mind. Using the ‘playing a game’ metaphor, analysts and patients might get confused during treatment if the game, either its rules or essence, suddenly changes because an analyst introduces elements from a different game, attempts to change a rule while playing, or overwhelms the players by playing different games simultaneously. For example, you do not introduce hockey sticks in the middle of a soccer match (or football, as the rest of the world outside the United States calls it), as this action may confuse the players.
To illustrate how this confusion may affect psychoanalytic treatment, allow me to briefly discuss the concept of countertransference. After the inaugural ‘analyst's need for more analysis’ understanding of this unconscious experience by Freud (1910), which was also sustained by Klein (Spillius, 2007) and expanded by Winnicott (1949b), Paula Heimann (1950) revolutionized psychoanalytic practice by saying that countertransference refers to the emotions felt by the analyst, thus creating a plethora of different approaches to this clinical phenomenon (Racker, 1969). That is to say, she opened the door for many analysts to explore different ways of playing with this concept. Just considering two of them for this exposition, one states that countertransference refers to the analyst's feelings resulting from their analysand's projection of their feelings into them (Carpy, 1989), and the other defined it as the emotional expression of the analyst's digestion of the unconscious elements projected by the analysand (Bion, 1959; Rosenfeld, 1971). Depending on which one an analyst chooses, their way of creating interpretations and their theories of the mind are deeply impacted.
I have found that Heimann's understanding of countertransference is predominant in many psychoanalytic regions and schools. One of the clearest examples of the prevalence of this view occurs when a supervisor, discussants, or audience members ask during a case presentation, ‘What is your countertransference?’ To me, this is an impossible question to answer on the spot. How can I or anyone be aware or conscious of an unconscious experience? Following Bollas (1983), as countertransference is truly an unconscious phenomenon, it may take months or even years to be understood. Thus, creating countertransference-informed interventions while taking the latter approach can only be done a posteriori. Moreover, until supervision, self-analysis, and/or the analyst's work on the analysand's material transforms the analyst's countertransference
into something thinkable, there is little to no possibility of creating interventions that can be used in the same session that a countertransferential phenomenon occurs, which is the opposite of Heimann's and related proposals. While an analyst who chooses to understand countertransference following Bollas's definition would create and time their interpretations at a slower pace compared to the “what I feel is what the patient feels” approach, it would also grant them time to reflect and digest their emotional experience in such a way that the risk of confusing their unconscious conflicts with their emotional reactions and countertransferential manifestations in their mind would be greatly reduced.
With all this in mind, I would like to offer the reader a statement: if an analyst suddenly changes their theoretical framework in the middle of a session, whether due to their countertransferential enactment or a clinical decision detached from their patient's material, it will produce a domino effect on how they listen to the material, experience their emotions, create interpretations, and see their patients. Therefore, using different understandings and techniques that greatly change the configuration of the analytic situation risks introducing confusion in the analytic relationship with the patient—it is akin to suddenly introducing hockey sticks into a soccer match without noticing it.
Hall's case presentation of Donna may be a good example of this. The author's view of her patient at times is closer to the Freudian understanding of a neurotic patient and to what Lacanians would call the ‘Subject of the Other’ (Etchegoyen, 2005), who reenacts the repressed unconscious and brings it to their therapeutic relationship or ‘the analysis’ through the transference. This happened when she directed her undigested rage toward her analyst. At other times, Donna is a patient whose growth is measured in terms of Ego strength and adaptation (Nunberg, 1942). Hall sees her loss of jobs and opportunities as an attack on her progress and the analysis. As the author pointed out, the analyst she described had at least three possible ways to understand Donna's negative transference, discussing three different clinical ways to work with it. By trying to step out of the transference, I understand that the analyst offered Donna a way to differentiate her transference from her ‘real’ analyst, trying to use her Ego strength to help Donna think about what was going on between them. Paraphrasing what she wrote, I believe the analyst said implicitly, ‘I do not want to be your mother, so let us think about what
is going on here. Transference happens, but sometimes it is not helpful.’ On the one hand, in my view, the analyst offered Donna a devaluation of her transference (by using a suggestive intervention?), strengthening her Ego and aligning her with what the analyst and the patient consider success. Moreover, the analyst then identified with her client's experience of losing a good object. On the other hand, it was unclear why the analyst had difficulties tolerating Donna's anger, especially after stating that they could contain it before. Again, I got confused. Maybe I missed something?
Soon after re-reading her presentation, I began to wonder what Hall meant by progress in Donna's life and why the author considered her patient was sabotaging it. If Donna's loss of jobs and opportunities were understood as sabotage to progress, would psychoanalytic progress be measured by getting a job? Or is the emergence of rage and destruction a sign of progress? According to Hall's view of what happens in psychoanalytic treatment, it could be both. I also saw inconsistencies in the author's therapeutic approach when offering the interpretation, I paraphrased above. The analyst offered themselves as a good object so that Donna could incorporate their attitude “alongside the troubling mother representation,” which Hall saw as a corrective experience. However, explicitly telling Donna not to engage in her negative transference because it was not helpful could also be understood as the analyst enacting her countertransference. I think that the analyst may have unconsciously invited Donna to be a good girl again, offering her a way to win her analyst's love (hockey stick) by letting go of her transferential rage (soccer match), thus confirming that being a good daughter will keep her mother's goodness alive1. What kind of analyst did Donna internalize? If negative transference is sometimes not helpful, does the same apply to negative countertransference? Could encouraging Donna to be a good girl be called progress? Or would it be sabotage?
Donna's case brought Hall's question in the introduction of this book about negative transference back to my mind: how much and how long it needs to be expressed. To whom is negative transference not always
Maybe her mother's depression relates to Andre Green’ dead mother (1983) and Donna has to keep her alive someway.
helpful to be expressed, the patient or the analyst? I think we as psychoanalysts need to be capable of distinguishing between the unconscious dynamics during a session and the frustration of not being a good analyst (Stein, 1991) in order to be able to offer patients what they need. Would this be something that distinguishes psychoanalytic treatment from other forms of therapy?
Along with this observation, it might be worth asking whether an analyst risks too much by attempting to offer a corrective experience, if such a thing exists, because of the possibility of becoming blind to their own wishes to be good to their patients. Much has been written about this critique (Knight, 2005; Christian et al., 2012; Aron et al., 2018). Can an analyst presenting themselves as a good object truly provide a corrective experience if it does not allow the (negative) transference to unfold? Hall's understanding of this psychoanalytic concept shows that an analyst can be internalized alongside the internal parental figures without replacing them, creating “different brain pathways that exist alongside […] the old ones,” which sounds more like a creative process than a corrective one. Then, what is a corrective experience? Is it the creation of new brain pathways, the re-transcription of memories, or both?
Returning to Hall's case studies, her second one, Bill, was trickier for me. I had difficulty grasping what was psychoanalytic about it. This brief vignette summarized Bill's life, his second analysis attempt with a female analyst, and how being listened to and repairing trust helped him change. However, I could not find what the analyst said or did besides the aforementioned actions—no soccer ball, no hockey sticks even. Although it could be said that the analyst's listening was psychoanalytic, as she was able to recognize that being a woman might be sensitive to Bill because of his past relationship with his mother, I struggled to find what was specifically psychoanalytic about Bill's treatment compared to what other psychotherapies might offer him, as there were no examples of the role of the analyst in this vignette. Furthermore, clinicians using other approaches such as Jungian psychology, systemic therapy, and the recently re-branded object-relations-informed practice called ‘Internal Family Systems’ could have reached a similar conclusion about the role of Bill's parents in his development. Is Hall's concept of development re-railing a structural characteristic of a psychoanalytic treatment exclusively?
In my experience, psychoanalysis is not the privileged device in which patients may express their intense feelings, rebuild their trust in others, or re-rail development, nor is it the only available therapeutic approach that may offer a space for these experiences to take place. Many patients readily bring their feelings to a session, not because of their treatments' effectiveness, frame, or progression, but as part of their transference and the complexity of their psychic and social conflicts. Can we consider the patient's emotional expression as evidence of the unfolding of psychoanalytic treatment, as Hall suggested at the beginning of her chapter? Ferenczi (1909) proposed that positive and negative transferences emerge from the patient's spontaneous psychic work, which the analyst might not have caused. Sometimes, we are just there, witnessing it take place, being the audience to an already written script, no matter how we are seated in our armchairs. For this reason, it is hard for me to conceive that the emotional expression of patients is always and necessarily linked to the progression of treatment.
Then again, what distinguishes psychoanalytic treatment from all other treatment modalities? Hall, for example, mentioned that psychoanalytic treatment differs from Cognitive Behavioral Therapy (CBT) in terms of their long-term outcomes, which left me wanting to hear more thoughts on it. Thinking about these differences made me reflect on my own experiences with CBT. In a seminar I had to attend, one participant asked the fairly known CBT therapist giving the seminar, ‘What do you do if a patient brings you a dream to a session?’ This clinician replied:
I once had a woman who came to treatment and brought a dream to the session. She told me about her dream, and I proceeded to work on the dream in a CBT way, asking questions about intermediate thoughts, cognitive distortions, and core beliefs. We talked about it on that day, and she never brought a dream again to her treatment. You see, long ago, I was talking to a psychoanalyst, and he told me that, in a way, psychoanalysts do CBT sometimes as they can also do those kinds of interventions. I told him that he was wrong, as he was not making CBT interventions as he was not thinking in a CBT way in his mind.
I think the CBT clinician had a point. Psychotherapy theories and practices, such as psychoanalysis, mostly live in a therapist's mind, in their
inner mental frame (Coloma, 2011). Moreover, psychoanalysis is a way of understanding the world and our psychic lives, a way of thinking, and a way of playing. Free association is one of the game rules that makes the psychoanalytic treatment experience possible, requiring the patient to speak their mind and the analyst to be ready and willing to hear everything they say2. I think Hall correctly described many daily-life experiences that psychoanalysis can listen to: “thoughts, feelings, dreams, wishes, fears, ideas, beliefs, opinions, […] expressed both in actions and words, both consciously and unconsciously.” I would add jokes, Freudian slips, fashion, music, and art. An analyst not only wants to listen to these experiences but also analyze them, meaning finding out the hidden or buried painful truth condensed in them or building meaning where there has not even been one. Through this process, what the patient cannot remember is enacted in the transference.
Having this in mind, I posit that free association is one structural element that significantly distinguishes psychoanalytic treatment from the rest, as it allows patients and analysts, following Hall's metaphor, to embark as travelers in the unknown territories of the transitional space created by the establishment of a relationship between them. Differently from the CBT therapist mentioned above, the participants of a psychoanalytic treatment create their journey as they travel through it. Alternatively, using Freudian language, psychoanalysis collects the pieces of the long-forgotten, broken, or intact artifacts while unveiling and unburying them (Freud, 1937). Also, given the manualized nature of CBT and other therapies, my experience has been that what the patient says tends to be saturated with meaning by the therapist, thereby communicating to the former that there are expectations of what to say and bring to the latter. Thus, the CBT therapist's inner frame is filled with meaning, a plan, and goals—they already know how and where to go. Using Hall's metaphor, the CBT therapist guides the patient through a path already written, where little to no deviations are permitted. Thus, a dream is no longer owned by the patient but by the therapist. The therapist owns the ball and the game, and the players can only play it in one way, a rigid way. No wonder their patient stopped bringing dreams.
One may wonder if the analyst can truly listen to everything the patient says and the limits of free association, but that is a discussion for a different time.
At this moment in this article, I feel compelled to clarify that I do not have a particular love for rules. I think Hall was right about moving away from authoritative, rigid, and orthodox psychoanalysis and creating her own ‘slang.’ However, I believe that creating and practicing your singular psychoanalytic style, as the author did, requires minimal conditions for it to exist, grow, and thrive. I see the psychoanalytic frame, particularly the rule of free association, as the supporting structure that allows travelers to embark on a journey and analysts and patients to play within the analytic situation. I think the living process that Ogden and Hall propose can only happen with this scaffolding underneath. What is the rule of free association but an invitation to play freely with the analyst? What is transference but the installation of a forced game within the therapeutic relationship, in which the analyst is pressured to play a role the patient unconsciously expects? As Bleger (1967) states, one of the first signs of resistance and transference in analysis is when the patient attempts and/or disrupts the frame, as their psychopathology installs itself within it. He also suggested that a sign of the analyst's enactment of their countertransference is when they disrupt the frame. For this reason, we analysts have to be extremely careful not to change the analytic contract by freely introducing our games and toys (hockey sticks) into the playing that the patient unconsciously proposes (soccer match), whether for loving theory, morality, or wanting to be good objects. Patients already have to bear with our poorly (and much needed by them) embodying and giving life to the characters in their unconscious script.
Finally, I would like to conclude this paper by adding a few observations to Hall's chapter. Even though it is clear to me that Hall's inner frame is psychoanalytical, I believe it loses its richness when theories such as neurosciences and early traumatic experiences are included in her chapter. On the one hand, I share the author's interest in neurosciences and would suggest the reader explore the remarkable work of Mark Solms on bridging it with psychoanalysis (Solms & Lechevalier, 2002; Solms, 2013). Nevertheless, Hall's way of presenting the relationship between mind and body tends to be superficial and diminishes the value of symbol formation, as she mostly focuses on the brain. This has been most interesting to me culturally, as I have noticed that people in the United States in their daily lives mostly use the word ‘brain’ instead of ‘head’ or ‘mind’ to refer to the place where thoughts or mental processes occur. I
believe Winnicott (1949a) was right when he proposed that the mind is not located in the brain, head, or any specific part of our bodies, given that our body representation is a construction strongly determined by our psychosexual development, unconscious fantasies, and early experiences (Doltó, 2023). In Freud's (1888) words, “hysteria behaves as though anatomy did not exist or as though it had no knowledge of it” (pp. 169). Ultimately, our experiences of our bodies will always be a construction despite the several brain and bodily processes involved. This is even more critical if we consider that it was recently discovered that memory and learning processes might not only occur in neural cells (Kukushkin et al., 2024). Because of this, I believe we are still very far from fully understanding the role of our bodies, including the brain, in our psychic processes, leading me to leave this topic to the experts. This is a soccer match I do not dare to join yet.
On the other hand, I appreciate that Hall is clear about the kind of patients and psychoanalytic work she has been doing over these past years, focusing on those travelers who have experienced deprivation from their caretakers during childhood and basing her work on the analytic dyad and getting development back on track. However, I have two remarks about the author's approach. First, many of our patients do not necessarily have experienced trauma during their childhood. Sometimes, psychotic children are born within well-enough families. Other times, there are events outside the scope of the caregivers, such as chronic diseases or acute illnesses, that deeply affect them during early childhood and leave their caregivers powerless. As Winnicott (1965) said, “It makes no difference if it was something in the parents that caused the child's illness. Often this is the case. But the damage was done neither willfully nor wantonly. It just happened” (pp. 68). On top of that, there is also a type of patient that may unconsciously use their traumatic experiences, although true and justified, as part of their secondary gain narratives. This topic is a tremendous clinical challenge and leads us to the land of sadomasochism. Psychoanalytic treatment is perhaps the only clinical device that gives space to these clinical phenomena today, and it does not have too much room in Mahler's approach and, therefore, in Hall's view.
My second remark concerns the analytic dyad. My argument does not involve establishing the number of individuals or objects present during early infancy, which could lead to an endless discussion
about pre-oedipal and oedipal experiences during the first years of life. Instead, I would like to point out that the analytic dyad exists within a third space, a transitional space (Winnicott, 1951), the place of playing and culture. This critique of the lack of mention of cultural structures in Mahler's separation-individuation theory is not new (Chodorow, 1978). I only found a few references in Hall's chapters given to me to read about the role that United States society, politics, and cultural nuances play in psychoanalytic treatment, which was mostly described in a catastrophic and anxiety-provoking way. Although there is some truth in how she views them, I believe her exposition loses richness by not including how culture supports and sometimes invades psychoanalytic treatment. I believe the analyst has a role in keeping hope that there is a world where we can all live, belong, and change (if we want to), which the caregivers transmit to their children as they grow in independence and autonomy. For this reason, adding the cultural environment surrounding psychoanalytic treatment to her views would enrich the author's exposition.