Emotional Presence in Psychoanalysis

Theory and Clinical Applications

John Madonna

• Publisher: Routledge
• Year: 2016
• ISBN:
  9781317496489
• Edition: 1
• Topic: Psychology
• Subtopic: Psychoanalysis
• Index: Psychology

Emotional Presence in Psychoanalysis provides a detailed look at the intricacies of attaining emotional presence in psychoanalytic work. John Madonna and a distinguished group of contributors draw on both the relational and modern psychoanalytic schools of thought to examine a variety of different problems commonly experienced in achieving emotional resonance between analyst and patient, setting out ways in which such difficulties may be overcome in psychoanalytic treatment, practical clinical settings and in training contexts.

A focused review of relevant comparative literature is followed by chapters featuring individual clinical case studies, each illustrating particularly challenging aspects. The uniqueness of this book lays not simply in the espousal of the commonly accepted importance of emotional resonance between analyst and patient; rather it is in the way in which emotional presence is registered by both participants, requiring a working through, which at times can be not only difficult but dangerous. Such efforts involve a theory which enables the lens to understanding, an effective methodology which guides intervention. The book also calls for the art of the analyst to construct with patients meanings which heal, and possess the heart to persist in commitment despite the odds. Emotional Presence in Psychoanalysis is about patients who suffer, struggle, resist and prevail. It offers distinctive, transparently told accounts of analysts who engage with patients, navigating through states of confusion, hatred and more controversial feelings of love.

Emotional Presence in Psychoanalysis features highly compelling material written in an accessible and easily understood style. It will be a valuable resource for psychoanalysts and psychoanalytic psychotherapists, psychologists and clinical social workers as well as teachers, trainers and students seeking to understand the power and potential of the analytic process and the resistances to it.

Part I

1 Introduction: emotional presence in psychoanalysis

Theory and clinical applications

John Madonna

DOI: 10.4324/9781315712956-1

We know now that it is not understanding ascribed from without by a distant voice that cures the broken human spirit. It is the resonating presence of the other, without provocation, allowing and allowed. Reflecting and mirroring like the good mother, the analyst sharing the primordial dawning of experience, at times in soundless rhythms, beyond words. Then, the eventual coming forth of the longings, fears, the furies, the person separate and suffering in the encounter. And then the light of knowing, which grows within, in the mutual presence which enables advance in psychic development. But this journey can be long, at times perilous. The patient resists out of desperate fear and a need for stasis, and then a dreaded mix of powerful feelings to hate and destroy, to love and preserve—and so recoils, a shattered mind. In less serious, but still profound instances, the individual proceeds through life emotionally and interactionally impaired.

Emotional presence is the ability to sense, feel, and then think the experience of the patient. This occurs as a result of the processes of projection, projective identification, the analyst's objective counter transference, as well as the analyst's innate inclination for empathy. Also crucial is the ability and determination to see through the resistances which are prevalent, appreciate and believe in the patient's potential for health. It is fundamental for starting anew, the chance again to relive, and so reformulate, the beginnings of human psychic experience. Though the urge to do so has a pull which is built in, it is so strongly resisted not just because of the feelings which cannot be managed, but because the urge for endings which lies beneath them is so compelling. The desire for eternal sleep, as Shakespeare (1603) said, which is the “consummation devoutly to be wished for” (p. 626), takes hold in the face of inordinate challenge. Freud's (1920) theory of death drive is based on this.

So the efforts of the analyst to make and maintain presence need to be both wisely fashioned, and at times heroic. An analyst is present according to the capacity for attentiveness to the patient, in the tolerance of the patient's various dynamics, and in the skill of his understanding. With more integrated patients, interpretation may be employed aimed at the reasonable ego in an attempt to address the “afflicted ego” of the patient (Geltner, 2013, p. 161). In more serious cases emotional communication is more productive in addressing transferential conflict and challenge. In the broadest sense presence is whatever the patient needs to be held in treatment and to move toward eventual relatedness. That might mean little contact or much contact, intellectual or emotional resonance as the circumstance requires.

Beyond his primary method of analysis of transference and resistance, Freud (1913) emphasized the broader context of the analytic relationship in which encouragement and education was also used to support and reinforce the patient's progress. Freud's presence as a benignly interested authority figure is well documented and reflects his capacity for empathy (Gay, 1988). Certainly his emphasis on the immediacy and salience of encounter was inherent in his thinking about transference itself:

Freud came to feel that the displacement of forbidden impulses and fantasies onto the person of the analyst is essential in helping the patient to experience and work through the issues as lived and deeply felt realities rather than intellectual abstractions and memories.

(Mitchell & Black, 1995, p. 231)

Even in the classical tradition the classical analyst needs to be able to be present and remain so in order to receive the transference and not, as Josef Breuer did, flee from it. In being present the analyst, as an interested authority, comes to understand and can help the patient through interpretation (i.e. making the unconscious conscious) to realize the origins of the transference.

The analyst as a separate figure was apparent in the concept of the superego which Freud developed later. “Repression is instituted and maintained not just because the forbidden impulses are dangerous (the ego's concern) but because the child thinks they are wrong, evil, bad (the superego's concern)” (p. 238). When the analyst interprets the transference the curative effect is not just related to the lifting of repression but the availability of the analyst as a separate but interested entity in the present. This lessens the projective-introjective repetition which keeps the grip of the superego tight (p. 239). As the patient introjects the mediating aspects of the analyst, the patient's internal attitudes toward self and others become more realistic and less punitive.

In this regard Sandor Ferenzci did much to weaken the power of the superego by carrying the notion of the analyst's presence to an extreme, engaging in at least two known instances of sexual encounter with female patients (Stanton, 1991). The impropriety of such behavior notwithstanding he innovated a method of mutual analysis which was to be the harbinger of transparency which characterized the later interpersonal and intersubjective schools of analytic thought. This set the stage for the focus on countertransference as the site for intervention.

The analyst as a separate parenting presence is emphasized by contemporary object relations theorists, Freudian ego analysts, and self-psychologists. They “all agree that what is curative in the analytic relationship is the analyst's offering some form of basic parental responsiveness that was missed early on” (Mitchell & Black, 1995, p. 240). There are two trends to this thinking according to Mitchell and Black. They cite Strachey's belief that “normal analyzing is not an absence but a presence that provides missing parental responsiveness” (p. 240). They also cite Pine (1985) who says that “the very activities of reliable attendance, careful listening, thoughtful interpreting are usually similar enough to attentive parenting to reanimate the stalled developmental process” (p. 240), which elevates transference dynamics for interpretative action.

Another trend of thought asserts that the analyst must be even more active in intervening, “has to do something different from ordinary interpreting, to create, in the analytic situation real experience that evokes the specific missed provision of childhood … to be more available … to respond to their needs in a more individualized way” (p. 240). Winnicott's altering of the environment and highly personalized intervention (Little, 1985) and Kohut's (1984) mirroring of patients with specific kinds of self-deficits are examples. The interpersonal tradition advocated honesty in the authentic here and now encounter. And it was in the working of the countertransferential field that these theorists made a tremendous impact. “Fromm felt that the analyst's frank and honest reactions were just what the patient needed to know about and understand … (through) judicious and constructive disclosure” (Mitchell & Black, 1995, pp. 244–245).

In line with this “Sullivan regarded the basic unit of the mind as an interactional field rather than as a bounded individual” (Mitchell & Black, 1995, p. 244). The Kleinian notion of projective identification, and the countertransference play that results, “regards the analyst's experience as the site where the patient's dynamics are to be discovered and recognized … a key device for gaining access to the repetitive self object configurations of the patient's internal mold” (p. 245). Working through the transference and countertransference neurosis is considered to be the fundamental core of the analytic work (p. 245). Neo Freudians (i.e. Chused, 1989; Jacobs, 1991) as well as some self-psychologists (i.e. Kohut, 1984; Stolorow, Branschaft, & Atwood, 1987) and others (i.e. Aron, 1991; Bleckner, 1992; Hoffman, 1983) also espouse the view of the utility of the analyst's versatile presence in the countertransference process in enabling the patient to gain therapeutic comfort with him/herself and for the eventual giving up of the transferential repetition.

The patient gaining comfort with the self is an important aspect of cure and while Pine (1990) asserts interpretation in the transference as central, the process of change he says also occurs “in the context of intense and intimate relationship where things matter for the patient, both verbal interventions and relational factors” (p. 255). This is not always easily achieved.

The difficulty associated with being present in the face of early pathology is well documented by practitioners in the Modern School of Psychoanalysis (Bernstein, 1992, 2013; Holmes, 2013; Liegner, 1995; Margolis, 1994; Spotnitz, 1985). Less concerned about the use of interpretation as primary, Hymen Spotnitz (1985) set the standard for establishing therapeutic presence with those individuals suffering severe narcissistic injury, merging across the fluid ego boundaries which characterize the preoedipal psyche. By measured responses to the patient's contact function (i.e. the manner by which the patient makes verbal or non-verbal contact with the analyst), the analyst provides an interactional environment which is not overly stimulating. It is an environment which respects the narcissistic defense constructed to prevent hostile destructive impulses from being enacted toward the objects in the patient's mind, as well as in the patient's actual world. Spotnitz asserted that by innovative processes of joining (i.e. allowing, accepting, and agreeing with what the patient presents in terms of non-verbal and verbal communication) and reflecting (i.e. echoing, reiterating, mirroring communications) of the patient's resistance to verbally focused relationship, verbal communication could eventually occur. Processes of joining and reflecting give the necessary and reassuring impression that the analyst is like the patient. This can at times, however, as Spotnitz (1969, p. 40) says, lead to a “torrent of threats, insults and verbal abuse” toward the analyst, as the inherent hostility embedded in the joining and reflection is expressed back and results in increases of intensity.

The extent to which the analyst is able to receive and tolerate the patient's expression of such feelings, often murderous, sustained by a persistent caring interest in the patient's mental health, will result in a growing realization by the patient that his words do not injure or destroy. The narcissistic defense then becomes unnecessary. In the caldron of numerous such exchanges, and increased tolerance for them, the patient comes to be able to differentiate those which had their origins during the preoedipal phase of development when self and object impressions were merged and confused, and more clearly defined later stages. Object relatedness occurs after that early hostility and rage, having found suitable expression, frees the individual to be able to experience more affectionate feelings.

Echoing Spotnitz, Meadow (2005) affirms the need for the analyst to conduct analysis “with the conviction that there is an innate urge to destroy” (p. 5). She says that this inclination must be recognized in every case with the aim of providing appropriate discharge in language. Detecting the presence of such feeling and intention can at times, however, be like searching for a rare coin. Much depends upon the analyst's capacity to listen well. “The analyst will get to know the patient by how he himself thinks, and more importantly, feels about the patient he is with” (p. 6). Careful attention to and toleration of one's induced feelings coupled with “object and ego oriented questions, explanations which facilitate communication … echoing … overvaluing and undervaluing … ego syntonic and later ego dystonic joining” helps to resolve the resistance to communication (p. 119).

Though it seems a straightforward enough process, Spotnitz (1985) warns of the complexity of such an undertaking. The difficulty lies in the need to receive and hold “the induced feelings deeply and undefensively” (p. 164), and to simultaneously analyze the residue of one's own pathology stirred as it may be by the patient's inductions. The perils associated with objective countertransference reactions are, according to Spotnitz, formidable in and of themselves; “The realistically induced feelings account more for failures in the treatment of schizophrenics than subjective reactions” (p. 163). This may be due to the variability and intensity of such inductions which can surprise the analyst with their occurrence, overwhelming defenses as well as composure. Insofar as the analyst may have some familiarity with his own subjective countertransference inclinations, he may be somewhat more able to recognize and deal with those. However, the subjective propensities of the analyst may in some cases become so infused by the patient's inductions as to reach a level of intensity which is nevertheless debilitating. To be present to the patient, the analyst needs to be acutely present to himself.

Spotnitz urged the analyst to allow the negativity associated with the objective induction(s) to grow within and not resist it by attempting to respond “therapeutically” in ways which are premature and hence pre-emptive. More specifically Spotnitz concludes that “the main source of countertransference resistance … is the therapist's need to defend himself against the rage and anxiety induced by the patient's hostile impulses” (p. 170). Despite the pressure on the analyst “selectivity and timing of interventions is crucial” (p. 165).

In keeping with Spotnitz, Meadow (2005) stated that, in an effort to reach a level of emotional awareness, the analyst's definitive awareness of self is crucial to the course and outcome of treatment. She asserted that a certain courage is required to face the “primitive residues in one's own personality,” as these, stirred by the inductions of the patient, collide producing “uncomfortable thoughts and feelings” that can propel us away from truly being in contact with the patient's intra-psychic experience (p. 74). Self-analysis, as well as consultation with a supervisor/colleague, can aid in the persistent holding of the induction(s), and can inform analytic intuitive awareness of the patient's inner world, and ultimately enable the analyst to construct emotional communications which foster and reinforce a sense of presence.

That said, owing to how strong the inductions can be with the consequent countertransference affects, the difficulty on the part of the analyst in recognizing, metabolizing, and utilizing these can be enormous. The prevalence of discussion regarding countertransference resistance behavior in psychoanalytic literature attests to this. Spotnitz (1985) provides a list of such behaviors which is, however, by no means complete:

Stopping a session early or late; having difficulty keeping quiet; finding oneself unexpectedly thinking about a patient between sessions; focusing one's mind to go in a particular direction; expressing feelings when one has no intention of doing so; unwillingness to communicate emotion; forgetting an appointment or name of a patient; impatience at feeling out of touch with a patient; behaving in a way to prevent the patient from saying something one does not want to hear; responding in a hostile tone of voice to the patient's hostility; striving to appear more knowledgeable than the patient; impatience over the patient's unclear communication or failure to provide analytic material; clinging rigidly to one technique; states of anxiety before or after, as well as during the session which do not appear to be connected in any way with the patient; accepting the validity of the patient's feeling that he is incurable; joining the patient in undisciplined discharge reactions; various feelings of anxiety or disturbance that interfere with analytic activity; cloudy understanding or misunderstanding of some information that the patient is communicating over and over again.

(p. 170)

Though the treatment destructive potential of such countertransference resistance behavior is ubiquitous, there may be instances when such behavior can be as useful. This supposes that irreparable damage has not been done to either patient or analyst and that the experience has yielded valuable information about the patient, analyst, and the process. Indeed, in some cases significant countertransference resistance is inevitable given the seriousness of the pathology. Though the intensity may signify that the resistance is there in force, so too is the heightened opportunity to address it. Caught in and navigating through states of countertransference resistance provides opportunity for a primal type of resonance. The fear provoked in the analyst associated with doing so, however, can be profound and at t...

Table of contents

• Cover
• Half Title
• Half Title
• Title Page
• Copyright Page
• Table of Contents
• Preface
• Acknowledgements
• List of contributors
• Part I
• Part II
• Part III
• Index