Some ambiguities in the method of free association and their implications for technique

SHIFTING BETWEEN ALTERNATIVE MODES OF COGNITION: CAN FREE ASSOCIATION, IN AND OF ITSELF, PROVE THERAPEUTIC?

From early on in his career, at the time of his treatment of Frau Emmy von N., Freud (Breuer and Freud 1895) recognized the value of listening to the patient's material without attempting to steer it along a particular course. His focus on the method of freie Einfalle (free association), to be presented to the patient as the fundamental rule of analytic treatment, led to his recommendation that the analyst listen with evenly suspended attention (Freud ). But is free association therapeutic in and of itself? The author proposes an affirmative reply to this question based on the contribution of free association to the patient's nascent ability to shift between active and passive modes of cognition.

Making conscious the unconscious in order to modify unconscious processing: Some mechanisms of therapeutic change

This paper examines some of the mechanisms through which interpretation aimed primarily at increasing conscious awareness can nonetheless produce unconscious changes, the latter being deemed the basic aim of psychoanalysis. The concept of valency or motivational weight of the interpretation is proposed to assess which forces of the various motivational systems the interpretation mobilizes (hetero/self-preservation, sensual/sexual, attachment, narcissistic, psychobiological regulation etc.), on which of the above-mentioned systems interpretation relies, and which would oppose therapeutic intervention and why. Certain conditions are also analyzed that could explain the so-called 'change through the analytic relationship', pointing out that, despite the major differences between this form of change and change through interpretation, both of them would share certain mechanisms. This conclusion leads to the need to qualify the idea that interpretation would be exclusively aimed at declarative memory, with no effects upon procedural memory. The paper examines the potential consequences for therapeutic techniques derived from recent findings in neuroscience on so-called labile state memory, and proposes the coupling of experiences as one of the analytical instruments used for therapeutic change. A clinical vignette is included to illustrate some of the theoretical and technical aspects considered.

PARRHESIA, PHAEDRA, AND THE POLIS: ANTICIPATING PSYCHOANALYTIC FREE ASSOCIATION AS DEMOCRATIC PRACTICE

This essay explores the mostly unexamined analogy of psychoanalytic free association to democratic free speech. The author turns back to a time when free speech was a matter of considerable discussion: the classical period of the Athenian constitution and its experiment with parrhesia. Ordinarily translated into English as "free speech," parrhesia is startlingly relevant to psychoanalysis. The Athenian stage-in particular, Hippolytus (Euripides, 5th century BCE)-illustrates this point. Euripides's tragic tale anticipates Freud's inquiries, exploring the fundamental link between free speech and female embodiment. The author suggests that psychoanalysis should claim its own conception of a polis as a mediated and ethical space between private and public spheres, between body and mind, and between speaking and listening communities.

'I noticed': the emergence of self-observation in relationship to pathological attractor sites

The author highlights self-observation as an important goal of psychoanalysis, separate from other concepts with which it is often confounded. To support this position, he presents clinical and developmental data, as well as observations by psychoanalysts on recent findings by cognitive neuroscientists. He introduces the term 'pathological attractor sites' to capture the challenge in moving from the belief in the reality of one's own thoughts to self-observation. Clinical techniques to deal with this specific challenge are presented.

Countertransference in defense enactments

A clinical term is introduced to capture a defense that develops with the patient's deepening but fleeting awareness of painful transference feelings. The analyst's attention to countertransference in such situations is central to the analysis of these defenses. An attempt is made to distinguish defense enactments from other types of defenses, and to differentiate the analyst's countertransference reaction to this type of defense from countertransference reactions that might appear similar. The reasons for this dynamic in the interpersonal space are explored, and a clinical example that describes this phenomenon in the analytic moment is given.

Inhibition of self-observing activity in psychoanalytic treatment

The author examines the topic of inhibition of self-observing function in some patients arising from conflicts over aggression. The author's thesis is that conflicts over aggression can interfere with the patient's task of shifting from passively reporting spontaneously occurring associations to actively reflecting on his thoughts in an analysis. This can result in the patient remaining in the role of passive reporter of his associations while ceding to the analyst the role of aggressive interpreter of the patient's psychic functioning. The active ego functions necessary for understanding and integration are inhibited, compromising the potential for growth and change. Clinical vignettes illustrate a close process analytic process to this phenomenon.

How can we know what we need to know? Reflections on clinical judgment formation

What distinguishes a psychoanalyst from any other psychologically minded, empathic human being? This seemingly simple question goes to the heart of our profession, the way we see ourselves as competent clinicians. To understand a patient's material beyond ordinary empathy--that is, to come to a clinical judgment--we need to step out of the dyadic, countertransference situation and reflect what we've experienced in reference to our clinical theories. An analytic vignette shows how a theoretical background can be used to understand and interpret to a patient in a way that is deeply meaningful.

Back to the future

Significant components of psychoanalytic technique, and the theory that underlies it, seem to remain buried in our past, but are central to the growth of psychoanalysis as a treatment method based on understanding a patient's mind. By updating technique based on a theory of mind with structure, the author views the increasing freedom of the patient's mind as central to the curative process, and takes the position that in interpretive work, the analyst needs to pay more attention to the patient's capacity to meaningfully receive and integrate the analyst's interventions.

On the question of the patient's right to tell and the ethical reality of psychoanalysis

This paper calls into question the view that it is ethically legitimate for the patient to say whatever comes to his or her mind: that is, to adhere to the fundamental rule. While there have been some variations in the application of this rule since Freud's time, it remains for many the bedrock of clinical practice, and the patient's right to free-associate has never been questioned. Recent debates on the importance of the analyst's strict confidentiality have highlighted this right. Ethical problems raised by adherence to the fundamental rule are explored through an examination of the general ethical limitations on what one may say to another person, and the special features of the analytic relationship that seem to do away with these limitations. The fact that there are ethical questions about adherence to the fundamental rule draws attention to what the author calls the ethical reality of psychoanalysis. The recognition of this reality has implications for the understanding and handling of ethical dilemmas regarding disclosure, as well as for other ethical issues that may arise in the course of an analysis.

Telling stories

Patients need to tell their stories. One of our primary tasks as analysts is to help patients tell their stories and own them. The freedom of mind to think, to feel, and to know are dependent on the ongoing capacity for storytelling. The analyst's stance plays a major role in the development of the analysand's storytelling capacities.

On trying something new: effort and practice in psychoanalytic change

This paper describes one of the ingredients of successful psychoanalytic change: the necessity for the analysand to actively attempt altered patterns of thinking, behaving, feeling, and relating outside of the analytic relationship. When successful, such self-initiated attempts at change are founded on insight and experience gained in the transference and constitute a crucial step in the consolidation and transfer of therapeutic gains. The analytic literature related to this aspect of therapeutic action is reviewed, including the work of Freud, Bader, Rangell, Renik, Valenstein, and Wheelis. Recent interest in the complex and complementary relationship between action and increased self-understanding as it unfolds in the analytic setting is extended beyond the consulting room to include the analysand's extra-analytic attempts to initiate change. Contemporary views of the relationship between praxis and self-knowledge are discussed and offered as theoretical support for broadening analytic technique to include greater attention to the analysand's efforts at implementing therapeutic gains. Case vignettes are presented.

The patient's part in analytic process: the influence of the analyst's expectations

The psychoanalyst's expectations of the patient are complex and crucial to the work of analysis. These expectations, operating at a level generally outside the consciousness of patient and analyst, are part of the "microstructure" of analysis, the interactional give-and-take that brings about change. The view taken here is that analytic process is necessarily interactive, as well as intrapsychic. In addition to transference-countertransference motivations, both parties to an analysis operate in a social context that prescribes a range of desired and undesired behavior. The analyst brings to the interaction professional analytic attitudes about how to listen and act, and a set of expectations of the patient. These attitudes and expectations modulate subjective reactions to the patient's transferentially driven actions, and influence the expression of countertransference. The mutative process of psychoanalysis involves the action of these attitudes and expectations on the patient, both in ways specific to individuals and in more general ways. Such expectations lie behind analytic tactics and, though not often written of, are part of the oral tradition of psychoanalysis. Here the expected patient role is described in terms of five bipolar continua: (1) reporting and editing; (2) transferring and containing; (3) thinking about oneself and thinking about the analyst; (4) regressing and listening/self-observing; (5) initiating trial action and mediating among inner states. The activity and thinking of the dyad move constantly along these continua. A clinical example from the beginning of an hour illustrates how these expectancies emerge in analytic work.

Understanding the patient's use of the method of free association: an ego psychological approach

While most of our methods of listening have been geared toward unearthing unconscious fantasies, those directed toward the ego's all-inclusive role in effecting the associative process have lagged far behind. It is the thesis of this paper that listening from the perspective of the ego allows the analyst to work more closely with what the patient is ready to understand. Clinical technique, using an ego psychological view, is elaborated, demonstrated, and compared to technique dependent on the reading of signs and symbols of the unconscious.

The ego and its significance in analytic interventions

Freud's view of the ego as Januslike, the one component of the psychic system turned toward the external world yet partly unconscious, should have insured its centrality in clinical interventions. However, history and experience do not bear this out. It is argued that a core part of the change process in analysis lies in the modifications that occur in ego functioning, making it necessary to carefully consider the role of the ego in clinical technique. Numerous clinical examples are presented to show the manner and significance of such an approach.

On trauma, perversion, and "multiple personality"

The role of perverse sexuality as an organizing influence in "multiple personality" is explored in this paper. Following a brief review of psychoanalytic thinking on sexual trauma and perversion, the author discusses his own views on dissociation and "multiple personality." A clinical case is then presented in which transsexualism, homosexuality, and sadomasochistic heterosexual practices were manifested during altered ego states. Analysis of the transference revealed the centrality of sadomasochism in this patient. It is hypothesized that various perverse structures may be formed within these seemingly autonomous, amnestic states, in order to contain anxiety and encapsulate the aggression which resulted from early psychic trauma. Issues relating to diagnosis, countertransference, reconstruction, and psychoanalytic technique are discussed also.

Beginning a psychoanalytic treatment: establishing an analytic frame

The opening phase of analysis has received scant attention. Freud initially included, as essential, the establishment of an analytic process via the method of free association in the opening phase. However, his stance in relation to this process we can now characterize as authoritarian, and as influenced by suggestion and manipulation. Recent literature, while contributing to the understanding of the range of dynamics possible when beginning an analysis, continues to ignore the manner in which the method of free association may be used by both participants in establishing an analytic frame. Two clinical examples of how this latter process may be inaugurated are given, and reasons for the drift away from it are suggested.

Do actions speak louder than words? A query into an enigma in analytic theory and technique

While action is increasingly viewed as ubiquitous throughout psychoanalytic treatment, our understanding of why it occurs is limited by rudimentary views of verbalization and action. Dynamic and genetic interpretations of action, usually given at a time of resistance impasse, give only a partial explanation of the phenomenon. The question is explored of why the behavior may appear in the form of action, as well as its implication for interpretive strategies. A major premise is that the role of the ego has been overlooked, especially modes of thinking associated with earlier developmental levels.