The Therapeutic Setting in Psychoanalysis and Psychotherapy
Gary N. Goldsmith
The role of the therapeutic setting in the history of psychoanalysis and psychotherapy was
for a long time taken for granted. It is not hard to see why this was so. Since the setting
describes the basic arrangement necessary for treatment to occur, it was seen as merely a
structural or physical prerequisite, plus a contract for treatment and a code of behavior for
patient and therapist, without much further meaning in and of itself. That is, it seemed to
need no further discussion - settings exist everywhere, in all different fields and situations.
Freud was the first to describe the role of the psychoanalytic setting as a basic platform for
treatment - in the series of Papers on Technique he focused on it in some detail. But its
function and psychodynamic meanings were not explored until much later, when other
thinkers could turn their attention towards it. They were aided by years of accumulated
clinical experience which showed that it could not be denied that the setting had dynamic
significance in its own right - experience with patients that challenged or breached the
arrangements of the setting required it to become an object of increasing clinical attention
and concern. A deeper sense of its dynamic function became understood when advances in
psychoanalytic theory (especially object relations) helped to shed light on different aspects
of psychological development in childhood, and when our experience with different
diagnostic entities had expanded.
For the purposes of this presentation, I will refer to the therapeutic setting as
something that is similar in psychoanalysis and psychotherapy, and in all of the various
approaches to psychodynamic treatment that they comprise. This is because the setting,
even if it differs in certain important particulars (such as the use of the couch, frequency of
visits, relative activity of the analyst), is nonetheless a fundamental feature in every
treatment, and plays a similar role. It is not the difference among the therapies that
interests me most here, but the role that the setting plays in the treatment. Nonetheless,
thinking about the setting is not “beyond theory.” Though common to every form of
treatment, it may still be understood in ways that differ according to one’s theoretical
approach. Some of those approaches are certain to be discussed in the different
presentations this week.
It has been said that “the foundation of psychoanalytic treatment, upon which
everything else rests, is the psychoanalytic setting.”1 From this it follows that the concept
of the therapeutic setting may be Freud’s greatest contribution to technique. 2 Without the
special criteria of the setting, free association is not possible - indeed, treatment itself is not
possible. Yet Freud devoted far more attention to other aspects of technique such as free
association, abstinence and analysis of the transference, because they are unusual and
unique to the psychodynamic therapies. His recommendations for the setting are in some
measure borrowed from the nature of the setting of hypnosis, from which psychoanalysis
departed when he discovered the value of free association. In hypnosis (and in the
relationships with one’s physicians in general) the patient’s compliance with the treatment
setting is assumed, and not explored. A positive attitude toward the physician is expected
as a matter of course. But in “The Dynamics of Transference” (1912) Freud suggested that
a smooth treatment is not inevitable, rather it flows from the unobjectionable positive
transference.” Remember that in that paper Freud divides the transference into three
different types: the erotic transference, the unobjectionable transference, and the negative
transference. The second type, the unobjectionable transference, was considered by him to
have sublimated erotic origins, and was more conscious than the other kinds, which he
considered as problematic forms of transference. 3 Freud felt that the unobjectionable
transference was necessary for a successful result of the analysis, since it was the basis for
a cooperative relationship with the analyst (later we would call this the therapeutic alliance.)
However, although he described the optimal conditions of the setting required for treatment
to occur, he did not elaborate them as he did
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with the transference, or show the relationship between the establishment of the setting
and the unobjectionable transference. He went no further in describing their intrapsychic
and interpersonal functions from a theoretical point of view - and thus from a potentially
technical point of view as well. He was more interested in describing the theory and
technical handling of the negative transference which arose in the course of treatment. And
this has been our experience generally in the history of psychoanalysis, as Modell reminds
us: “It is easier to identify the forces that interfere with the progress of an analysis than to
understand what contributes to its therapeutic success.”4
The reason that Freud could exempt the setting from further theorizing was that he
was thinking only of those patients (now called “classical” patients) for whom, in his mind,
the setting itself did not need to become a focus of the treatment. In general, neurotic
patients accept the arrangements for treatment without much conflict, as a quiet
background enabling other, more overtly conflict-based aspects of the treatment to become
manifest. You will recall that in cases such as the Rat Man, he saw no violation or even
contradiction in departing from the usual setting, when he gave his patient a meal. For him,
the setting did not extend beyond the office in such a situation. In other words, he saw the
setting as a kind of silent presence, limited to the confines of the office, and not drawing
special attention to itself.5 So not only has our understanding of the setting changed, but
the setting itself has developed into a more broad-based concept than it was for Freud.
Why do we now say that the setting is not just a passive scaffold for the treatment,
but something that has dynamic significance in its own right? For one, it is because it
inevitably becomes invested with meaning, becoming part of the interpersonal relationship
between therapist and patient. To give a brief example: [CASE MATERIAL DELETED FOR
WEB VERSION] ……This is a fairly typical way in which problems are revealed in therapy - I
use it here not to review the entire treatment, but rather to illustrate the combining of the
patient’s attitude towards me and towards the setting, which she thought she was violating.
It demonstrates how difficult it is to separate the setting from the perception of the analyst
- for the patient they are fused, especially since the patient sees the analyst as the
explainer and enforcer of the setting. And indeed, there is some truth to this, because it is
the analyst who sets the rules at the beginning, even if we later on take the position of
being non-judgmental and abstinent. For some patients this ambiguity is a source of doubt
about our neutrality. (If this were a later stage of the treatment I might have looked with
the patient for the possible motives for “forgetting” the payment, and also wondered if she
were acting out something involved with my earlier, perhaps too strenuous, efforts to
pursue her affect about childhood events. However, at the present stage of the treatment it
seemed to me that it would have been excessive and inappropriate. I also made the
assumption from the patient’s associations that this was a maternal transference reaction,
but I would have wondered about the paternal aspects of the transference as well.) Here I
needed to do little to maintain the setting. For this
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patient the opposite was true - she already perceived the setting as controlling and
punishing, and proper “role responsiveness” required a different reaction on my part. (I am
using the term in Sandler’s original sense: “In the analyst's overt reactions to the patient as
well as in his thoughts and feelings what can be called his 'role-responsiveness' shows itself,
not only in his feelings but also in his attitudes and behaviour, as a crucial element in his
'useful' countertransference.”6)
I wish to make a second point here, that follows logically from the above. The
manner in which the analyst manages the setting is a significant part of his analytic
function. It is not just the patient who may perceive the setting and the analyst as a single
entity. The analyst, on his part, also sees the patient’s attitude towards the setting as part
of his or her character, and he works to a significant degree by his use and management of
the setting, knowing that this is a response to manifestations of character and transference.
This is not only because of the “rules” of treatment that he has learned and internalized, but
also because it serves important psychological functions for him as well, helping him to
maintain his own perspective and balance in the treatment. It is a source of constraint for
his behavior, and helps him to guide the treatment along a useful path and to note
diversions from that path. My point here is that the manner of his doing this demonstrates
his understanding of the analytic task, as well as aspects of his character, and includes the
countertransference issues that are active in him. The meeting ground between the
patient’s reaction to the setting and the analyst’s working within the setting, is the field
where the analysis takes place.
It follows then, that movement in the treatment is marked by periodic perturbations
of the setting. Such events inevitably point to areas of resistance and conflict, therefore
they become issues for exploration, and eventually, for interpretation. In ego analysis we
seek to analyze the resistance at the point of optimal usefulness, and the setting provides
the stage for this analytic drama to unfold over the course of the treatment. Just as there
are periods of relative quiet in the transference that are interrupted by crises, enactments,
or moments of lack of empathy, so too the stresses upon the setting will provide evident
signals of this movement.
By this time you may have already asked yourself the question of where the setting
ends and the transference begins, because at certain moments I am using the term
“setting,” or “attitude toward the setting,” when it may seem that “transference” is implied.
In general, the setting refers to the ground rules, the rules of the “game” that allow the
treatment to occur, to provide the optimal circumstances for the expression of transference.
Some would say that it “concentrates” the factors that permit transference to blossom.
However, there is admittedly something incomplete or ambiguous in this description, since
as I suggested before, everything that occurs between the patient and the analyst is
potential material for the transference, including the setting itself. Thus, while we may be
able to descriptively separate these aspects of treatment, in the active work of the therapy
there may be an inherent confusion in trying to differentiate them. Their interaction is
central to the treatment itself, and gives rise to tensions and questions that are productive
for analytic reflection; the ambiguity enriches the analytic dialogue. This occurs in part
because of the overlap between the verbal and non-verbal aspects of the treatment, which
are occurring simultaneously. Setting is basically non-verbal, but provides a template for
the recovery of verbal memory and affective response. That is, it promotes the emergence
of transference. And the transference in its turn acts again upon the conditions of the
setting. In general, however, the analyst would not be thinking of making distinctions
between setting and transference while he is treating the patient. If he finds himself asking
this question, then there is already significant acting out that requires his attention.
5
”In “Remembering, Repeating and Working Through” Freud made it clear that the
patient “acts” before he “remembers.” His character and conflicts express themselves in
one form or another before the recovery of textual memory occurs. Much of that “acting”
occurs by way of “testing” the setting, as a sign of resistance or as an effort to learn
whether the analyst can be trusted. This may occur in such ways as silence, avoidance of
free association, confusion over appointment times, fees, etc. It is the analyst’s empathy
which helps him to decide what the meaning of the behavior is, or at least, to point him in
the direction of where to look for that meaning. In this effort his manner should be
inquisitive and not authoritarian, since the analyst must have respect for all that he doesn’t
yet know, and always be attentive to the quality of the therapeutic alliance.
This brings me to my next point. I believe that the setting is not only a physical
arrangement, a contract for treatment and set of rules for behavior. The setting is also
something that lives in the mind of the analyst. Even when it is disrupted by psychological
forces in the patient, the analyst’s internalized model of the ideal setting serves as a kind of
gyroscope to help keep him in control of the treatment, in control of his understanding of
what is happening. Another way to say this is that it is part of the analyst’s work ego,
contributing to the climate in the analytic environment - and it becomes part of what the
patient eventually internalizes. In a wild treatment situation, for example with an actingout borderline patient who tests the analyst’s patience by gross disruptions of the setting, it
may be only the analyst’s internalized conception of the setting that helps him to manage
the turmoil, and to measure how far from the ideal situation the treatment has gone.
Imagine a patient (and I’m sure you have all had similar experiences) who misses an
appointment, requests a new appointment, and then misses that one too. On the phone the
patient blames you for not being sympathetic to the difficult circumstances of his life,
especially after he had already trusted you so much to understand. Now you have
disappointed him like everyone else in his life has done. Now he doesn’t know if he will
return to your office. If you make an effort to remind the patient of the contract for
treatment, you will be accused of putting that ahead of the patient’s needs, of being even
more insensitive than he had thought, and probably of being more interested in earning
money than in helping him. If you suggest to the patient that discussing these matters
together might prove useful to understanding the crisis you have gotten into, he will say,
“well it obviously hasn’t helped so far, why will it now? Maybe it’s useful to you, but I don’t
think it’s useful to me.” Here is a situation testing any therapist’s skill. The setting has
become the stage for acting out, the relationship has deteriorated into one of blame and
anger, and the patient deprives the therapist of any opportunity to find a resolution that will
shed light on the source of the problems. The patient, in addition, by means of projective
identification, has guessed the therapist’s anger, and in retaliation accuses him of the worst
possible crime, selfishness and lack of empathy. I suggest that here the therapist needs to
evoke his internalized memory of the setting to weather the storm which may help him
ultimately to find his way. And he must remember that he is not the one imposing the
setting, rather it is imposed on both members of the dyad - it is imposed on the treatment
situation. We cannot describe this situation without referring to the conditions of the
setting, so it becomes the reference point for working through the problem that this patient
presents. It is just this kind of situation, in work with patients unable to differentiate the
treatment setting from external reality, that required an expansion of our understanding of
setting, after Freud’s initial work.
Since it may sound as if the setting is a rigidly fixed arrangement, the question
arises as to whether or not it can be modified. How flexible is it? The answer, of course,
depends in part upon the individual therapist, as in many questions of technique. However,
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to approach it in general, one might say that, once confident of his internalized notion of the
setting, confident that it has become part of his analyzing ego, the analyst can then modify
it appropriately in an effort to respond to the patient’s needs. Some patients simply can’t
work within the setting as given. This was the case with my patient, Mr. Y. [CASE
MATERIAL DELETED FOR WEB VERSION]….
Here I am halfway through my talk, in which I am supposed to set the table for the
week’s discussions, and I must confess to not yet having answered precisely the question,
“what is the setting?” Although I’m sure you all have a good idea of what it is, I preferred
to leave it undefined, to allow a sense of its meaning to accrue as I spoke, and for us now
to compare your non-expressed definition of the setting with what various analytic thinkers
have said about it. All I said at the start was that it was an arrangement of space and
time, and a contract for behavior between two participants, without more detail.
Nonetheless I notice that most of us have respected the setting today without too much
acting out. Our setting here is an agreement to meet at a particular time and in a particular
place, for me to talk for a very long time without interruption, while you, for the most part,
remain quiet and presumably attentive to my words. We have a contract that addresses
issues of physical space (and time), and our behavior. Violations of this unspoken contract
often invite a restless, aggressive or irritated reaction - for instance if I decided to talk
about something useless to your education, or if you were noisy (recall how angry one gets
in a movie theater when someone talks nearby, or a cell phone rings and destroys the
magic of the moment.) These reactions suggest that there are potent dynamics underlying
the implicit contracts in the setting. If that is so, it is all the more pertinent in our
professional work, where much more is at stake than in non-clinical situations.
Winnicott at an early stage in his work described the setting very simply as the
“summation of all the details of management.”7 Stone preferred to call it by a different
name, the “psychoanalytic situation.” He described it as “the common and constant
features of the analytic setting [arrangement of time and space], procedure, and personal
relationship in both conscious and unconscious meanings and function.”8 He understood
that one could not separate out the physical arrangement from the interpersonal
relationship.
Winnicott later summarized Freud’s idea as follows, adding a dose of humor to his
text: “At a stated time, five or six times a week, the analyst would be reliably there, on
time, alive, breathing. For the limited period of time prearranged (about an hour) the
analyst would keep awake and become preoccupied with the patient. The analyst expressed
love by the positive interest taken, and hate in the strict start and finish and in the matter
of fees. Love and hate were honestly expressed, that is to say not denied by the analyst.
The aim of the analysis would be to get in touch with the process of the patient, to
understand the material presented, to communicate this understanding in words.
Resistance implied suffering and could be allayed by interpretation. The analyst’s method
was one of objective observation. The work was to be done in a room. . . that was quiet,
yet not dead quiet and not free from ordinary house noises. The analyst. . . keeps moral
judgment out of the relationship, has no wish to intrude with details of the analyst’s
personal life and ideas. In the analytic situation the analyst is much more reliable than
people are in ordinary life; on the whole punctual, free from temper tantrums, free from
compulsive falling in love, etc. There is a very clear distinction in the analysis between fact
and fantasy, so that the analyst in not hurt by an aggressive dream. An absence of the
talion reaction [punishment as retribution] can be counted on. The analyst survives.”
Despite this being a version of Freud’s definition, one can see here the influence of
Winnicott’s own contribution, and that of other object relations theorists, by his emphasis on
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the manner of expressing love and hate, and the analyst’s “surviving” the patient’s affect.
It is curious to me, however, that Winnicott seems to be so sure that a clear distinction can
be made between fact and fantasy, but that is not our main subject today. I believe he was
trying to emphasize the physical aspects of the setting as “reality,” as opposed to the
projective aspects. However, as we all know well, the subjectivity of these aspects is not
reducible simply to “reality vs. fantasy.” Also making this definition a little dated is the idea
that the analyst relies only on objective observation, since we know quite well that the
analyst’s subjective reactions are also key data for understanding the patient. Nonetheless,
Winnicott emphasizes certain essential elements of the analyst’s behavior in the setting the effort to help put feelings and experiences into words, to have the patient’s experience
be the sole focus of attention, to be neutral and non-judgmental, to be reliable in his
personal behavior, to “survive.” By “surviving” he means that the analyst is able to endure
(and not succumb to) the extremes of the patient’s emotions, from affectionate, loving (and
sometimes seductive) feelings, to expressions of rage and hostility - and at the same time
maintain a therapeutic setting in which these affects are not rejected, but explored.
Bleger preferred to use the label of “psychoanalytic situation,” as Stone had done
before him. By that he meant the “totality of phenomena included in the therapeutic
relationship between the analyst and the patient.”9 He separated these phenomena into
two parts. He labeled as “process” that part of the material of treatment that is studied,
analyzed and interpreted, and he separated it from what he called “non-process,” meaning
the part that “is made up of constants within whose bounds the process takes place.” In
acknowledging that however, Bleger still noted that it is a mistake to leave the setting
unanalyzed simply because it may remain quiet or “outside of process.” This was the case
with my patient, where, had there not been the intrusion of her predicament with the
payment, it might have remained “quiet”, but it could have been an error to leave such a
quiet setting unexplored forever. This is sometimes difficult technically, since it is often
hard for the patient to perceive this behavior as dynamically motivated. Only when we can
see apparent non-resistance as “resistance hiding behind compliance,” can we begin to be
more successful in bringing it under the microscope of analytic observation.
Rycroft referred to the setting in this way: “Psychoanalytic treatment is not so much
a matter of making the unconscious conscious, or of widening and strengthening the ego, as
of providing a setting in which healing can occur and connections with previously repressed,
split-off and lost aspects of he self can be re-established. And the ability of the analyst to
provide such a setting depends not only on his skill in making ‘correct’ interpretations but
also on his capacity to maintain a sustained interest in, and relationship with, his
patients.”10 You can hear in Rycroft’s description an object relations idiom. He contrasts
the earlier topographical theory (“making the unconscious conscious”) and structural theory
(“widening and strengthening the ego”) with a focus on the relationship with the patient
and the therapist’s personal capacities, in the context of a two-person psychology.
Marion Milner (1955) introduced the fruitful notion of the setting as a frame.11 Her
contribution stems from the function of the frame of a painting. Both in psychoanalysis and
in painting, the frame creates a boundary between the enclosed contents and the outer
world. Modell, following Milner, views the frame “not only as a constraint but as
[something] that. . . encloses a separate reality. . . .The ‘frame’ of the psychoanalytic
setting is separated from ordinary life as it institutionalizes a unique contractual as well as
communicative arrangement between the two participants.”12 The ability to move between
the two different realities is important diagnostically, and plays a role in deciding among
treatment alternatives and technique (analysis or psychotherapy), and the degree to which
the patient can tolerate the analyst’s abstinence. The Rat Man was instinctively able to
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recognize this difference; many borderline and severely narcissistic patients are not.
Discussing further the metaphor of the frame, Modell goes on to remind us that the
illusion of transference has often been compared to the illusion of the theater: “In both
instances the affects that are experienced are ‘real’ but the affective experience occurs
within a demarcated frame.”13 And we are on similar territory in pointing out the analogy to
play, as Winnicott has done, where there are rules for conducting the game, and guarding
the play space from “external reality.” The full gamut of emotions is experienced, but in a
clearly separate “transitional space” that is safely enclosed. As in the theater, this allows
for the expression of fantasy and illusion, and thus for loosening of the bonds of reality that
could hamper creative imagination. In the therapeutic situation, it allows access to
unconscious fantasy and primary process material, once the safety of the frame is
established. (The setting, or the frame, is not automatically safe. It is the therapist’s job
not only to construct it, but to work in a manner that convincingly and consistently
guarantees its safety.) Thus the paradox that the very fact that there is a set of rules
governing the play is what allows it to occur freely and safely. The setting, or frame,
permits the “separate reality” of the transference relationship to achieve its full affective
quality, protecting the “imaginary” field from the intrusions of “outside reality.” John Kafka
has written eloquently of the multiple levels of reality that exist in the treatment situation,
with particular attention to the role of time in their construction.14
Winnicott’s work on transitional object phenomena (including the transitional space
of the treatment situation) and their relationship to play has been crucial in understanding
the creative and growth-promoting aspects of the treatment: “Playing facilitates growth
and therefore health; playing leads into group relationships; playing can be a form of
communication in psychotherapy; and lastly, psychoanalysis has been developed as a highly
specialized form of playing in the service of communication with oneself and others.” 15 And,
“psychotherapy is done in the overlap of the two play areas, that of the patient and that of
the therapist. If the therapist cannot play, then he is not suitable for the work. If the
patient cannot play, then something needs to be done to enable the patient to become able
to play, after which psychotherapy may begin.”16 (Here he was making no distinction
between psychotherapy and psychoanalysis.) The patient who is suitable for psychoanalytic
treatment must be able to make the distinction between the transitional space of the
analytic setting, and external reality. In other words, he must be able to experience and
tolerate the “as if” nature of the treatment that, when protected by the rules of the setting,
permits the transference field to take form. Ogden has noted that “the capacity for mature
transference (as opposed to delusional transference) involves the capacity to generate an
illusion that is experienced at the same time as real and not real.”17 Recall Freud’s
observation that the love the analysand feel’s toward the analyst is both “real” and “unreal.”
This fits Winnicott’s definition of the transitional object, transferred from the realm of
concrete objects into that of “human objects.”
Winnicott’s concept of the holding environment adds a further dimension. He states
that the analyst’s constancy and reliability in listening, his authenticity, and his attending
primarily to the patient’s needs and not to his own, repeat aspects of the early childhood
relationship with the parents. He wrote that “it often takes the form of conveying in words,
at the appropriate moment, something that shows that the analyst knows and understands
the deepest anxiety that is being experienced, or that is waiting to be experienced.” These
analytic functions are analogous, but not identical, to a protective parental relationship, so
that analysands may experience being emotionally “held” by the analytic setting, just as the
mother actually held the child during infancy.18 This is another instance of different but
simultaneous “realities” occurring in treatment. Patients who are unable to accept the
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paradox of these multiple realities inside and outside the frame are not able to shift among
the realities of the transference, the therapeutic setting, and the actuality of the therapist as
an ordinary person. The absence of the fantasy dimension of transference leads it to
become overly literal and concrete.19
One need not travel far from the idea of “holding” to reach the notion of “safety,”
which Joseph Sandler has elaborated. By the successful application of his various functions
(reliability, constancy, exclusive focus on the concerns of the patient, etc.) in the setting,
the analyst enables the patient to experience a sense of safety in the treatment, a
prerequisite to therapeutic regression. Sandler considered this a vital ego function: the
“feeling of safety is more than a simple absence of discomfort or anxiety, but a very definite
feeling quality within the ego; . . .We can. . . regard much of ordinary everyday behaviour
as being a means of maintaining a minimum level of safety-feeling; and. . . much normal
behaviour as well as many clinical phenomena (such as certain types of psychotic behaviour
and the addictions) can be more fully understood in terms of the ego's attempts to preserve
this level of safety.”20
Modell considered the setting to be part of the mechanism of therapeutic action, and
not just something that facilitates the action. “We believe that there are elements of
caretaking functions implicit in the object tie of the patient to the analyst, functions that are
part of ordinary psychoanalytic technique.21 He notes that Loewald said the analytic setting
represents a new object tie.22 “In addition to these ‘real’ elements, there is the fantasy that
the analytic setting functions in some magical way to protect the patient from the dangers
of the environment, a fantasy similar to that of perceiving the analyst as a transitional
object.”23 These fantasies can and should be interpreted. As noted above, in the treatment
of most neurotics the “holding environment” functions, as it were, silently. But “where
there is ego distortion, the analytic setting as a holding environment is central to the
therapeutic action.”24
It is striking how rarely the issue of confidentiality is mentioned in descriptions of the
analyst’s behavior in the setting. In my research for this paper, I did not come across it
even once. Yet confidentiality, a feature of the therapist’s conduct, is essential for
successful treatment. “Confidentiality and trust are so deeply embedded in psychoanalysis
that to envision effective treatment without them is not possible.” 25 The concept of the
frame helps to understand this: “The purpose of the analytic frame is to create a boundary
line between the world of social interaction and the consulting room, in more than the
geographic sense. Confidentiality is a chief feature of that boundary; it extends the frame
beyond the notion of a given time, place and setting, to an essential principle of the
relationship.”26 The setting tries to optimize the conditions for the emergence of illogical,
primary process material, by means of free association, so as to gain access to the
unconscious sources of emotions and behavior. “This is a shared making of meaning by the
analytic dyad, and is part of a willing suspension of reality, for a therapeutic purpose. All of
this needs the protection of the analytic setting to allow its “as-if” function to play out fully
in the evolving transference. Once we cross the border to the social sphere [by violating
the rule of confidentiality], with its more traditional properties of language and speech and
meaning, where words are closer to actions [and] are not explored for their unconscious
derivatives, . . .we have lost the essence of the process.” 27 It should be self-evident that
there is a close relationship between confidentiality and trust, reliability, and safety.
I hope that I have shown how paying careful attention to the setting is necessary for
successful psychotherapy and psychoanalysis to occur. At times there is a need for subtlety
and care in working within the frame, that is part of the therapist’s craft. So just imagine
the damaging effect upon our task when the therapist is involved in deliberate breaches of
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the treatment setting, in other words, when he engages in boundary violations, destroying
the boundaries (physical, contractual, behavioral) imposed by the requirements of the
therapeutic setting. By all measures, acting outside of the frame harms not only the
individual treatment, but the profession itself, since we all have an interest in preserving the
reputation and integrity of our field. Actions that deviate from the therapeutic task of trying
to put actions and feelings into words, that place the needs or desires of the therapist above
those of the patient, that rationalize bodily contact between therapist and patient, or that
impair the reasonable effort to establish an atmosphere of trust, are the ways in which such
boundary violations can occur. Looking at the key functions of the setting and its
maintenance help to put this issue into perspective.
Before ending, I feel that it would be an oversight on my part to not acknowledge
the challenges in establishing a therapeutic setting, for many practitioners in Eastern Europe
and the Former Soviet Union. There are patients who are difficult to treat in all cultures and
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societies, but the absence of a psychological culture, and the population’s lack of familiarity
with psychodynamic therapies, has imposed an added burden on practitioners in Eastern
Europe. Added to this, of course, is the fact that you were new therapists, still learning how
to work, internalizing the rules of conduct for treating patients, trying to consolidate a new
identity, and yet being forced to work with difficult patients unused to this kind of treatment
- all of which posed a challenge to your skills. The historical and cultural backdrop,
economic constraints, lack of space, and lack of therapeutic traditions, imposed additional
burdens on the establishment of the setting in treatment. The situation has improved in
many parts of the region, but remains a challenge in many others. For a long time I have
been impressed with the ability of practitioners in the East to improvise, in an effort to bring
good treatment values to the profession.
In writing this paper, I was reminded more than once of some words of Milan
Kundera that have always intrigued me. In his speech accepting the Jerusalem Prize for
Literature in 1985, he declared that “great novels are always a little more intelligent than
their authors.”28 What does this have to do with the setting? I think that there is an
important analogy to be made, and this will serve as my conclusion. Just as the form of a
successful novel carries meanings and effects beyond the words of the author, and the
novel’s “wisdom” requires the author to follow and respect his characters’ wills, so too,
successful treatments always feel more wise, or more therapeutic, than the application of
the therapist’s own philosophy or technical skill is able to produce. I think that this is
because the actions of the setting, among other elements inherent in the proper conduct of
the treatment, carry their own genius with them, beyond the therapist’s application of his
will or intelligence. It is the job of the therapist to respect this, to guard it, and minister to
the vicissitudes of the setting as the therapy advances. The result of this work, like the
growth of the farmer’s crops or the author’s characters, involves functions beyond those
that exist in the caretaker himself. If the setting is properly administered, the natural
processes of growth will be re-established. In this way, the therapist must remain modest
before the powerful affects the treatment elicits, and accept the role of inquisitive student or
researcher, as he applies his technique and watches the treatment unfold with his
assistance. He learns and grows from it too - this is one of the permissible gratifications of
the work. We do not force the patient to improve, rather we apply a process, both with its
verbal and non-verbal components, that has psychodynamic and therapeutic functions
embedded in it.
Literature
1. Modell, Arnold, Other Times, Other Realities - Toward a Theory of Psychoanalytic Treatment
(Cambridge; Harvard University Press, 1990), p. 23
2. Modell, A. (op. cit.)
3. Freud, S., The dynamics of transference (SE 12), pp. 97-108
4. Modell, A., “The Holding Environment” and the Therapeutic Action of Psychoanalysis (Jl
Amer Psychoanalytic Assn: 24:285-307), 1976, p. 285
5.Modell (1990, op. cit.)
12
6. Sandler, J., Countertransference and Role Responsiveness (Intl Rev Psychoanalysis 3:43-47),
p. 44
7. Winnicott, D.W., Clinical varieties of transference (1956), in Collected Papers, (New York,
Basic Books, 1958)
8. Stone, L. The Psychoanalytic Situation, (New York; International Univ. Press, 1961), p. 9
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(New York, Basic Books, 1955), p. 86
12. Modell, A. The Psychoanalytic Setting as a Container of Multiple Levels of Reality: A
Perspective on the Theory of Psychoanalytic Treatment, (Psychoanalytic Inq; 9:1), 1989, p. 78
13. Modell, A. (Ibid. p.79)
14. Kafka, J.S., Multiple Realities in Clinical Practice, (New Haven: Yale U. Press), 1989
15. Winnicott, D.W., Playing and Reality, (Routledge: London and New York), 1971, p. 41
16. Winnicott, D.W.. Ibid., p. 54
17. Ogden, T.H., Playing, Dreaming, and Interpreting Experience: Comments on Potential
Space, in From, G and Smith, B.L., The Facilitating Environment - Clinical Applications of
Winnicott’s Theory (Madison, CT: Intl Univ Press), 1989, p. 271
18. Winnicott, D.W., Metapsychological and Clinical Aspects of Regression Within the
Psychoanalytic Set-up, in Collected Papers, (Basic Books, 1958)
19.Modell, A., (1989, op. cit.) p. 79
20. Sandler, J. The Background of Safety, (Intl Jl. Psychoanalysis 4:352-256), 1960
21. Modell, A., The ‘Holding Environment’ and the Therapeutic Action of Psychoanalysis, (Jl
Amer Psychoanalytic Assn: 24:285-307), 1976
22. Loewald, H.W., On the Therapeutic Action of Psychoanalysis (Intl Jl Psycho-anal, 41:1633), 1960
13
23. Modell, A., Object Love and Reality, (New York: Intl Univ Press), 1968
24. Modell, A., (1976, op. cit.)
25. Goldsmith, G., Confidentiality and the Psychoanalytic Relationship (paper read at 11th PIEE
Summer School, Kiev), 2004
26. Goldsmith, G., Ibid.
27. Goldsmith, G., Ibid.
28. Kundera, M., The Art of the Novel, (New York: Harper and Row), 1986, p. 158