Abstract
Whatever the other motivations, a serious analyst analyzes in order to learn how to analyze. Candidacy is the start of training, not its end. Thus, the question of what works better clinically and what less well is always on our minds. Our professional lives demand a self-supervision, and with it a self-analysis, that never ends.
Aware of the power of self-delusion, we know the wisdom in the tennis coach’s old saying, “Practice makes permanent.” Long practice can lead to growing skills, but merely repeated, experience can also lead us to call something growth that in fact is only personal comfort.
As a result, we seek outside checks on ourselves. Ideas of regular return to personal analysis or formal supervision live more in our literature than in our actuality. Peer supervision certainly helps. Looking for more, we ask what could make more sense than to turn to those who know how we work better than anyone else—our patients.
Indeed, during the course of analytic work, our patients, eager to get better whatever the power of their disorders, endlessly press us to do better. Perhaps most often nonverbally, they do what they can to teach us to become the analyst they need. Our studies of the analytic process have been too blind to the extent to which during the course of their analyses it is our patients who inform us and influence us on what they need in their analyst. That is an essential process that lies hidden in the shadows of everyday analytic work.
What could be more logical than to see what can be gleaned not from the muddle at the middle of an unfolding analysis but from patients who return afresh after long interruptions? What could be more straightforward than that our returning patients identify for us failures in our technique, taking a role like that of the unsatisfied customer who returns to tell the tailor, “Sam, you made the pants too long”?
If only it were so simple, so measurable. If only “postanalysis” were so quantifiably objective a “transference/countertransference-free zone.”
In this issue, we have the benefit of reports from three outstandingly thoughtful analysts, colleagues who have brought us clinical accounts that honor us with their trusting frankness. Because of their candor, perhaps the first thing we hear, the inference we immediately draw, is that even in the most experienced of hands there is no such thing as a royal road for clinical analysis.
Dreams well may be the royal road to academic understanding of the unconscious, but there is no royal road for analytic inquiry. True exploration defies tidy order. Clinical analysis is necessarily a journey through a bewildering bog of uncertainty and a ragged underbrush of unbridled anxiety.
When we are sufficiently open to ourselves that we can be effective in our work, we take part in what Racker called a “paranoid ping-pong.” We aid a patient’s introspection best by learning about both ourselves and the patient from our engagement in the clinical encounter.
Our first observation immediately makes clear that “good enough” analytic skill can never attain the perfection our idealizations envision. We do a disservice to our leaders as well as to ourselves when, feeling at a clinical impasse, we fall into the fantasy that if only Charlie Brenner or Betty Joseph or Frieda Fromm-Reichmann or Lacan or Kohut or whoever were here, then that person would know just what to say or just what to do to make everything right. Thus, feeling helpless, we perpetuate our omnipotence by moving it outside ourselves onto our chosen model.
In contrast, in their reports each of our presenters is more direct, each having an analytic center that holds. Each first felt insufficient, and then each came to be more able to confront whatever had threatened to emerge. Each came to accept vulnerability and insufficiency. Each resisted the pressure to posture him- or herself as the expert who knows, as the one of the clinical couple who knows how the mind should be used and how life should be lived. Instead, each came to accept personal vulnerability well enough to stay with the working task of trying to figure out the meanings of whatever was going on.
My comments about the specific cases will be brief in order to address what all may have in common. That brevity should not be misread as any lesser appreciation for the clarity and richness of the reports offered.
Theodore Jacobs opened with that sensitive respect for the clinical partners, that insistent openness, and that uncommon clarity that are the hallmarks of his thinking. It was he who proposed our question, “What can I learn about my own work from follow-ups?” and it is he who has set the tone for the forthright clinical material presented here.
That question is itself revealing. It demonstrates that, like the patient’s transferences, the curiosity that had been essential to the analyst’s work also does not end with the formality of termination.
Along with appreciation, I add one small distinction. While trying to be evenhanded in considering the debate over an analyst’s instigating follow-up studies, Jacobs’s words, I think, present a slight bias in their favor, a bias I would question.
I know he and I agree that in an analysis the analyst works in the service of the patient. Yet, as Jacobs goes on to say, “Our traditional attitude toward follow-up appointments . . . may not serve all our patients equally well” (p. 932). However, when at work we are in the service of each individual patient, one at a time, not “all our patients.” We must be cautious over the risk of compromising the individual for the general good. As we would not do so in response to outside community pressures, so must we be wary about doing so in our wish to extend psychoanalytic knowledge. Psychoanalysis is there for the patient’s sake; the patient is not there for the sake of psychoanalysis. I have no doubt Jacobs agrees, even if we tend to lean in different directions when dealing with the conflicting pulls all of us share.
We have the opportunity in these papers to hear from patients who after long intervals return on their own, to hear reports of valuable openness and depth. Each merits full discussion, yet we must limit ourselves to highlights as we try to gather possible inferences.
At the time his patient terminated analysis, Shelley Orgel was concerned about her inner stability without the analyst’s presence, so he was not surprised that it was a new object loss that led his patient to return later for his “steady presence.” However, where in the first work he had focused on early preoedipal mother issues, in the later period he found erotic-aggressive issues coming more clearly to the fore. In this new work, Orgel resisted the pull to what might be called empathic sympathy and instead exposed more self-reflections of uncertainty. It was a different kind of steady presence he now put forward, and that change, he feels, facilitated the shift in the patient.
Of course, we cannot know how much the earlier focus had actually been determined by lack of such self-revelations and how much it had then resulted primarily from the power of where the patient had been at the time.
Still, it is clear that between the two periods of work both partners had changed. The patient’s return, in itself, is evidence that something was actively moving within the patient. During the separation, Orgel’s life also had progressed. His mind had grown more open, allowing him to move profoundly beyond the limits of what he came to see as his earlier, idealized version of technique. His patient’s return provided a mirror in which he could see his own growth.
How much of the difference in how he worked came from the losses that accompany aging and from his new appreciation of the many meanings of “reality”? How much of the difference came from newly learned theoretical understandings? Indeed, how much of the difference was actually a function of the patient’s now being at a new place? Despite our current concern with technique, when dealing with the analytic encounter of two people and their two lives, matters both separate and entwined are more complex. The plot necessarily thickens.
It is similar with Judy Kantrowitz, who describes a change in her emotional availability, also related to idealization, for her the more specific question of tolerating aggression. Her later work with her patient led her to conclude that in the first period of analysis she and her patient “had colluded in avoiding . . . her feelings toward me, . . . fearing the intensity of her dependency longings” (p. 950). For Kantrowitz it was anger that had first been underemphasized, perhaps in part even avoided.
In the twenty-year interval between the periods of work with her patient, Kantrowitz’s analytic and personal experiences had led to an increased capacity for tolerating aggression and hatred toward both self and other. This is powerfully moving, because we know such lessons are learned only at the price of great pain.
However, it was an unexpected explosion of hostility that led her patient to return, so the opening of sadomasochistic forces in the clinical work was brought by the patient. Kantrowitz emphasizes her own new readiness to hear such conflicts, stating that “the depth of the work in the second period reflects a developmental growth in both my patient and me” (p. 953). While acknowledging the change in the patient, she implies that without her own emotional growth during the interval before the patient’s return she would not have been able to tolerate the power of the aggression at hand.
Orgel’s increased readiness to engage difficult oedipal areas and Kantrowitz’s increased readiness to engage primitive aggression were both, at least in important part, functions of changes in the range of the analyst’s emotional capacities. Neither was merely a shift in theoretical understandings and associated technical maneuvers, alterations chosen by the analyst’s conscious decision.
Like Orgel in the case he presented, Richard Almond thought his patient had made use of her first analytic experience more for the steady presence of the analyst and the analytic situation than for insight-oriented introspection. And, like Kantrowitz with her patient, Almond thought the early work had avoided the emergence of what was deeply negative.
After very many years his patient returned, frightened by powerful sexual interests she deemed “inappropriate.” Like Orgel and Kantrowitz, Almond sees the change in his later work as coming from his having become more openly engaged with whatever was emotionally evoked in the immediacy of his patient’s active engagement.
Our three presenters have brought us reports of how returning patients exposed to their consideration their own personal and professional growth. Certainly, growth in the psychoanalytic field was also present. That was so whether in the specifics of how they understand psychopathology—evident, for instance, in Orgel’s reference to his patient’s Persephonal conflicts, clearly an understanding made possible by the analytic advances of Kulish and Holtzman—or in the broadening technical possibilities made available by the advances of new theoretical viewpoints within the analytic community.
What is particularly significant for us is what Kantrowitz and Almond have called changes in their analytic identity, what Orgel in an earlier draft explicitly defined as the place of developmental changes in the analyst at work.
I strongly agree with what they suggest, that there is a developmental line of maturation for the analytic professional. It is not a simple direct line, one that can be neatly charted on a graph, but then that never is the nature of developmental maturation. Rather, it is a line that, while influenced by changes in the field, has its own internal pattern; as part of the analyst’s mind, it is as vulnerable to fixations and regressions as any other developmental movement.
Working through is as essential as working out for psychic growth. In fact, within these three reports lies a specimen of preparation that exposes the reworking at the heart of analytic maturation: impulse felt, reflected on, altered, and then again felt, with continuing progress of the pattern.
Our presenters had each sent me an earlier draft of their presentation, for me to prepare my discussion. What each had first sent was more than good, yet each later sent alterations. Indeed, cumulatively I received several drafts. Mostly what was involved was literary polishing. However, it also seemed to me that in the successive drafts there was also some softening of tone, moments where seeming self-criticism was replaced by more modest—and, ironically, more solid—self-reflection.
The several drafts I received were followed, quite naively and foolishly on my part, by my writing several discussions, or at least by rewriting these comments ever to adjust to the shifting presentations. Now, when I go further and compare what I myself am now saying with my own first draft, I see a similarly subtle but progressive shift from what might be called defensive certainty to more solidly secure uncertainty.
A patient’s termination and subsequent return give the impression of an abrupt set of separate steps. However, from a more detached perspective we can see that emotional engagement and movement do not fit into such distinct blocks. In and out of contact, shifts in meaning continue subtly to unfold.
So in these reports, as more importantly in clinical thinking, we can observe that, as it has been said, an understanding is a place where the mind comes to rest. Continued self-questioning is essential to continued growth. In clinical work, the absence of such self-inquiry, an analyst’s resulting prolonged comfort, may well serve as a signal that something important is being sidestepped.
In her classic paper on adolescence, Anna Freud observed that adolescent turmoil is evidence of what hard work it is to form an adult character. Once we are embarked on our analytic careers, I would suggest we are ever in the growth phase of our professional adolescence, ever trying to tolerate the growing pains of increasingly knowing ourselves as we use those selves to help others in their own struggles. When we pull back from that approach, we pull back from analyzing.
We partake in a lifelong professional developmental process when we practice analysis. Growth in clinical skill requires growth in character, because working in the service of someone else’s analysis demands increasing respect for both the validity of the patient’s uniqueness and also the associated capacity to stay with ignorance and anxiety while at work in the service of the other.
We start as true beginners, needing help to overcome our conventional and idiosyncratic biases, much needing education into the field. Even the most gifted musician learns to play the scales. Even the greatest musician must practice the use of his instrument. Our institutes, our teachers, and our literature introduce us to the discipline of our field.
But a time comes when any true musician must learn to stop merely playing notes and begin to make music. Making music well calls on internalizing the discipline of the scales that were learned, and using that knowledge not mechanically but in the greatest relevant freedom. This is not a situation where anything goes. It is not chaos. It is that the learning tames license for the sake of creative freedom. Discipline does not break creative talent but helps it achieve its greatest power.
For the analyst, theory is not merely helpful; it is inevitable. There is no thinking that is not shaped by background theories. And learning analytic theory, like learning to play musical scales, places reins on unbridled impulsivity, a restraint that can open unexpected possibilities, something essential to successful work.
However, the temptation to limit oneself to the safety of theory is intensified by the emotional challenge that individual clinical work poses for the analyst. Analysis is not a spectator sport, and clinical analysis is a lonely and frightening place to be. Analytic schools, with the theories they favor, offer a comforting security to the lonely individual explorer.
We absolutely need theory, but we do not need absolute theory, for even as we know that theory is necessary, we also know that theory is necessarily wrong. That is so because theory generalizes; it accumulates experience and divides it, and piles up categories. Actuality, on the other hand, is always entire, unitary, and whole. As much as any actual experience may have in common with other similar experiences, each is always particular and unique.
So the analyst must ever oscillate between old understandings, with their comfort, and new uncertainties. To paraphrase Proust, analyzing that shows the analyst’s theories is like wearing new clothes with the price tag still on them.
I, as do all of us I think, cherish analytic learning. We do not diminish its importance. However, the developmental line of clinical analytic growth requires an ever rising oscillation by which theory is mastered and integrated—ever in the service of the analyst’s growing skill in mentally opening to what can only be learned in the actuality and immediacy of clinical practice. Landmarks are needed, but old landmarks never relieve us of searching in the dark for what is new.
We need our teachers, but we must never feel so expert that we do not also hear our patients as our new teachers. If we listen to them and to what they evoke in us, we find they become our most dear supervisors. While it seems natural to focus on shifts exposed when work previously thought finished is newly reopened, I think we can learn the most about our own vulnerabilities in the thicket of what is called everyday, garden-variety analytic work.