What Is Really Going on in the Analytical Session ?
Eike Hinze
I chose the title of my paper rather associatively and intuitively. It might invite
the reader to associate freely I thought. You can think of “Finally I will know what
is really going on in my parents’ bedroom.” or of Woody Allen’s movie “Everything
you always wanted to know about sex but were afraid to ask.” It is a bit
provocative and leaves enough space to elaborate my thoughts about the subject,
I thought. But with the Summer Seminar approaching and having to write my
manuscript I became more and more afraid that my choice had too much of a
primary process thinking. Is it not pure megalomania to promise solving an issue
like this one? And besides this there is no one-dimensional “What is really going
on” in psychoanalysis because we know that every phenomenon is
overdetermined and there are many ways to understand it.
Let us stop here for some moments and think about how we are learning in our
training what is going on in the analytic session. Every candidate has the
experience of his own analysis. Then he will read Freud’s papers on
psychoanalytic technique and will have seminars dealing with other authors
writing about this issue. (For reasons of simplicity I always use “he” in a nongender-specific way.) He may become a bit confused and may wonder whether
analysts of different theoretical orientation, belonging to different schools,
conduct the same analyses. Is for example what is going on in a Kleinian analysis
the same as in an analysis of the French type? He starts fantasizing about the
theoretical approach of his personal analyst or wonders whether he has one at all.
He starts listening to case presentations of other candidates or more experienced
analysts and is amazed at the great variations in technical approach. When I
remember my own training I have to admit it took me some time to make sense
of these case presentations and to develop a really understanding access to the
inherent process of the presented analytic material. And then one day in your
training you are authorized to start your first own analysis. It is like throwing
somebody into deep water who has had only a few elementary lessons in
swimming. Learning by doing is the motto. You have the support of your
supervisor, it is true. But again, starting your second case, you may be
confronted with a surprising diversity of technical approach. Everyone may ask
himself, how much space there was in his training for asking and discussing
explicitly my title’s question. In my training at least the tacit assumption seemed
to reign that any gifted candidate did not need to discuss this question. If he did
not find the right way of analyzing this was his personal problem. Most likely his
personal analysis had not yet been deep enough. I assume this was (or still is?) a
widespread fantasy of candidates preventing them from asking certain questions.
And there I am back at Woody Allen’s film.
The diversity in technique is poignantly described by Paul Denis’ commentary to
Peter Fonagy’s detailed report of an analytic session in the International Journal
of Psychoanalysis (2004). He starts his commentary with: “The psychoanalytic
culture to which Miss A’s analyst belongs is undoubtedly very different from that
of the majority of analysts trained in France: the style of the interventions and
their frequency are a long way removed from ‘the French way of analyzing’. In
the majority of cases, the French analysts who are members of the IPA have
adopted a technical approach that seeks to avoid a large number of lengthy and
explanatory interpretations. In writing this commentary, I even found myself
feeling envious of a patient who received 16 interpretations in one session – that
is to say, more than I received myself in over 10 years of personal analysis.” One
may object that in a single institute the variations are not so marked. But on the
one hand this is presently no more granted. And on the other hand this
theoretical and technical plurality is one of the greatest challenges for the
scientific foundation of psychoanalysis. Moreover as PIEE-candidates you have a
unique advantage –or burden- of being trained by teachers, analysts and
supervisors of a larger variety as a candidate usually is confronted with.
After delineating so many difficulties is there any light at the end of the tunnel? Is
there any realistic chance of finding a deeper access to my topic? Following the
good analytic tradition I will start with a case.
CONFIDENTIAL CLINICAL MATERIAL
Why did I choose this example? One reason is that I hope some of my thoughts
can be demonstrated in this material. Another reason is that I recently presented
this case in a group with a Kleinian supervisor. This supervision widened my view
on the dynamics in this session.
The patient started the session by describing an accident he had been witnessing
immediately before. Two basic views on this material are possible. The patient
described something that had happened outside the consulting room. It might be
possible to understand how this had affected him, and perhaps one can finally
connect this material with some transference manifestations and say for example:
“You are afraid of developing a more personal relationship with me because then
a conflict with me about your wish to be attached to me and your wish to be
independent may explode and cause a clash between us like that you observed
before the session.” In this view the patient tells or associates something that has
happened outside, and the analyst tries to link it to other elements of his internal
life. A second different view (and here I am citing David Tucked to whom I am
indebted for many of my thoughts) is that the patient experiences the accident as
taking place in the session. “From this perspective when associations come to the
patient’s mind they can be thought of as ‘made in the room’. They are
representations of experienced anxieties, impulses and sensations stimulated by
lying there. They are transformed there and then into ideas, wishes and thoughts.
In this model although the patient does indeed talk about incidents and
happenings which have usually ‘really’ happened, they are not news items
brought in from outside. They take the apparent form of news simply because
what is selected works for the patient as a means to express conscious and
unconscious experience in the room here and now.” (Tuckett, 2009) Analysts
differ in regard to these two modalities. Looking at this session I am inclined to
favor the second view. In hindsight I think that the patient talked about a clash
between us which had already happened and had materialized in cancelled
sessions. Not adopting this view helped me to deny the more aggressive aspects
in the patient’ associations. Here a second aspect of the session becomes
apparent I want to dwell on. Both, the patient and me, were engaged in a kind of
enactment. The patient acted as a son striving for being seen and acknowledged
by his father while at the same time defiantly fighting for independence, whereas
I enacted a father who appreciated his son’s development but who tried not to
experience his son’s aggressiveness in full strength. But then my final
intervention contained a sadistic counter-attack. What I said can be understood
as: “You may try to go away but then you will break your legs!” I am stressing
here the counter-transferential aspects of this enactment because they are simply
part of this session, but also because we are very often engaged in collusive
enactments that we can only understand afterwards, if at all. Being engaged in
enactments of various kinds is an intrinsic and essential part of our daily work as
analysts. It enables us, by exploring our counter-transference, to understand
better the vicissitudes of the transference and the analytic process. But we should
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not fall into the trap of believing that we always understand our countertransference and can master it. Sometimes it needs more time than we would like
to, and sometimes we need supervision. There are many analogies or metaphors
describing the couple analyst/analysand. One is the interplay between mother
and infant. Like all analogies it has its merits and its limitations. Another analogy
I appreciate very much is that of a ballroom-dancing couple. Lichtenberg states:
“from the standpoint of the observer, each (analyst and patient. E.H.) is a
necessary partner in the interpersonal dance – it takes two to tango” (1989, p
297). Usually you do not see or feel your own mistakes but experience them
mirrored and enlarged in your partner’s dancing. The trainer is then as
indispensable as a supervisor for the analytic couple. The parallel seems striking.
Very often you only get aware of your counter-transference by observing the
patient’s reactions to your interventions. This is the essence of the often cited
“listen to the listening” (of the patient).
Picture 1
The view that an analysis consists of a chain of enactments with the analyst
playing an active role in them and that every part of an analysis is happening in
the consulting room is more or less shared by a great number of analysts today.
In this perspective the patient’s past is coming to life in the consulting room
again. But this is not the only approach to psychoanalytic technique and to “what
is going on in the analytic session”. There is no authoritarian manual prescribing
what really good analysis is and what not. But the analytic community has begun
to study analytic processes in analyses of different analysts more deeply and
across the lines drawn by so-called schools. One initiative to understand better
what is going on in analyses of different analysts is the EPF Working Party on
Comparative Methods (WPCCM). Groups of experienced analysts from different
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European societies discuss case material presented by a colleague and try to find
out the often implicit working models and concepts the presenter is using in his
clinical work. These groups are not intended to learn more about the dynamic
unconscious of analysts. This would have to be done in a different setting. But
they shall –and can- explore the concepts and models we are applying in our
analytic work. These models are often implicit or preconscious, and often the
analyst himself is not aware of them. The way these groups are discussing is
rather unusual. We are used to discuss case presentations in a supervisory mode.
The group members propose a different, better or deeper understanding of the
case, often transforming into a group that always knows everything better than
the presenting analyst. From your training you know this type of discussion. I
included the session in my paper mainly in order to discuss the way I am
working. But you will certainly experience the urge to discuss it in a supervisory
mode. In the CCM groups it proved to be very useful to start a discussion by
trying to classify the type of the different interventions in the session (picture 1).
At first sight this kind of categorizing looks a bit strange and not appropriate for a
psychoanalytic approach. But discussing for some interventions the right category
may sharpen the view on how this analyst is working in the session. The second
step seems more interesting (picture 2)
Picture 2
Working on many case presentations in the CCM groups showed that the way an
analyst is working can be described in 5 axes. My case may serve as an example.
My short remarks about the patient’s biography and my commenting the session
demonstrated that I have some ideas on how and why his disturbance came
about (What is wrong: Theory of psychopathology). These thoughts inevitably
lead to my thoughts about how analysis works, that is to my transformational
theory (How analysis works: Theory of psychic change). I think it is a myth that
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there is a thing like an analysis without a tendency, without an aim. We always
have some ideas about the specific psychopathology of a patient and about how
change may happen. We want the patient to change and develop. Otherwise we
would not start an analysis. Analysts have different ways of listening to the
patient (Listening to the unconscious: Theory of the unconscious). The ideal of
the evenly suspended attention may be differently realized in different analysts.
Take for example the above mentioned difference between listening to the
patient’s associations as describing something always originating in the consulting
room or as being partly introduced from the outside. Analysts have different
styles of intervening (Furthering the process: Theory of clinical technique). And
analysts may have different views of the analytic situation, that is how the past
comes into the present (Analytic situation: Theory of transference and repetition).
The CCM approach does not give a final answer to my central question but it may
help to think about it more clearly. One can better understand different styles of
analyzing and can often recognize the underlying logic in seemingly purely
intuitive interventions. In a way it is demystifying the analytic encounter. But
again: what is psychoanalysis, what is really going on in an analytic session? The
simplest answer could be: Two persons meet in a room for 50 minutes and talk to
each other without any disturbance from the outside. But we share this procedure
with many psychotherapists of different orientation. We have to add a specific
element: a psychoanalytic theory. Two persons meet under the umbrella of a
psychoanalytic theory or contained by the frame of psychoanalytic theory.
Picture 3
The 5 Axes and the 3 Frames
Conceptual Frame
Observer Participant
Frame
Listening to the
unconscious
Furthering the
process
Interventional Frame
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Picture 3 shows the importance of theory in psychoanalytic practice by visualizing
it. It is a condensation of the known Three-Frames-Model and the Five-AxesScheme. I now want to introduce a seemingly simple theoretical tool, which may
help to understand the dynamics of a session and which moreover may be useful
in one’s daily practice. Again I owe David Tuckett the elaboration of this idea.
Picture 4
Anna Freud put forward the idea that the ideal position of an analyst is a point
“equidistant from the id, the ego and the superego.” Translated into everyday
language this means the analyst should not love or hate the patient and neither
teach nor judge him. The picture 4 shows this ideal mental position of the analyst
with the black dot in the middle of the triangle. This triangle lends itself to
different applications and interpretations. The analyst may think he is in this ideal
centre of the triangle whereas in reality he has already moved to one of the
corners. Take for example my last intervention in the session. Consciously I
thought that my intervention stressed the patient’s developmental progress to a
more libidinal relationship and autonomous position. I felt very much in the
centre of the triangle. But unconsciously I was expressing my hate. My
interpretation came more from the right lower corner. The triangle may describe
the mental functioning of the patient or how the analyst views him. But there is
also another triangle describing how the patient experiences the analyst. Some
days ago I asked a patient to tell me more about an encounter with a difficult
neighbor whereupon she became extremely furious at me. Shortly before the end
of the session she could tell me that she had interpreted my question as a severe
accusation. I thought I spoke from the centre of my triangle while she had put
me in the extreme upper corner. The triangles, that of the patient and that of the
analyst have a great heuristic value. One should always bear in mind how they
interact with each other and how they are experienced from the other side.
Thinking in terms of these triangles may help to preserve one’s orientation in the
fire of mutual enactments. It may also help not to forget that our task is to speak
about the patient and not mixing up our triangle with his.
By thinking in terms of the two triangles the role of the patient comes to the
foreground and his impact on the analytic encounter. The fact that this encounter
is shaped by both participants, the analyst and the analysand, seems so obvious
that one almost neglects that all papers about the analytic situation and
psychoanalytic technique are written from the analyst’s perspective, viewed
through his eyes. But if we want to know more about the analytic situation and
about what is going on in analytic sessions we should also ask the patients
themselves. How would they answer the question? There are only very few
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studies or papers written from the patient’s perspective. I will draw on three more
recent publications which are relevant in this context: Lora Heims Tessman’s
report about interviews with analysts from her Boston Institute how they had
experienced their training analyses (2003), Christine Hill’s book about interviews
with former analytic patients (2010) and the results of a very thoroughly
conducted catamnestic study of the German Psychoanalytic Association
(Leuzinger-Bohleber, 2002). What can we learn from these studies that is
relevant for our topic? First one has to overcome an objection against this kind of
studies. How reliable are the accounts of former patients? Are they not imbued
with transference residues, loaded with defences and neurotic distortions? This
objection has to be taken seriously. And the first two mentioned books show
indeed some instances of this possible bias. But it is not a sufficient reason for
dismissing the reports of former patients at all. The catamnestic study showed
that after successful analyses memories and general evaluation showed a striking
similarity between analyst and former patient. One interesting finding was that
the analyst’s theoretical orientation was not decisive for the patient’s satisfaction
with the analysis and the outcome. But this does not contradict my previous
statement that theory plays such an important role in the analytic session. The
catamnestic study showed that a professional attitude – and this includes being
able to link theory with clinical practice – was an essential factor in promoting a
patient’s satisfaction with his analysis and a favorable outcome. Flexibility and the
ability to attune very personally and specifically to the patient were other decisive
factors. For the patients’ satisfaction it was of utmost importance that an
emotional match between him and the analyst existed and that the latter invited
him to participate as an active partner in the analytic process. The emotional
match was not simply a question of mutual sympathy but a complex process of
emotional attunement. And it was striking that most patients were able to
differentiate between an analyst who was only nice and friendly and an analyst
whose professional stance was part of a dedicated human attitude. An analyst
was seen as contra-productive if he knew everything in advance and behaved as
a keeper of the truth. Hinshelwood (1997, p 105) once commented humorously:
“If the psychoanalyst’s aim is that the patient should know his/her own mind
better than before the analysis, can that be achieved by the analyst knowing
better what the patient should think and decide? If the psychoanalyst knows for
the patient, does this in the long run contribute to the patient knowing better for
him/herself? It becomes a paradox.” What we can learn from all these findings is
that in an analysis we are not the experts who know everything about a patient’s
unconscious. He needs to be taken seriously in his conscious experience and has
to be invited to actively take part in a shared journey to explore the denied and
disclaimed parts of his mind.
I am slowly coming to the end of my paper. I apologize for not having given you
a comprehensive answer to the question what is really going on in the analytic
session. But I hope having invited you to think more courageously about this
question and not to be stuck in scholastic thinking of whatever kind. In a world,
where pluralism is progressively infiltrating many domains of social life, pluralism
in psychoanalysis is at the same time an exciting challenge and a danger for our
existence. We need you as the next generation of analysts to come to grips with
these problems and questions.
But I do not want to finish my presentation with such solemn words. At the end I
want to tell you a funnier story about my participation in a CCM group as a
presenter. In a session I presented an unfamiliar noise could be heard at the
beginning. The water flushing of my toilet beside my consulting room was broken
and was running for a very long time. My patient asked for the reason of this
noise. And I bluntly answered that my water toilet was broken. The group burst
into laughter sensing my acting out of a counter-transference reaction. They were
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right. At that moment I did not realize the unconscious use the patient made of
this incident. Later on I started to think about different possible interpretations
various analysts might have given in this moment. Giving an interpretation is
always an active choice between different options. Analyst A might have
interpreted links the patient had made between the noise and unconscious
anxieties. Analyst B might have understood the patient’s question as an
expression of an unconscious scene he was creating in that very moment. Analyst
C might have thought that first he had to validate the realistic observation of the
patient before going on to interpret unconscious material. Analyst D might have
stayed silent waiting for the patient to unfold his representational world without
paying much attention to transference and counter-transference. Analyst E might
have reacted like me, but with focusing on attachment theory in the back of his
mind. Before reaching analyst Z I will stop here. But a multitude of possible
interpretations is appearing. And with this confusing multitude I end my
presentation.
References
Denis, P (2004): Commentary to Miss A (Fonagy). Int J Psychoanal, 85, 814-816.
Freud, A (1937): The Ego and the Id.
Heims Tessman, L. (2003): The analyst’s analyst within. The Analytic Press,
London.
Hill, A.S.CH. (2010): What do patients want? Psychoanalytic perspectives from
the couch. Karnac, London.
Hinshelwood, R.D. (1997): Therapy or Coercion? Does Psychoanalysis differ from
brainwashing? Karnac, London.
Leuzinger-Bohleber, M (2002): “Forschen und Heilen” in der Psychoanalyse.
Ergebnisse und Berichte aus Forschung und Praxis. Kohlhammer, Stuttgart.
Lichtenberg, J (1989): Psychoanalysis and Motivation. Hillsdale NJ, The Analytic
Press.
Tuckett, D (2009): Inside and outside the window: Some fundamental elements
in the theory of psychoanalytic technique. Paper read in London, not yet
published.
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