Although meetings of The American are not, like the biennial meetings of the IPA, organized around a theme, invariably they reflect a clustering of concerns, recurrent themes and issues that reflect the current state of psychoanalysis.
At the December meeting these revolved around the nature of the psychoanalytic situation and the differing emphases placed on insight and interaction in the curative process. This was the subject of George Allison's plenary address, “On the Homogenization of Psychoanalysis and Psychoanalytic Psychotherapy.” Allison's main thesis—that definitions of psychoanalysis and psychoanalytic therapy should be based on some agreement on their mode of therapeutic action—may serve as an organizing focus for many of the issues debated at the meeting. The murkiness and confusion surrounding the relative advantages of the technical approaches advocated by different schools of psychoanalysis stem from difficulties encountered in articulating the principles of therapeutic action.
Allison proposed that psychoanalysis and psychotherapy exist as treatment modalities along a continuum defined by transference analysis at the psychoanalysis end of the spectrum, and unanalyzed interactions at the supportive psychotherapy end. According to Allison, interactions, even when analyzed, are because of the structure of the treatment—e.g., use of the couch, frequency of sessions—experienced differently in psychoanalysis and psychoanalytic psychotherapy. Another factor differentiating the two modalities is the nature and extent of the therapist's activity. The psychoanalyst is less active, less directive, less goal-oriented, and less consciously supportive than the psychotherapist. Implicit here is some judgment about the patient's needs and how to meet them. There is a kind of quantitative agreement about advice and direction: more of it moves the treatment away from the analytic ideal, presumably because the patient in analysis is not in need of knowledge about how to deal with the problems and decisions of everyday life, but rather suffers from unconscious conflicts that cannot be altered by direct intervention.
The role of attunement, empathy, and human responsiveness is less clear-cut. For one thing, these qualities are hard to define or specify. Most often they are discussed in the context of some extreme breach of these qualities in a treatment situation. Allison noted that psychoanalytic psychotherapy is no guarantor of human responsiveness, nor does psychoanalysis preclude it. “Judicious responsiveness,” he observed, is a quality that has usually been implicit in the conduct of an analysis. The problem arises only when it is viewed as a formal constituent of analytic technique. It is in this context that the question of therapeutic action becomes relevant. For some analysts, Allison maintained, judicious responsiveness becomes dangerous license.
Arguing against the homogenization of psychoanalysis and psychotherapy on the basis of their different modes of therapeutic action, Allison appealed to a consensus on this point among analysts as diverse as Wallerstein, Gill, Rangell, Stone, Oremland, Weinshel, Renik, Sachs, and Michels. For Allison the defining feature of psychoanalysis as a treatment is the fact that transference is fully interpreted and resolved by “interpretation, reconstruction, or working through.” By contrast, “unanalyzed interactional, supportive, or relational factors predominate in the therapeutic action of psychotherapy.” There is agreement, Allison maintained, that insight (intellectual and affective) is mutative, even though “inadvertent … unanalyzed transference-countertransference enactments, corrective emotional experiences, and identifications with the analyst” occur in analysis as well as in psychotherapy.
Allison's address, a plea for maintaining the distinction between psychoanalysis and psychotherapy, leads naturally to a discussion of the meeting's final panel, chaired by Lawrence Friedman, on Kurt Eissler's classic paper, “The Effect of the Structure of the Ego on Psychoanalytic Technique.” That paper was an effort to maintain the sharp boundary between classical analysis and modifications, proposed by Alexander and his followers, that would blur the distinctions between analysis and psychotherapy that existed in 1953. The paper was described by several panelists as an effort to maintain this distinction by defining the special circumstances in which it could be breached. Arnold Cooper referred to the paper as the Maginot line of orthodox technique: deviations from standard (i.e., interpretive) technique are necessary and inevitable, but Eissler maintained that the effect of the breaches must be repaired through interpretation so that the primary mode of treatment can be resumed. Cooper noted that Eissler's discussion considers the analytic ideal only in terms of variables in the patient and in the situation. Analyst variables (such as countertransference) seem never to enter the discussion.
Paul Myerson addressed himself to the needs of patients unable to use interpretations. He felt that Eissler had not fully realized the importance of the context in which an interpretation appears. Many of the difficult patients Eissler was writing about lack the experience, the skills, or the integration to form the kind of realistic relationship within which an interpretation can be accepted as a helpful offering. A “preunderstanding” is necessary before the particular understanding of the interpretation is possible.
Shelley Orgel's poignant contribution was a description of what it was like to be trained in the fifties according to a set of technical precepts that most analysts today would view as rule-bound, rigid, and fraught with warnings. “The air of my institute,” he observed, “was heavy with the conviction that we were being trained to join the ranks of the better analysts, in fact, the true analysts, as opposed to members of other schools, who soft-headedly derailed and ‘ruined’ the process and lapsed unknowingly into psychotherapy. Those others, we observed, gratified manifest derivatives of their patients' unconscious wishes and allowed discharge of the pressing energy of the drives instead of channeling it into verbal thought and speech that would yield insight and structural change.”
In stark contrast to the ethos of his training, he went on to articulate an interactional perspective: “the ordinary personality of the particular analyst (including his countertransferences), interacting with that of the particular patient, results in creating the forms in which the manifestations and origins of unconscious conflicts and the more or less structured compromises comprising their shifting solutions, including major resistances and transferences, appear and can be studied and understood in the analytic situation. One may question whether some of the stubborn resistances needing finally to be approached using parameters are not those which ‘match’ the analyst's own; the analyst's difficulty is in working with them interpretively [rather] than making noninterpretive action necessary to resolve impasses.”
Citing other models, best exemplified by the writings of Rudolf Loewenstein in the fifties, Orgel indicated that he gradually came to realize that “humane and sensible behavior[s] by the analyst are indeed possible within the rules and frame of classical analysis” and that “it is neither necessary nor desirable to draw sharp, inviolable boundaries in order to sustain adherence to the psychoanalytic ego ideal.”
Roy Schafer's point of departure was the problem, addressed by Eissler, that arises in efforts to treat patients who are “deeply traumatized or terrified.” Eissler, he said, distinguishes the “unavoidable parameters” accepted as part of “standard analysis”—the personality of the analyst, the necessary use of questions, nonverbal communication,
etc.—from interventions that reflect “unanalytic therapeutic zeal.” Schafer notes where Eissler may have shown countertransference response of his own and emphasizes what Eissler left aside, that the act of interpretation cannot be viewed in vacuo; it too can be used disruptively—for example, “to subdue, seduce, mislead, or hurt patients.” Schafer's strongest objection is in regard to Eissler's recommendation that “the analyst use only analyzable parameters.” For Schafer this entails an omniscient posture that assumes the analyst can decide in advance what is or is not analyzable. Against this, he counsels humility and warns of “excessively meticulous circumspection” on the part of the psychoanalyst.
For Cooper, the problem with Eissler's paper is its tone—scientistic, authoritarian, and conveying the idea that the classical analyst knows exactly what analysis should be and that “we can measure the dimensions and effects of the different activities of the analyst and its effect on the analytic pair.”
The issue of action and interaction in the psychoanalytic or psychotherapeutic situation cannot be separated from the problem of transference. Robert Waelder, writing in 1955, identified three “guideposts, or coordinates, of the problem of transference in psychoanalytic technique.” They are “transference as an obstacle to the treatment, transference as a vehicle (or as the most important vehicle) of the treatment, and transference as the opportunity of direct influence, through identification or retraining.” He observed that all three approaches have their justification and their proper area of application. And it did indeed seem that the panelists and presenters at the December meeting were offering variations on these three aspects of transference.
The panel “Love in the Analytic Setting,” chaired by Henry F. Smith, was of course concerned with transference love. Smith reviewed Freud's paper on the subject, in which he referred to transference love as the work of resistance, then as something “composed of repetitions and copies of early reactions, including infantile ones”—features transference love shares with love in general. It differs, however, from other types of love in being “less adaptable and capable of modification.” Smith cited Lawrence Friedman on the dialectic in Freud's thinking about technique and cure; the dialectic of experiencing and enacting/remembering, and the parallel dialectic for the patient of “passionately committed experience” and “detached contemplation.” Smith quoted Freud's warning to analysts that it “is just as disastrous to the analysis if the patient's longing for love is gratified as if it is suppressed.” It may be noted in passing that the dispute between Freud and Ferenczi was over this very issue of love in the analytic setting. Many, including, most recently, Ernest Wolf, have suggested that it was Ferenczi who launched the debate over the nature of the curative process in psychoanalysis, including the question of the analyst's active participation in the process.
The Smith panel was, in the main, more concerned with countertransference love, the analyst's love for the patient, than with transference love. Smith justified this emphasis by stressing the similarity between transference and countertransference responses: both should be treated as something unreal in a manner for which there is no model in real life, and both have a signal function, alerting the analyst to the psychic state of the analysand. Theodore Jacobs, in discussing the panel contributions of Glen Gabbard, Otto Kernberg, and Estelle Shane, put Freud and Gabbard on one side, and Shane and Kernberg on the other. The former maintain that real love and transference love share much in common, whereas the latter focus on distinctions.
For Kernberg, the difference between childhood love (love organized as the oedipal situation) and transference love is that the latter offers the “possibility, under optimal circumstances, of full exploration in the transference of the unconscious determinants of the oedipal situation.” The difference for him between oedipal and transference love is the same as it is for Brenner: the latter can be analyzed. Kernberg also captured the dialectic of renunciation and retention that is part of object relations: “The working through of transference love also signifies the working through of the renunciation and mourning that normally resolves the oedipal situation, but also acknowledgment of the permanent nature of the oedipal structuring of reality as a consistent frame for all future love relationships. The patient has to learn, in the context of the resolution of his or her transference love, that the search for the oedipal object as a desired reencounter as well as for the healing of the oedipal wounds, is going to be a permanent, implicit feature of all love relationships.”
Perhaps the most original part of Kernberg's contribution was his observation that “it appears to be much easier to explore and read about aggressive countertransference than erotic countertransference.” The most intense erotic countertransferences, he noted, occur in four situations: (1) male analysts treating female patients with strong masochistic features, who develop an intense love for their male analyst as an unavailable oedipal object; (2) analysts of either gender who themselves struggle with strong, unresolved narcissistic features; (3) female analysts with strong masochistic features who are treating seductive, narcissistic men; and (4) female masochistic patients who work at generating powerful rescue fantasies in their male analysts. Kernberg emphasized the importance of recognizing that the patient's erotic transference may be “manifest content” covering latent aggressive transference, “an effort to escape painful conflicts around oral dependencies,” or “the enacting of perverse transference (the wish to seduce the analyst in order to destroy him).”
Kernberg stressed the role that the analyst's exploration of both erotic and aggressive countertransference can play in helping the analyst better understand the driving forces within the patient. It provides, according to Kernberg, “a unique experience for the analyst to penetrate the sexual life of the other sex.” From the technical point of view, the proper analysis of transference love requires (1) the analyst's tolerance of the development of sexual feelings, both homosexual and heterosexual, toward patients; (2) attention to the patient's defenses against the full expression of transference love, while steering a middle course between phobic reluctance to explore and the risk of seductive invasiveness; and (3) analyzing “very fully both the expression of the patient's transference love and the reactions to the frustration of the transference love that unavoidably will follow.” In any case, Kernberg's formulations and prescriptions all fall within the notions of transference as resistance and transference as vehicle (Waelder's first and second aspects).
Gabbard emphasized that “the effort to draw distinctions between transference love and love that occurs outside the analytic situation really misses the point.” Both situations, he argued, “involve the coexistence of new feelings associated with a new object relationship…and a displacement of old feelings connected with a childhood object relationship.” What is distinctive about transference love is not its nature but how it is handled in analysis—specifically, the analyst strives to achieve a dual state of awareness in which he or she is both a participant in, and an observer of, the patient's immediate experience. Gabbard's clinical example concerns the analysis of a male patient who developed a homoerotic transference. In this case it was Gabbard's patient who was interested in using the transference as a means of direct influence (Waelder's third aspect), whereas the analyst was viewing the transference as both an obstacle and a vehicle of treatment (the first and second aspects).
Consider Gabbard's interpretation: “I suggested to Mr. M that in a similar vein he was not so much interested in insights and understanding in the analysis. Rather, he wanted to create a stable relationship with me in which he would be the recipient of interventions that he would experience as punitive and sexually charged, while thwarting my efforts to provide understanding.” Patient and analyst were subsequently able to agree on the insight-promoting quality of transference (the vehicle aspect), with the patient asserting that his relationship with the analyst was much like his childhood relationship with his father, and also reflected a wish for the kind of relationship he missed with his father, who was in the army and frequently away. Gabbard described his discomfort at the frank discussion of his patient's love, a discomfort he could connect to his own longing for an expression of love from his own father. Thus, we have an example of concordant identification, or concordant countertransference.
Stepping back from this vignette, Gabbard focused on his sense of “feeling coerced into playing a particular role vis-à-vis the patient.” According to Gabbard, this could be understood as countertransference “induced by the patient as a way of actualizing an internal scenario.” Only by experiencing this scenario could the analyst grasp “the nature of the patient's internal world.” Here we have an example of countertransference as a vehicle of insight. Gabbard leaves us with the suggestion that we may have underestimated how intolerable the “naked expression of love and affection” in the analytic situation can be for the analyst. He suggests that our language may reflect this dis-ease; we find it easier to talk about erotic transference than about love.
Shane's contribution, “Varieties of Love and Intimacy in the Analytic Setting,” is based on the proposition that from the vantage point of “self-other relatedness” there are two kinds of patient. One type is self-centered; the other is object related. The self-centered patient develops transference in which the influence aspect predominates, whereas that of the object related patient tends toward resistance and insight. According to Shane, Freud maintained this distinction in holding the self-centered patient essentially unanalyzable. She illustrated her thesis with two clinical examples. Her first patient, of the self-centered, object-impoverished variety, went to the analyst for affirmation and admiration. Shane, having made a judgment about the essential nature of her patient's personality and needs, acted accordingly: “In terms of therapeutic boundaries, I did not interrupt her particular experience of our relationship with either confrontation or interpretation. I certainly understood that she was getting gratification from it, but this, far from disturbing me, seemed to me to be necessary for this patient in order to augment her shaky sense of self and low self-esteem.” Shane stressed the importance of not conveying to the patient her countertransference reactions to the patient's complaints, demands, and expectations. Shane acknowledged the sharp contrast between her approach and that of Kernberg. She drew a sharp contrast between her first patient and two others, for whom the transference had little to do with the need for “self-enhancement or self-cohesion.” In these latter instances, transference-countertransference configurations clearly line out on the axes of Waelder's first and second aspects.
In his discussion of the panel, Theodore Jacobs stressed that, in regard to both love and hate, analysis is a two-way street. The analyst has feelings, generated both from within and in response to the patient's affects, and they inevitably lead to enactments. “While clearly such enactments can create serious difficulties in an analysis,” He observed, “they usually do so when what is enacted on the analyst's side gratifies needs of his own that he cannot or will not examine.” Stressing the need for the analyst to analyze his role in the analytic interaction, Jacobs observed that enactments must be analyzed not merely to obviate difficulties in the analysis, but also for the insight they offer into the nature of the analysand's unconscious conflictual configurations. Jacobs also stressed the analytic dialectic of transference as both a repetition of the past and a new creation.
Each of the presentations and panels examined thus far has a technical import. All of them address various boundary-related issues: the boundary between psychoanalysis and psychotherapy; the range of noninterpretive interventions (parameters) consistent with psychoanalysis; and the boundaries between transference love and mature love, neurotic love and childhood love. The panel on “Interpretive Perspectives on Interaction in the Psychoanalytic Relationship” took up these concerns within a more general focus on patient and analyst in the analytic interaction. As Morris Peltz, who chaired the panel put it, the aim was to explore “how the mutual interactions between the patient and analyst are experienced, understood, and interpreted.”
Peltz began by asserting that the analyst's functioning as a blank screen is no longer accepted, if it ever was. He went on to note the shift in analytic terminology from the pejorative “acting out” to the insight-promoting “enactment.” Peltz proceeded to identify broad areas of agreement among the panelists that subsumed the more specific points on which they disagreed. This consensus included the centrality of Waelder's type 1 and 2 transference to any definition of psychoanalysis. But who, after all, would not embrace a credo that includes (1) the centrality of interpretation to the analytic task; (2) the need to scrutinize interactions for their interpretive meaning; (3) the need to authentically engage the patient in the therapeutic situation; and (4) the need to respect the patient in a way that transcends specific theoretical commitments? The panel—which included an interpersonalist, Edgar Levenson; Evelyne Schwaber, with her particular approach to analytic listening; and three more classical analysts: David Raphling, Owen Renik, and Dale Boesky—reflected a dynamic of its own. Schwaber's paper served as a pivot for the discussions of Renik and Boesky, and as a counterpoint to Raphling's paper. There was a polarity in the positions of Levenson and Boesky, and some commonality of approach between Renik and Levenson.
Schwaber's paper about the concept of interaction stressed the importance of a shift from an interpersonal, interpsychic social purview to an intrapsychic focus. She proposed that this shift can be achieved by using the qualifier “experienced” before the term “interaction.” A focus on interaction as seen from the patient's point of view helps the analyst avoid premature closure dictated by theoretical commitments or emotional needs.
According to Schwaber, the analyst is an observer of, and a participant in, the intrapsychic reality of the analysand. The analyst encourages the analysand to convey to the analyst the analysand's experience of the interactions between them. This approach resolves for Schwaber the paradox of defining psychoanalysis as a “one-person psychology” with “coparticipating” elements.
Schwaber's vignettes each contained a disjunction between the analyst's sense of the interaction, theory-driven or countertransferentially driven, and the analysand's sense of it. For Schwaber it is the latter and not the former that constitutes the psychoanalytic database. She described her perspective as “highlighted by the recognition that in the effort to locate the patient's intrapsychic reality I must not blur the boundaries of our differing perspectives nor assume a greater truth lying within my own.” This approach, Schwaber maintains, has “profound mutative potential.” One of her patients reflected, “You understood the way my mind works without saying it should work another way; you found logic in my responses that let me experience more about how my mind works.”
In his discussion of Schwaber, Boesky raised a key question: how do her criteria for deciding when to intervene or interpret differ from those of other analysts? His question took for granted the validity of Schwaber's strictures on closure arising out of theoretical commitment or emotional need. Boesky allowed that analysts agree that we should be as aware as possible of our biases, our needs, and our subjectivity. But he insisted that the matter does not end there: at some point the analyst will intervene and offer an interpretation to the patient, and the interpretation will draw from a menu of possibilities particular to that analyst, reflecting theoretical interests and predilections, life experience, and clinical experience. According to Boesky, more is required than open-mindedness, empathic attunement, humility, and patience.
Renik agreed with Boesky and Peltz that the image of the psychoanalyst as the detached surgeon is dead. For Renik, the analyst is, par excellence, a participant-observer who brings to the analytic situation a subjectivity including needs and wishes. Renik maintained that it is neither possible
nor necessary for the analyst to avoid expressing countertransference in actions. Noting that counter-transference enactment always precedes countertransference awareness, he characterized this sequence as corollary to the Darwinian principle that a motor behavior lies at the core of every affect; this notion contradicts the Freudian idea that thought and behavior are mutually exclusive alternatives.
Renik characterized these precepts about the analytic situation as part of a theory of intersubjectivity. He went on to criticize Schwaber's approach, asserting that it is impossible for the analyst to set aside personal values and views of reality when listening or interpreting. He questioned Schwaber's assumption that an analyst's parental responses can be isolated or subtracted from the rest of analytic activity. He returned to his view of the analyst as a participant-observer whose countertransference enactments are a constant aspect of technique: “Sometimes it is useful for an analyst to accept the need to act under the influence of personal motivations of which he or she has been aware before these motivations can be thoroughly investigated.”
Renik asserted that the unconscious personal motivations expressed in action by the analyst are not only unavoidable but are necessary to the analytic process. It is precisely because of the analyst's capacity for self-deception that he or she is able to enter spontaneously into corrective emotional experience with the patient without the presumption and hypocrisy of deliberate role playing. For Renik, the emotional involvement of the analyst is a prerequisite for successful analysis.
Renik retained a place in the analytic interaction for the analyst to offer an interpretation of reality different from that of the patient. He thus joins analysts like Irwin Hoffman in urging analysts to “speak their minds.” For Renik, this recommendation derives from a perspective which allows the patient, whose autonomy is stressed, to accept or reject the analyst's inferences. Renik suggested that his approach can be liberating for both patient and analyst, while guarding against the negative effect of idealization, of making the analyst the ideal mother who “understands” perfectly. He concluded with a plea for a recognition of the irreducible subjectivity of the analyst.
Boesky viewed Renik's presentation as a contribution to our understanding of countertransference. Just as the patient cannot avoid transference acting out, similarly the analyst cannot avoid countertransference enactments. He approved Renik's stress on the “inevitable subjective bias of the analyst's interpretations and the impossibility of achieving objective closure.” Like Renik, Boesky was less sanguine than Schwaber that an “analyst's personal responses can be even listed and subtracted from the rest of his or her analytic activity.”
For Boesky, “interactions are a royal road to analytic understanding of the patient's psychology.” Putting it this way avoids the dichotomy of interpretation versus relationship in regard to the therapeutic action of psychoanalysis. The important dialectic to be explored is that which emerges from a shifting emphasis on listening from the point of view of the patient and having ideas about the patient. Boesky does not believe that neat rules of conduct can be prescribed for the analyst. The royal road is bumpy, tortuous, hard to see, and hard to traverse.
Raphling's paper, “Interpretation and the Anxiety of Influence,” contrasted sharply with Schwaber's high valuation of listening from the patient's perspective. Raphling insisted that the analysts's task is not merely to understand the patient but to intervene according to some view of what constitutes analytic progress and how it can be fostered. We cannot be indifferent, he argued, to the results of our interventions.
Thus, for Raphling, the analyst cannot always be occupied with simply doping out things from the patient's perspective: the analyst makes judgments and comparisons according to “theoretical assumptions about pathogenesis and technique,” and these may be different from Schwaber's. Her judgment seems to be that what is technically effective is listening with a focus on the patient's perspective and sharing with the patient the recognition of failures to do so. Such an approach, Schwaber believes, avoids any directive aspect to interpretation. Raphling, like Renik and Boesky, believes this is neither possible nor desirable. The analyst's agenda for the patient is legitimate and should not be hidden.
Raphling put forward a view of interpretation as a compromise formation for the analyst and a vehicle of information and direction for the patient. The analyst's task is to minimize the distorting influence of countertransference; the task for the patient is to assimilate and use the analytic insight while maintaining autonomy, a point stressed by Renik as well.
Edgar Levenson was emphatic in his assertion that “every interpretative offering of the therapist…reveals as much about the therapist as it does the patient” and that “the patient usually knows it.” Levenson went even further in deconstructing the classical psychoanalytic position, which has emphasized the patient's subjectivity (transference) and the analyst's objectivity (as neutral observer and interpreter). For Levenson it cannot be that “the therapist is the agent of change for the patient through an explication of the patient's unconscious internal process which is signaled by ego defenses and distortion.” Indeed, the very terms we use—corrective emotional experience, parameter, enactment—circle the central principle that the therapist participates in the treatment process “out of his/her own being, own life experience.” Levenson derives this principle from interpersonal psychoanalysis, a theory that emphasizes the importance of a social and cultural experience “channeled through the family” for a “superordinate intrapsychic system.” From this standpoint, “anxiety is interpersonal and relational” and the “relationship between historical and contemporary experience [is] complex.”
Levenson filed a brief for mutuality in the analytic relationship, noting that change is a two-way street: “Cure becomes a mutual process and the patient is not only the interpreter of the analyst's experience but a collaborator in the therapist's cure.” For Levenson there is nothing special about the psychoanalytic interaction, though he acknowledges the importance of the “safety of restraint” that makes the process possible.” But ultimately, for Levenson, the symmetry of analysis as an interpersonal process means that “the patient does not learn from us how to deal with the world.” Rather, “the patient learns to deal with us in order to deal with the world.”
Boesky's reply to this is revealing of the boundaries of agreement and dissent within the diverse psychoanalytic community. Boesky suggested that there is a consensus across the theoretical board that the analyst participates emotionally in the analytic interaction. The issue is whether the interaction is “genuinely mutual.” He invoked the one person/two person axis in categorizing the theoretical difference between Levenson's interpersonal view and the intrapsychic perspective: “I prefer a one-person psychology to investigate two-person interactions.” He observed that the problem of the validity of the patient's perceptions of the analyst is conceptualized differently within the two frames. He agreed that the interpersonal is the proper subject of psychoanalysis and that it includes “the real and actual behavior of parents in the past and of the analyst in the present.” But he contended that this interpersonal domain can be studied through an intrapsychic methodology.