The Work of Psychoanalysis

Sexuality, Time and the Psychoanalytic Mind

Dana Birksted-Breen

• Editorial: Routledge
• Año: 2016
• ISBN:
  9781317332145
• Edición: 1
• Categoría: Psychology
• Categoría: Psychoanalysis

Psychoanalysts working in clinical situations are constantly confronted with the struggle between conservative forces and those which enable something new to develop. Continuity and change, stasis and transformation, are the major themes discussed in The Work of Psychoanalysis, and address the fundamental question: How does and how can change take place?

The Work of Psychoanalysis explores the underlying coherence of the complex linked issues of theory and practice. Drawing on clinical cases from her own experience in the consulting room Dana Birksted-Breen focuses on what takes place between patient and analyst, giving a picture of the interlocking and overlapping vertices that make up the work needed in psychoanalysis. Some of the key topics covered include: sexuality; aspects of female identity; eating disorders; time; dreams; disturbances in modalities of thought; and terminating psychoanalysis.

This book draws different traditions into a coherent theoretical position with consequences for the mode of working analytically. The Work of Psychoanalysis will appeal to psychoanalysts and academics in psychoanalysis, psychotherapists, as well as postgraduate students studying courses in these fields.

1 SETTING THE SCENE

DOI: 10.4324/9781315658803-2

Once the stage is set, psychoanalysis ‘gets to work’, inevitably, immediately and as of its own accord. Transference, repetition, regressive modes of thinking are set in motion. The scene includes an analysand who is suffering and making a demand, a psychoanalyst who is offering help, is receptive and unhurried, sessions at an intensive frequency and at regular times in the same place, and with the analysand in the reclining position. Bion (1979b, p. 247) writes:

In analysis, the patient comes into contact with the analyst by coming to the consulting room and engaging in what he thinks is a conversation which he hopes to benefit by in some way. Likewise the analyst probably expects some benefit to occur – to both parties. The patient or the analyst says something. It is curious that this has an effect – it disturbs the relationship between the two people. This would be true if nothing was said, if they remained silent.

But the ‘scene’ is above all a reference to the scenarios which will, from the first moment, be created by the patient with the participation of the analyst, with whose own scenes they will interlock. There will be a constant process of locking and interlocking, which it is the task of the analyst to monitor and reflect upon. A feature of the scene is the implied ‘other’, be it another mental space, another realm, another time, another object, in short a fantasy scenario, even while the ‘here and now’ of the two people in the room is clambering. Whether we call it ‘psychic reality’, ‘unconscious’, ‘illusion’, ‘phantasy’, ‘transference’, this element is a defining feature of psychoanalysis. The stage is set in order to facilitate maximal observation of this other scene, if the analyst is able to weather the ‘emotional storm’ (Bion, 1979b, p. 247). From this encounter develops a ‘language’, one which gives meaning to experience. The psychoanalytic interpretation is made within this context, “a context whose co-ordinates are fixed by the patient’s demand, the analyst’s expectations and the contract defining the analytic situation” (Baranger, 1993, p. 15). This is the frame without which there is no stage.

Like classical theatre it has a unity of space and time. It has rules, what Freud called ‘the fundamental rule’ or the rule of free association, a rule which is broken due to the fear of recognising unconscious anxieties (Green, 2000), and this is meaningful in terms of where and when it is broken. The analytic space has a ‘curtain up’ and ‘curtain down’ on the inner world and a particular way of talking which can appear strange to the outsider, which is why the record of a session can seem meaningless. On this stage, the internal world is played out, with a strict beginning and a predetermined end. The scenes become familiar as they repeat themselves with variations of cast, set and historical period, revealing desires and defensive movements. Within this frame, memories, scenes, dream images interweave and join up to construct a ‘story’, a story reminiscent of the past like Plato’s shadows on the cave walls. How close or how far is it to what actually happened? How much is reconstruction and how much is a new construction? In any case, as Laplanche writes, “Historical reconstruction in psychoanalysis cannot be understood except as a reinterpretation of more archaic scenarios” (1974, p. 468).

The physical setting is sometimes ‘silent’, just a background which becomes assumed, as Momigliano (1988) put it, “like the darkness in a cinema, like the silence in a concert hall” (p. 608). For other patients the physical setting becomes the object of deep attachment or, on the contrary, persecution. The couch can be experienced as the lap or womb of the analyst, which offers the hope of a new beginning, a return to an idealised past or to good moments from the past. It can be connected to the sensation of the body moulding into the mother’s body, an ‘embodied memory’ (Leuzinger-Bohleber, 2008) or it can be an ‘embodied phantasy’ (Bronstein, 2015). On the contrary, the couch can be experienced as dangerous and the out-of-view analyst intolerable. The reclining position and the necessary ‘passivation’ (Green, 1986) arouses fears connected with femininity (with its refusal as ‘bedrock’), castration, homosexuality, seduction (Perelberg, 2003) and loss of control. There is a counterpart to this in the psychoanalyst’s necessary ‘passivity’ which Scarfone refers to as ‘passibilité’,¹ a reference to the capacity to receive the transference, to being “disposed to being touched”² (2014, p. 8). It is not unlike Bion’s notion of containment, but it emphasises the preparedness to be taken over, or I would say a preparedness to ‘giving oneself over’ in order to emphasise the aspect of this being in the service of the patient.

It may also be said that the psychoanalytic setting is a ‘participant’ if we take ‘setting’ in the widest sense to include its symbolic meaning. Psychoanalysis is never just a two-person affair, in spite of appearances. There is always a triumvirate of which ‘the setting’ is one important party: patient-psychoanalyst-setting, each of equal importance. The setting is the guardian of the analysis, a silent participant. There are two people in the room, but the shadow of a third is present. This presence/absence is significant and essential in defining the setting in its Oedipal configuration; the configuration comes in different forms, with the paternal as unspoken ‘absent other’ imposing a rule on the analytic pair, or in the form of the analyst as distinct from the analysis, as when Winnicott says to his patient at the end of the session: “I am coming in between you and analysis and sending you off” (1986).³ This calls for the analyst’s own bisexual functioning.

The setting marks the ‘rules’, both spatial and temporal. It marks the prohibition on incest and defines difference within the triangular situation. Steiner, introducing Segal’s ideas, suggests that the attack on structure is the hallmark of the death instinct: “Anything that emphasises difference is an expression of structure and the ultimate goal of the death instinct is the achievement of randomness, of chaos, and of a structure-less state in which nothing exists which can give rise to envy” (Steiner, 1997, p. 7).

By restricting physical action, talking takes a central role, not only in the content of what is communicated but also as an ‘action’. The pair talking/listening become libidinised as the central mode of exchange. Words are exploited in their ambiguity and double meanings. Freud made use of the “imagic aspect of words – the phonetic similarities of homophones, puns and alliterations” (Litowitz, 2013). Language may be used to communicate or to obfuscate. Language is also a vehicle which comes from outside the dyad and disturbances are reflected in how language is used. French authors note the “transference on to speech” (Donnet, 2001, p. 136) in the analytic situation. Language is also imbued with preverbal elements, the sound and musical quality, for example, of certain words, something which conveys meaning in itself, and with phantasy elements connected with the relation to objects. The latter is observed clearly with patients who speak more than one language learned in different circumstances and times, and who prefer defensively, for instance, the more ‘neutral’ language acquired later in life for their analysis rather than the ‘maternal’ one. When I pointed out to a supervisee that it seemed ‘mad’ that she and her patient spoke in English when they had a shared mother tongue, she was taken aback at the idea, saying it seemed ‘incestuous’.

Bleger (1967) considers the psychoanalytic situation to be the patient’s most primitive ‘family institution’. He describes the ‘metaego’ as being that institution which exists silently in the background and which is necessary for the formation of the ego. The frame often goes unnoticed but it contains the first stages of the organisation of the personality, specifically that of symbiosis. Hence the frame is the receiver of the psychotic part of the personality. He compares it with the body image and the phenomenon of the ghost member:

we must accept that institutions and the frame always make up a ‘ghost world’ … for Melanie Klein, transference repeats the primitive object relationships, but I think that what is still most primitive (the non-differentiation) repeats itself in the frame…. The frame is the most primitive part of the personality, it is the fusion ego-body-world, on whose immobility depends the formation, existence, and differentiation (of the ego, the object, the body image, the body, the mind).

(Bleger, 1967, pp. 514–515)

He adds that it is the most regressive, psychotic part of the patient, “for every type of patient” (p. 516, italics added).

The frame gets noticed only when it is broken, creating disturbance in the patient (for instance, if the analyst has to cancel unexpectedly or relocates). Faimberg (2014) suggests that Bleger resolved the paradox that it is necessary to overcome the ritualisation of the frame while maintaining the analytic frame by positing that there are two frames, the one maintained by the psychoanalyst and consciously accepted by the patient, the other the frame of the fantasy world, the ‘ghost world’ on to which the patient projects. Donnet (2001) adds to this that the transference on to the setting goes unnoticed when the analyst similarly idealises the setting, and argues that this transference needs to be worked through and dissolved.

When we separate language, setting, mode, we do so artificially. In the clinical encounter one or the other may be more prominent but they form part of a whole. An interpretation will be made in a particular way. For instance, it can be ‘saturated’ or ‘unsaturated’ (Ferro, 1996), or ambiguous (De M’Uzan, 1983); it can be addressed to the secondary process of the patient, or it may aim to impact at the level of primary process. How the interpretation is phrased rests on important theoretical differences (Aisenstein, 2007). The patient will also hear it in a particular way. The interpretation may be experienced as expressing the love of the analyst or on the contrary may be felt as an act of aggression. The analyst’s voice may unconsciously convey a message congruent or not with the words, or the patient may interpret it as if the analyst has become an internal object. The voice of the analyst itself with its sensorial and musical aspects may be cathected, and this also belongs to the setting.

Part of the setting is also the quality of the object’s presence with its specific psychoanalytic mode of attentiveness, different from what is experienced outside sessions. I will come back to this in the section on the analytic attitude and go into it in greater depth in the latter chapters of this book.

While there is a large body of literature on the role of ‘insight’ or ‘interpretation’ versus ‘experience’, in my view this is another artificial division, since insight is part of the experience. The literature on therapeutic action and curative factors which addresses this division⁴ is usually part of a larger theoretical debate; for instance, between relational analysts who emphasise the ‘experience’ and Freudian/Kleinian psychoanalysts who emphasise ‘interpretation’.⁵

‘Insight’ is not a simple notion. It does not appear as a psychoanalytic concept in Laplanche and Pontalis. For me, ‘insight’ includes knowledge at different levels of consciousness and is mostly different from simple intellectual understanding (Grinberg, 1980). It is evidenced in a different way of experiencing external and internal reality. Insight is something which builds up during an analysis via the reintegration of aspects of the self and a change in the relationship to reality and objects, including the analyst. Changes bring further changes. Psychoanalytic insight is thus not monolithic and takes effect at various levels of consciousness. Insight given by the analyst in the form of interpretation is received in complex ways, which may or may not result in the patient acquiring insight. In my view, the psychoanalyst needs to convey her or his own understanding in a way which will be appropriate to the patient at a particular moment. This may or may not come in a form which describes or explains (see Chapter 11). Even when interpretations are given in a way which describe or explain, insight will in general not be remembered as such when the analysis is over (Segal, 1962). The analysand will usually just remember, besides the general experience, a few moments which stood out, for positive or negative reasons, and very often not those the analyst would consider important. What one hopes is that the patient will have developed, as Ferro puts it, “tools that allow the development and creation of thought, that is the mental apparatus for dreaming, feeling and thinking” (2006, p. 990).

Frequency

Derivatives of psychoanalysis use a lesser frequency of sessions. The goals are usually more specific and circumscribed. The psychoanalyst is not uninterested in the patient’s symptoms, in their appearance, disappearance and replacement by other symptoms, but the removal of symptoms is not the primary aim, as in some more focused forms of therapy.

The psychoanalyst is addressing what I call a ‘difficulty with living’. Cooper (2005) distinguishes psychotherapy and psychoanalysis as follows: psychotherapy is ‘an event’ while psychoanalysis is ‘an experience’. It is ‘psychoanalysis as an experience’ which meets what I call the ‘difficulty with living’ and not ‘psychotherapy as an event’, which may nevertheless give short-term solutions.

Psychoanalysis is, by its nature, a very slow process, often painfully so for both parties. Freud uses the image of the battlefield to convey the strength of the conflicting forces which become played out with “the transference becoming the battlefield on which all the mutually struggling forces should meet one another” (1917, p. 454). He is here referring to the forces of repression and “the tenacity or adhesiveness of the libido, which dislikes leaving objects that it has once cathected” (1917, p. 455). In his later work, Freud ...