Towards a Two-Track Model for Psychoanalysis1

In my 2010 IJP paper, “Creating Analysts, Creating Analytic Patients,” I wrote about the need for a “two track model” of psychoanalysis. Although the terminology may have been new, this was not an “original” concept. It derives in large part from my reading of Andre Green, particularly his paper given at the London IJP Congress (Green, 1975) in which he drew a clear distinction between neuroses on the one hand and borderline or ‘limit cases’ (etats limites) on the other. Perhaps the most important thing that I took away from Green's paper was the realization that each of these categories is based upon a different and distinct underlying psychic organization and may imply and require a different understanding and approach to analytic listening and technique.

Green's paper has become a classic and is foundational, as one of many writings that have called specific attention to this discontinuity (caesura) – I might even say, fracture - in analytic theory. It challenges us to widen the net of our thinking, to build a conceptual bridge that is truly psychoanalytic across this divide and to work out the clinical and theoretical implications of the duality that Green brings to our attention. In so doing, however, Green was of course “merely” – and I use that designation ironically, because of the powerful and far reaching effects of his work on our thinking – following upon the work of Freud, who eventually came to recognize that while his first topography provided us with the clinical and theoretical tools needed to understand and treat neurotic patients, his formulations were not sufficient to understand and address certain kinds of unconscious guilt and negative therapeutic reactions, pathological narcissism and the consequences of pre-verbal and massive psychic trauma. In short, all those patients and difficulties that lay ‘beyond the pleasure principle.’ Put another way, the first topography addressed that which was organized, formed, but hidden in the psyche, while the second topography, the ‘structural theory,’ allowed us to better understand and address the very process of psychic formation, the movement from unrepresented to represented mental states.

Time does not permit me to elaborate upon this, but I will briefly note that Freud's shift towards the structural theory (his second topography) moved analytic thinking away from a mode of theory that was heavily based on veridical, sensory-empirical data and representations (Scarfone, 2011) – e.g., the unconscious as formed, verbalizable but disguised or repressed contents - to one that was based on metapsychological principles – e.g., the Id as force in search of content and containment; construction, myth and the playful, creative and self-generating work of nachtraglichkeit (après coup).

This perspective and its implications for technique were absent in my own training, which took place under the dominance of North American ego psychology, where Freud's (1923) introduction of the structural theory was seen as more or less continuous with and a natural extension of the topographic theory that had gone before it. There was little attention given to unrepresented states or recognition of the ways or the extent to which the second topography shattered what had been a homogeneous and unitary vision of psychoanalysis (Green 2005, p. 47). But in fact, the effect of Freud's reformulation was much like that of placing a glass crystal in the path of a clear beam of light. It diffracted analytic theory into multiple components: Ego Psychology, Klein, Winnicott, Lacan, Bion, etc. Contemporary psychoanalytic theory and practice, with its comparative thrust and more eclectic bent – the very subject that brings us together today - is still trying to understand and work through the tensions and consequences that followed upon this change.

Rather than emphasizing and appreciating the discontinuities between neurosis and what lay beyond, the analysis that I grew up with attempted to maintain the vision of a unified theory in which almost, if not all relevant psychic occurrences could be attributed to the interplay of structurally organized unconscious motivation, anxiety, phantasy and defense. These assumptions placed analysts in a paradoxical, cognitively dissonant, and often impossible position vis-à-vis the actual patients they were seeing. I have already described (Levine 2010) how suppositions about analyzability did not successfully predict outcome or conform to the actuality of which patients were analyzable by which analysts. In regard to the treatment of adults who had been sexually abused as children, I have also recounted (Levine 1990) how theory led me to (mistakenly) expect that analysis of defenses and reliance on the patient's developing capacity for free association would eventually and predictably lead to the emergence of associations within the patient's discourse that pointed, albeit in disguised or cryptic fashion, to the salient pathogenic traumatic events.

In retrospect, although some of the difficulty undoubtedly came from my misunderstanding or misapplication of ego psychological principles, the reason that things were not working out as my then theory predicted was that it was encumbered by a number of unrecognized and unstated assumptions. One such assumption was that the relevant and sought after analytic material was potentially verbalizable, but repressed or otherwise defended against. That is, although this material was unconscious, it was assumed to be psychically represented, elaborated and embedded in narrative structures and connected to other psychic elements by associative chains. If this was the case, then with free association by the patient and sufficient analysis of resistance– i.e., with patience on the part of the analyst and attention to the anxieties inherent in the analytic situation and relationship and/or the defenses those anxieties evoked in regard to the emergence of certain feelings, fantasies and wishes– these hidden and disguised thoughts, feelings and fantasies would make themselves known by virtue of their pressure on the patient's more accessible thoughts, feelings and fantasies. Interpretation and analysis of defense would then initiate a process of working through and conflict resolution that would strengthen the therapeutic alliance and help the patient to tolerate the underlying anxieties and eventually come to use the potential of the analytic setting for the reworking of conflicts and psychic growth.

As you no doubt recognize, this is a traditional description of the analytic process, which I categorized under the heading of the archeological model (Levine 2010). It is admirably suited to the treatment of neurotic patients and is predominantly derived from Freud's first topography, according to which analytic praxis was based on the pleasureunpleasure principle, dream interpretation, the treatment of hysterical neurosis and the psychopathology of everyday life. It is also consistent with how Freud was usually portrayed as working analytically. That is, he would make a dramatic interpretation of some forgotten childhood (often sexual) event with the assurance and conviction that his reconstruction was historically correct.3 The implications of his 1937 paper, in which he allowed that reconstructions could often be psychically and therapeutically valuable even if not historically correct, and acknowledged that an historically incorrect construction could stand in for and assume the dynamic function of a recovered accurate memory, had not yet been fully appreciated or integrated into analytic thinking.4

As I wrote in 2010:

“the archaeological model was best suited for situations in which psychic elements have achieved representation and have been more or less symbolically invested and associatively linked to one another. It is this symbolic tie to dangerous and/or unacceptable wishes, feelings, fantasies and needs that leads to the familiar situation of psychic elements becoming enmeshed in conflict, undergoing the vicissitudes of repression or other defensive disguise and remaining hidden from conscious awareness, while continuing to exert a pressure on the psyche until the conflicts they are involved in are discovered and worked through to some resolution.” (p. 1387).

The archeological model worked well enough for the treatment of many neurotics, but proved increasingly problematic when applied to what was then called the “widening scope” of analytic patients; what most of us would today call our everyday caseloads! It remains an open question of the extent to which the nature of patients seeking analytic treatment has changed or our understanding of the depth and complexity of their pathology

has deepened since the time of Freud's first theory. Whatever the case, I can attest to the fact that in almost 40 years of practice and supervision, the so-called “good neurotic” patient has proven to be the exception rather than the rule.

In the many instances where non-neurotic and even manifestly psychotic cases were successfully treated within – we might say despite - this archaeological formulation of the curative process, success was less often due solely to the rigorous application of an archeological theory of technique and more often due to the additional influence of ‘non-technical factors,‘ such as the analyst's unique subjectivity or intuitive response to the patient's needs, the inspired application of what used to be referred to as the “art of psychoanalysis,” engaging the patient in a search for meaning almost independent of the nature of the discovered meaning itself or the salutary effect of non-specific therapeutic factors in the analytic relationship – e.g., consistency, empathy, non-judgmental concern, maintenance of an analytic frame and attitude, etc.

But success in these non-neurotic cases was often difficult to come by and as you can imagine – and as many of you have experienced first hand – having a theory that does not conform to clinical reality or help you to adequately understand or function in the clinical situations in which you find yourself can prove very frustrating. And, as impasses, treatment difficulties and failures accumulate, in either one's practice or even worse, in one's own personal analysis, such a theory can only be discouraging. I believe it is this discouragement and the absence of an analytic theory that included the effective understanding and treatment of many patients who presented for treatment that has added to the socio-cultural difficulties in case finding and building an analytic practice.

This seemed to be the case in the US. After an initial period of excessive optimism, expectation and over-application, archeological analysis:

• Proved increasingly restricted in its application (e.g., analytic treatment of psychotic or psychosomatic cases has all but disappeared in North America);

• Was challenged by alternative analytic formulations (Self Psychology, Infant Development based theories, the Relational School, etc.);

• Ceded the therapeutic field to non-analytic forms of treatment (CBT, DBT, etc.).

In some quarters, analysis began to lose its specificity and was seen as a kind of ‘super psychotherapy’ aimed more at conflict resolution and better adaptation than at growth of the psyche. (It is not that these are unimportant or not part of the outcome of a successful analytic treatment. It is that when the central goal of the analysis is excessively taken over by pragmatic therapeutic concerns, there is apt to be a loss of the power and dare I say magic that is inherent and unique to a true analytic engagement). Residues of this latter shift can still be detected in those candidates who apply for psychoanalytic training with the aim, not of going on to become practicing analysts, but of becoming better psychotherapists. This may be a problem that is more immediate in the US, but is apt to occur in any region where selection standards come under pressure as recruitment of candidates fails to meet institutional expectations and needs.

This then was the background of the 2010 IJP article, which wound up reflecting the confluence of two somewhat different streams of intention. The first was didactic and pragmatic. As case finding became increasingly difficult for both candidates and graduate analysts, I had turned my attention to trying to identify and understand why this might be so and to see if I could develop some concrete suggestions concerning the timing and working through of the suggestion to intensify the frequency of treatment. As part of this investigation, I conducted a number of clinical seminars for candidates and recent graduates on intensifying the treatment, converting patients from therapy to analysis and developing analytic patients. Some of the more pragmatic, clinical considerations, recommendations and conclusions of that work are included in the 2010 paper.

But while this direction was one I thought useful, I began to realize that a broader and more profound reorganization of my thinking was required and indeed seemed to be quietly taking place. Increasingly, I began to feel that a significant part of the problem of case finding involved analysts' inability to feel that they could apply analysis to the kind of patients, problems and settings with which they were confronted. Even more so, as treatment of psychosis, psychosomatic, borderline and other primitive personality disorders was ceded to non-analytic modalities, it seemed harder and harder for

analysts to think analytically about these patients and their problems. Consequently, I came to believe that in order for an analyst to venture into these relatively uncharted waters, it was necessary to have in mind a guiding theory that covered the necessary territory and that an analyst could feel was truly psychoanalytic. This led to my articulation of the second track, which dealt more with catalyzing and participating in the creation of mind and meaning than with uncovering what was pre-existing but hidden. It was for this reason that I designated this second track as transformational.

The transformational model “centers upon the functioning of the mind of the analyst as a part of the analytic dyad in the creation and/or strengthening of psychic elements rather than, or in addition to, their uncovering or discovery.” (Levine 2010, p. 1388). It:

“…emphasizes that psychoanalysis is a pair specific, two-person activity that is liable to be as much if not more about the creation of symbols, thoughts, feelings and the unconscious than it is about their uncovering or discovery. In some situations, the task of the analyst may be less about analyzing defenses or uncovering hidden or disguised meanings and more about lending one's psyche to the work of facilitating the patient's development of thoughts, feelings and mental states; of naming and elaborating these newly formed psychic elements and linking them to other components, in the mind of either participant or in the intersubjective mental space that lies between them. In short, of ”binding the inchoate, and in containing it within a form“ (Green, 1975, p. 10) and working ”with the patient in a double operation: to give a container to his content and a content to his container“ (Green 1975, p.8).” (Levine, 2012, p. 1388).

The transformational model opens up the possibility that despite little or no evidence of a therapeutic alliance or a split between the patient's observing and experiencing ego, an analytic process may still be present and on-going. However, that process may have to be sustained within the mind of the analyst, rather than within the patient or in the discourse between the two, sometimes for considerably lengthy periods of time. While this places a greater burden and responsibility upon the analyst and the countertransference and may increase the risk of dependency, suggestion and compliance, it also widens the scope of application of analysis and offers the analyst the possibility and even comfort of a theory that can bridge the divide between the borderline and the neurotic-normal.5

Such a theory holds out the promise of extending classical thinking and allowing:

“…analysts to think and act analytically in the face of unrepresented as well as represented mental states, disorganized as well as organized sectors of their patients' psyches, and autistic, psychotic and borderline phenomena as well as neurotic-normal phenomena. The addition of the transformational track completes a more comprehensive theory that can be applied to a wider scope of patients and will therefore help in the matter of case finding, as it emboldens analysts to encourage even ‘sicker’ patients to enter into analysis and more intensive treatments.

With the expectation that each analysis or analytic therapy will require an unconscious, joint improvisation, the process will begin from the initial contact, with the analyst – and hopefully, but not necessarily, the patient - wondering and discovering what and how this pair will begin to improvise together, unconsciously, spontaneously. In initiating treatment, the ‘diagnostic questions’ then shift from the traditional focus on the individual patient and his or her ego capacities to the functioning of the mind of the analyst in response to the patient and to the analytic pair.“ (Levine 2010, p. 1389).

The transformational theory that I am describing derives from and is consistent with the work of Bion, Ferro, Green, the Paris Psychosomatic School, Cesar and Sara Botella, Rene Roussillon, etc. It hypothesizes the existence of unrepresented, proto-mental states and a level of registration that could be called “pre-psychic” (e.g., ).

It is interesting to note that the distinction between pre-psychic and psychic, between unrepresented registrations and represented mental states is analogous to one that Freud (1900) hypothesized in chapter VII of his Dreambook, when he attempted to distinguish between a system for registering perceptions (Pcpt.) and a system for creating and registering memories (Mnem.).6

“We shall suppose that a system in the front of the [psychic] apparatus receives the perceptual stimuli but retains no trace

5. And as Donnet , has noted, in extreme cases, the inadvertent provision of an ‘analytic false self’ may be the best that one can help the patient to achieve.

6. I am indebted to Sara Botella (2010), for pointing this out and to Andre Green (2012), for calling this to our attention.

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of them and thus has no memory, while behind it there lies a second system which transforms the momentary excitations of the first system into permanent traces.“ (p. 538).

In Freud's view, the system Pcpt., which is without memory, “provides our consciousness with the whole multiplicity of sensory qualities” (p. 539), while memories, especially the memories of earliest childhood which have made the greatest impressions upon us are themselves, for the most part unconscious (pp. 539-540). This dual registration theory and its evolution in Freud's work and in psychoanalytic theory has important implications for our consideration of the two track model, as it underlies the idea of two categories of unconscious phenomena, the unformed or unrepresented unconscious, which consists of a non-evolving and not yet evolved field of sensori-somatic inscriptions or traces, and the dynamic unconscious, which consists of formed but repressed mental elements.⁷

The transformational theory also reflects the evolution of the theory of countertransference in which the term first appeared in Freud as a potential interference; then broadened to encompass all of the analyst's reactions to the patient and the analytic situation- countertransference in its ‘totalistic’ sense; began to be recognized as a necessary and valuable receptive attitude in the analyst; and found its most radical position in the assertion of Paula Heimann (1950) that the countertransference of the analyst actually reflects and belongs to the personality of the patient. When combined with Bion's (1962, 1970) assertion of the potentially communicative dimension of projective identification and his theory of alpha function and container/contained and an appreciation of the protective, homeostatic dimension of representation and elaboration of narrative, the concept of countertransference taken in its widest possible sense, finally emerges as a component of the analyst's subjectivity on the way to becoming absorbed into a truly intersubjective field theory and formulation of psychic development and the analytic process.

As Green (2012) so aptly put it, when confronted with non-neurotic patients or areas of the mind:

“The countertransference makes up for what has not been (or could not be) lived: it is about inventing the possible.” (p.1243)

This trajectory can also be viewed from the perspective of psychic reality: What began for Freud as empirically observable and historically verifiable ‘facts’ – traumatic childhood experiences that were repressed and otherwise disguised, because of the anxiety that they were associated with – and then expanded to include repressed or disguised childhood phantasies, wishes and fears, – i.e., ‘facts’ of psychic reality - have increasingly become seen as ‘markers’ of pre- and proto-psychic sensori-motor inscriptions and disturbances, inchoate and barely organized somatic turbulences, that are in search of subjectivization, temporalization, verbalization and containment, in the form of one of many possible narrative ‘dialects’ (Ferro, 2002). In clinical terms, positivism yields to phenomenology; observation and deduction are assisted by intuition and inspiration; empiricism is supplemented and even supplanted by creativity, invention and imagination.

It is my belief that the addition of the transformational model to the archeological model will offer analysts “a more comprehensive theory that can be applied to a wider scope of patients. It should therefore help in the matter of case finding, as it emboldens analysts to encourage even ‘sicker’ patients to enter into analysis and more intensive treatments.” (Levine, 2010, p. 1389). Furthermore, it:

• Supports the view that assessment of prognosis and analyzability is pair specific for any given dyad.

• Requires the consideration of analyst-centered variables along with patient-centered variables in the determination of the treatment setting and the assessment of analyzability.

• Emphasizes the emergence of spontaneous, unconscious, interactive and intersubjective processes of transformation that allow for the creation and strengthening of psychic representations, symbols and meaningful chains of associations.

• And underscores the fact that “the creation of a given analytic patient will be a function of the degree to which the analyst will be able to internally create and maintain him or herself as an analyst with and for that particular patient.” (Levine, 2010, p.1390). This makes central the inter-affectivity and potential interactions and emotional connections that may develop between any given analyst-patient pair and implicates the

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  mind of the analyst as the crucial location of the analytic process, especially in the treatment of psychotic, psychosomatic, primitive narcissistic and borderline patients.

In the 2010 paper, I offered a number of technical recommendations that are useful to keep in mind when considering a shift from therapy to analysis or recommending that the treatment be intensified. These included:

• Maintaining an analytic perspective and keeping alive an internal sense of an analytic process from the very beginning and throughout contact with the patient.

• Keeping open the possibility that any negative assessment of the patient, including wishes to send the patient elsewhere or for non-analytic forms of treatment may be transference-countertransference responses that need to be understood - perhaps initially internally and silently by the analyst - from an analytic perspective.

• De-centering oneself from the status quo of an on-going therapy in order to take a ‘second look’ at the treatment process, re-assess potential areas of stasis and reconsider whether the treatment structure and setting is optimal for the patient's needs.

• Being sensitive to possible changes in mood, accessibility, aliveness or level of discourse, etc. that may ebb and flow with gaps between sessions. Commenting on and exploring such shifts may allow the patient to recognize the ways in which the gaps between sessions may be impeding the treatment process or unconsciously contributing to regression or stasis.

• Recognizing the importance of offering the patient a first hand experience of the value of analytic exploration and interpretation before recommending an intensification in the meeting schedule, so that the matter of session frequency can be reflected on in the light of personal experience rather than resting predominantly on the authority of the analyst.

I do not have additional clinical principles to offer you at this time. These, if they exist, will have to emerge in the course of future discussions and case studies. However, I do not wish to end without speaking, albeit briefly, about some clinical material and so I will offer two brief sketches that may help indicate how the broad concepts and principles I have presented today may be applied.

The first case is that of a middle-aged man with severe ‘social anxiety,‘ obsessions and phobias that was brought to me for consultation by an analyst-colleague. Mr. A, as I shall call him, was in a twice weekly, face-to-face psychotherapy because of his crippling symptoms. He had had a very traumatic childhood that included repeated homosexual seductions by an older boy that had become condensed in his mind with humiliating experiences in school, a close friend and a relative who each committed suicide and, in adolescence, a cousin who died in an auto accident after an intense day of drinking and recreational drug use. What gradually emerged in the therapy was the extent to which Mr. A's internal world was filled with violence and erotized sadistic fantasies that terrorized him, filled him with intense shame and were directly connected to his phobias and social withdrawal.

When I was first consulted, the analyst had been responding to Mr. A's panic attacks and crippling symptoms by referring him for medication and offering encouragement, structure, support and reality testing. This represented a shift away from her more customary explorative/interpretive stance and it was meeting with only limited success. Our initial conversations helped the analyst to step back from her enmeshment in what appeared to be an unproductive transferencecountertransference enactment and re-think what might be going on from within a more analytic frame. This ‘second look’ allowed her first to re-engage herself more analytically in thinking about the material and then to more openly address the patient's shame and terror that if he revealed the content and extent of his erotic sadistic fantasies, he would be seen as ‘crazy,’ ‘disgusting’ or ‘perverted.‘

As these fears were named and addressed, the treatment began to get untracked. The patient recalled his sexual seduction, expressed fears of being destructively or seductively out of control and revealed how much he blamed himself for his friend's auto accident. His affect became richer, his associations freer and more productive and the sessions became more alive. For example, on the eve of a holiday break, Mr. A talked of his fascination with the aborigines in an Australian film he had seen, described it as depicting “a dark and savage magical place” that was their “real world” and linked it to the

artifacts he had bought to use as inspiration for a novel that he was trying to write. He then described how the physical presence of the artifacts in his study had become so terrifying that he had to put them out of sight in order to remain in the room.

The analyst silently understood this as communicating how interested Mr. A had become in the dark and primitive side of his psyche, a part of himself that the treatment was helping him to explore and try to understand, but also how terrifyingly overwhelming and real his fantasies could feel to him.

An unsaturated interpretation about Mr. A's interest in and fear of the savage and primitive led to associations about his cousin's car crash, the gruesome way his uncle killed himself and left himself to be found and Mr. A's envy of what he assumed was the freedom and abandon of his cousin's sexual relationship with the girlfriend, who also died in the car crash. The analyst responded by noting that the patient felt his cousin had found his soul mate, but then they died, to which Mr. A movingly confessed how guilty he felt for participating in the drinking and drug use that preceded the accident, how he could not tear himself away from the cousin's coffin at the funeral and then in the session burst into tears. This ushered in a long delayed mourning reaction for the cousin and further analysis of the patient's sense of guilt.

Over the following weeks, the analyst helped the patient notice the changes in his affective availability and how it seemed to intensify with therapeutic contact and wane in the gaps between sessions. This led to the analyst's wondering if there would be some advantage to adding a third or even fourth session to try to maintain momentum and keep the affect alive. Although this tentative suggestion brought forward intense dreams of homosexual pleasure and of a building that looked lovely from the distance but proved to be only a façade covering rot and decay, dreams the analyst could then interpret as fearful responses to what a more intensified treatment schedule might reveal, the patient was ultimately able to accept the importance of more frequent sessions and the analysis deepened further.

The second patient, Mr. B, was an even more dysfunctional and traumatized middle-aged man, who had been homosexually seduced by a foster father and other figures as a child. Years before beginning treatment, Mr. B had impulsively ended a troubled marriage and exiled himself from his three children. Then, he killed a woman in an auto accident and his life broke down completely in an onslaught of primitive guilt, fear and self-hatred. At the time I was consulted, Mr. B was beginning the second year of a twice weekly, face-to-face psychotherapy with a young analytic candidate, who practiced in a rural area and had limited access to referrals. The candidate was being pressured by his Training Committee to begin a first control and was somehow hoping that despite the patient's life circumstances – Mr. B had been unemployed and non-functional for several years, was phobic about appearing in public and virtually housebound, unhappily remarried to an impulsive and sometimes abusive woman and spent all of his time caring for a severely regressed, autistic sounding adolescent step-son – that this patient would become his first ‘official’ training case.

Prior to beginning the consultation, the candidate had been unsuccessfully trying to make empathic contact with Mr. B by emphasizing the many traumas, losses and betrayals in his history and encouraging him to re-engage with the world. In contrast, the first phase of the consultation helped the candidate to better understand and address the enormity of Mr. B's unconscious guilt, self-blame, need for punishment and fear of his own rage. This shift in therapeutic focus, away from the trauma induced by ‘bad objects’ to the patient's internal, psychic sense of agency, guilt and murderous, destructive wishes soon began to produce a palpable change in the sessions. Mr. B then described the auto accident in which the woman was killed in a new way. The candidate learned that it did not take place on a clear, sunny day, but that the weather conditions and visibility were poor. The patient was driving his young children somewhere, and two of them were quarreling in the back seat. The third was fussing in the front seat and when he refused to get something for Mr. B from the glove box, Mr. B irritably reached for it himself. It was at that moment that the accident occurred and the woman was killed.

This new version of the event astounded the candidate and allowed him to better explore and analyze the patient's guilt and self blame and sort out the difference between a terrible and tragic accident and an act of intentional murder. It also allowed him to re-examine Mr. B's failure to defend himself at trial, his wish to be sent to prison and his depressive withdrawal and collapse from the perspective of self-blame, need for self punishment and wish to avoid anger and conflict at all costs. This led in turn to associations to and

examination of Mr. B's guilt and self-blame for the initial break-up of his childhood family (8 years old); his feeling that he must submit to the sexual abuse of his foster father and brothers as punishment and confirmation of his worthlessness; etc.

After several months, the treatment had deepened considerably and the candidate decided to apply to have the case considered as an official training case. I should add that in his Society, which is independent and not part of the IPA or APsa, candidates are required to have 2 training cases at a minimum of 3-4 times per week, but may request approval for a third case that is deemed ‘atypical.‘ The response of the Training Committee was that he should begin to see if he could arrange to add a third session. It was at this point that I intervened.

While I am very much in favor of intensifying the frequency of treatments, I felt that there was nothing in the material to indicate that there was an internal, unconscious pressure to do so. The motivation seemed to be coming from requirements of the Training Committee and their view of the candidate's training needs. In this case, especially, given that the patient's childhood was filled with disregard of his needs and interests and his being narcissistically and sexually appropriated for the use and needs of others, I felt that to use him once more for the needs of others – i.e., the candidate - could be dangerously unproductive. Would it be or be felt as forcing him to submit once more and sacrifice what was in his best interests to the rapacious needs of others? Would a poorly timed intensification of meetings overload and outstrip his capacity to use the setting, a capacity that had just been newly mobilized in recent months?

I raised these questions and concerns with the candidate, who then reported them to the Training Committee. A meeting was held to discuss the case that included the candidate and myself. We eventually agreed that acceptance of the case as an ‘atypical’ control should be considered on the merits of the treatment and not be contingent on the setting being forced to meet an external administrative requirement about frequency. This would allow the case to continue at its present frequency. The question of increasing the frequency, should it become indicated or useful, would better be dealt with in relation to the case itself and at a time that the process indicated would be useful to consider. What I wish to convey in offering this second example is that despite our conviction about and enthusiasm for psychoanalysis and the intensification of the treatment process, the latter must always be considered in the current context and tailored to fit the needs and capacities of the patient and the pair.

9 March 2013