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

Mentalization, insightfulness, and therapeutic action: The importance of mental organization

Continuing debates over the relative importance of the role of interpretation leading to insight versus the relationship with the analyst as contributing to structural change are based on traditional definitions of insight as gaining knowledge of unconscious content. This definition inevitably privileges verbal interpretation as self-knowledge becomes equated with understanding the contents of the mind. It is suggested that a way out of this debate is to redefine insight as a process, one that is called insightfulness. This term builds on concepts such as mentalization, or theory of mind, and suggests that patients present with difficulties being able to fully mentalize. Awareness of repudiated content will usually accompany the attainment of insightfulness. But the point of insightfulness is to regain access to inhibited or repudiated mentalization, not to specific content, per se. Emphasizing the process of insightfulness integrates the importance of the relationship with the analyst with the facilitation of insightfulness. A variety of interventions help patients gain the capacity to reflect upon and become aware of the intricate workings of their minds, of which verbal interpretation is only one. For example, often it seems less important to focus on a particular conflict than to show interest in our patients' minds. Furthermore, analysands develop insightfulness by becoming interested in and observing our minds in action. Because the mind originates in bodily experience, mental functioning will always fluctuate between action modes of experiencing and expressing and verbal, symbolic modes. The analyst's role becomes making the patient aware of regressions to action modes, understanding the reasons for doing so, and subordinating this tendency to the verbal, symbolic mode. All mental functions work better and facilitate greater self-regulation when they work in abstract, symbolic ways. Psychopathology can be understood as failing to develop or losing the symbolic level of organization, either in circumscribed areas or more ubiquitously. And mutative action occurs through helping our patients attain or regain the symbolic level in regard to all mental functions. Such work is best accomplished in the transference. The concept of transference of defense is expanded to all mental structure, so that transference is seen as the interpersonalization of mental structure. That is, patients transfer their mental structure, including their various levels of mentalizing, into the analytic interaction. The analyst observes all levels of the patient's mental functioning and intervenes to raise them to a symbolic one. At times, this will require action interpretations, allowing oneself to be pulled into an enactment with the patient that is then reprocessed at a verbal, symbolic level. Such actions are not corrective emotional experiences but are interpretations and confrontations of the patient's transferred mental organization at a level affectively and cognitively consistent with the level of communication. Nonetheless, the goal becomes raising the communication to a symbolic level as being able to reflect symbolically on all aspects of one's mind with a minimum of restriction is the greatest guarantee of mental health.

Neediness and narcissistic defensive action

Action-prone patients are difficult for most analysts to treat. The author describes patients who act in treatment by pressuring themselves and the analyst to get rid of what is wrong, to change the imperative, life-and-death qualities of need into something else. Viewing neediness in treatment as narcissistic defensive action helps the analyst address the patient's pressured flight away from focusing on the need of the analyst and toward action aimed at riddance. Ghent's (1992, 1993) views on neediness are discussed and seen to be complemented by a view of action as protection against narcissistic vulnerability. Analysts' intolerance, vulnerabilities, and needs with such patients are considered.

A shadow concept

The author focuses on the significance of preconscious thinking, and its relationship to what we think of as unconscious fantasies. He reopens Freud's forgotten struggle with preconscious thinking, while he explores preconscious thinking as the basis for thinking about psychoanalytic treatment. This includes our goals in bringing an idea to the analysand's attention, and the role of transitional space where thoughts and feelings can be played with.

'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.

From developmental metaphor to developmental model: the shrinking role of language in the talking cure

Psychoanalysts have invoked infant development diversely to understand nonverbal and unspoken aspects of lived experience. Two uses of developmental notions and their implications for understanding language and the therapeutic action of psychoanalysis are juxtaposed here: Hans Loewald's conception of developmental metaphors to illuminate ineffable aspects of the clinical situation and Daniel Stern's currently popular developmental model, which draws on findings from quantitative research to explain therapeutic action in the nonverbal realm. Loewald's metaphorical use of early development identifies and thus potentiates a central role for language in psychoanalytic treatment. By contrast, Stern and his colleagues exaggerate the abstract, orderly, and disembodied qualities of language, and consequently underestimate the degree to which lived interpersonal experience can be meaningfully verbalized, as demonstrated here with illustrations from published clinical material. As contemporary psychoanalysis moves toward embracing developmental models such as Stern's, it is concluded, psychoanalysts accept a shrinking role for language in the talking cure.

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.

Action as ejection

The systematic analysis of acting-out episodes can be used in assessing analytic progress. Variables to be considered are the nature of the wish, the type of defense, and the degree of concreteness (versus symbolization) of the mental processes used in attempting actualization (as distinct from the resort to action). Two acting-out episodes of a borderline patient who acted out as a character trait, both occurring outside the analytic setting, are presented as illustrations. In the first one, occurring relatively early in the analysis, when split-off negative and positive self-images had to be rigidly maintained, ejection of the negative self-image was actualized via the regressive use of a symbolic equation and the mechanism of displacement, obliterating the distinction between an internal feeling and an external thing that here was literally thrown out. The later episode, occurring after the split was healed and within the context of a frustrating heterosexual involvement, contained an acted-out allusion to identification and competition with the mother. As in a dream, via associations, an unconscious wish for oedipal victory was revealed. Whereas in the first episode the goal of ejection was central, with splitting and denial the underlying defenses, it was absent from the second, in which an attempt was made to actualize a repressed infantile wish and made greater use of symbolization. It is concluded that acting-out episodes at different periods of the analysis, when systematically analyzed, can serve in assessing a patient's progress.

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.

What is a deep interpretation?

Important differences are emerging regarding the place where analysts believe the most meaningful analytic work takes place. One area that highlights these distinct ways of working is the analyst's view of deep interpretations. Models underlying the differing perspectives on this issue are presented, along with an extended clinical example that illustrates the importance of considering, in formulating analytic interventions, the concept of a structured mind. A view of the analytic process that accords the patient's perspective greater privilege is introduced.

The overstimulated state of dyslexia: perception, knowledge, and learning

Dyslexia is far more than a learning disorder; it has significant impact on personality organization. While dyslexia usually begins to manifest most clearly in early latency when the challenge of learning to read is at its height, often the dyslexic child's ego development and functioning has already been adversely affected. The literature from neuropsychology suggests that dyslexia is a subtle language-processing disorder that affects emotional, cognitive, and social development. The neuroanatomical literature also suggests a significant correlation between the neurodevelopmental basis for dyslexia, the caregiving environment, and psychological development. These two bodies of literature and analytic observations of a dyslexic patient suggest that the dyslexic individual may have a neurological deficit that increases vulnerability to overstimulation. The author hypothesizes that emotional and cognitive states result and reappear within the analytic encounter. This complicates clinical assessment and technical decisions. The author presents an analytic case and examines (1) the impact of deficit on the development of conflict; (2) the impact of the overwhelmed ego on the mastery of developmental tasks; and (3) the impact of dyslexia on dysgnosia, transference, and analytic process and technique.

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Psychotherapy is an interpersonal and interactive process. As this view gained acceptance, methods in psychotherapy research for analysing the intersubjective dimension of the psychotherapeutic dialogue became more important. Ethnomethodology with its research program of conversation and context analysis has a long tradition in research on social interaction and can follow this development. With a conversation analytic approach means and practices can be reconstructed that patient and therapist use to coproduce the psychotherapeutic encounter.

Where the action is: the enacted dimension of analytic process

Enacted processes--variously addressed in the current literature by such terms as enactment, actualization, and interaction--represent the conceptual reuniting of Freud's concepts of transference and acting out. These various concepts include a recognition that transference may be represented not only on the verbally symbolized level but also on the enacted level, through psychic organizations and processes that use behavior, silence, and even speech as symbolic vehicles. Countertransference too finds representation within the enacted realm, in response to and in concert with the patient's enacted processes, though in more attenuated fashion. Enacted transference-countertransference processes are conceptualized as a continuously evolving second dimension of analytic treatment. This enacted dimension of analytic process exists alongside, and inextricably interwoven with, the treatment's verbal content, with characteristics unique to each analytic dyad. It occurs naturally and inevitably, without conscious awareness or intent, and is outside the domain of explicit technical interventions. The observable outcroppings or end points of processes within the enacted dimension are what are currently referred to as enactments. Attention to these unintended but meaningful and often elaborately developed characteristics of the treatment process furthers our understanding of the therapeutic action of psychoanalysis. The process of integrating the enacted with the verbal dimension of treatment enables the analysand to achieve higher levels of psychic organization.

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.

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.