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Psychoanalytic Technique Expanded

A Textbook on Psychoanalytic Treatment

Pitchstone Publishing

THE THERAPEUTIC SETTING

Some years ago, Dr. Edgar Lamb (not his real name), a candidate at a psychoanalytic institute who was in his mid-thirties, was presenting his second psychoanalytic case to me as his supervisor. While I found no fault in my young colleague's understanding of the psychodynamics of the case, its lack of therapeutic progress puzzled me, as his interventions and interpretations seemed to be correct. The patient Daniel, who exhibited a neurotic personality organization, was in his late twenties, was smart, psychologically minded, and determined to get well. In his daily life, Daniel often found himself in competition with others, particularly older men, as if driven into one competition after another. Dr. Lamb focused on this theme and slowly connected Daniel's behavior pattern to his obvious competition with his father. Daniel's mother was "in love" with her son, her only child, and on many occasions slept naked with him until the boy was eight years old. His mother's overtly seductive attitude toward her son had intensified Daniel's competition with his father. In turn, Daniel had a severe condition, known in psychoanalysis as castration anxiety. As an adult, during repeated competitions with older men at work, Daniel felt that he was subjected to "cutting remarks" from his competitors following which, he would engage in self-punitive activities. For example, he would lose his car keys, forget to pick up his girlfriend, and even on some occasions cut his fingers "by accident." By punishing himself, he would try to control his castration anxiety, as if it were better to self-punish than wait to be punished by others.

During the first year of his analysis, Daniel acquired an understanding of the developmental origins of his repeated competitions with older men and his subsequent self-punishment. However, Dr. Lamb did not see such issues emerging in the relationship between him and his patient. What was happening between them was like an intellectual exercise with no progress in sight. Dr. Lamb and Daniel seemed at an impasse.

One day, during supervision, Dr. Lamb inadvertently mentioned a beautiful sword that hung on the wall next to the couch where his patient lay. A history buff who liked to read about early American political and military leaders, Dr. Lamb had bought the sword at an antique shop soon after he began working with this patient. It hung there on the wall as if ready to cut apart anything unfortunate enough to rest beneath it. After hearing about the sword, I had an idea why Dr. Lamb and his patient could not develop a workable therapeutic relationship with appropriate affects and why the patient could not progress in his treatment. In each session, Daniel was reminded concretely that his analyst was a potential "castrator."

Daniel was at the end of his first year of analysis when Dr. Lamb told me about the castrating symbol on his office wall. I asked Dr. Lamb, who was himself still in training analysis, whether Daniel had brought the sword to his analyst's attention. Dr. Lamb said he had not. I found myself wondering about my supervisee's unresolved issues. It appeared that Dr. Lamb was unconsciously acting as a potential "castrator" toward his male patient instead of working through the developmental issue in his own analysis. I urged Dr. Lamb to bring this issue to his analysis, and he did so and ultimately removed the sword from his wall.

As Stanley Olinick (1980) describes it, an analyst functions as a "therapeutic instrument." Analysts, of course, are not like mechanical instruments. On the contrary, they are highly trained individuals who can develop a most intimate, empathetic relationship with their patients, with the ultimate aim of analyzing the patients' internal worlds. Analysts function in a setting — an office — which also becomes their extensions, and items in this location, like Dr. Lamb's antique sword hanging over his couch, can influence the relationship between the analyst and the patient. The setting's importance necessitates that the analyst attend to the details concerning the office thoughtfully and carefully.

The Office

The analyst's office, including the waiting room, is where, in a symbolic sense, the patient and analyst come to "play" and where the patient's psychological problems come to life. Metaphorically, the office is the location where the patient plays the music he began composing in childhood. Since the patient has a neurotic personality organization, the music initially is chaotic; it is sometimes harsh, sometimes soft. It often involves crying and sometimes even more primitive sounds of the body, such as clearing the throat, sucking, or passing gas symbolically or actually. In this performance, the psychoanalyst acts not only as the conductor, but joins the patient in rewriting the music. As they work together and as the patient's composition changes, the music becomes more refined and expressive of understandable thoughts and feelings.

As the setting for such an intimate routine, the analyst's office should be accessible, reliable, and comfortable. Analysts are responsible for keeping access to their offices unobstructed, as a practical means of ensuring safety and reliability, as well as a symbolic means of guaranteeing access to themselves as analysts as they are imagined and recruited into their patient's composition.

A young analyst once had an office on the fourth floor of a hospital. His patient could reach the office via either the elevator or stairs. If using the stairs, however, the patient had to walk through a small conference room, which was usually empty. One day the elevator did not work, and so the patient climbed the stairs, only to find a meeting in the conference room. He felt awkward about walking through the meeting and thus did not attend his session. The young analyst was upset and wanted to charge the patient for the missed hour; however, his supervisor told him he should not, as it was the analyst's responsibility to ensure reliable access to his office. Any such break in the therapeutic frame should be rectified and, to whatever extent possible, explained in order to maintain the stability of the setting. In a similar spirit of guaranteeing unfettered access to the analyst, I believe that the patient should be able to access the analyst directly, rather than through a receptionist. This preserves the space of the analysis as unique, exclusively between the patient and analyst.

Another practical way of preserving the therapeutic space is good soundproofing. The patient needs to know that only the analyst hears what is said during the session. The analyst is also responsible for making the therapeutic space, once accessed, both comfortable and reliable. For example, no light should shine directly in the patient's eyes, in order to avoid distraction and any similarity to an interrogation room. The analyst also must reliably maintain the boundaries of time, be responsible for starting and finishing the sessions on schedule and, as such, manage the clock. Although some analysts allow patients to see the clock so they might more cooperatively manage the session, my own experience tells me that it is a good idea to place the clock outside the patients' sight to avoid distraction from the therapeutic task.

The Analytic Couch

Before developing psychoanalytic technique, Sigmund Freud practiced and trained extensively in hypnosis. As he developed psychoanalysis, I assume that he sought to simulate the "sleep" patients experienced while hypnotized and so borrowed the tradition of lying on a couch. The year 2006 marked what would have been Freud's 150th birthday and many psychoanalytic organizations across the world celebrated his legacy at that time. Austria declared 2006 the "Year of Freud," as well as the "Year of Mozart." That year I was elected the Fulbright-Sigmund Freud Privatstiftung Visiting Scholar of Psychoanalysis and spent four months in Vienna with the use of a small office in Freud's home, now the Freud Museum. In honor of Freud's birthday, the museum had prepared an extensive exhibition called "The Couch." During the exhibition's opening, I was repeatedly asked whether contemporary psychoanalysts still need to use the analytic couch. With changing times, almost every firmly accepted psychoanalytic concept such as this one is being questioned. My answer is that analysts are required to continue using the couch.

One crucial aim of psychoanalysis is to help the patient with a neurotic personality organization to evolve a workable transference neurosis. To accommodate this, the psychoanalytic movement has followed Freud's lead to put patients on the couch. We assume that when patients do not see their analyst while on the couch — in other words when they do not perceive the "reality" of the analyst — an atmosphere is created that allows the patient to develop a deeper and workable transference neurosis by displacing realistic or fantasized images of significant persons or things from childhood onto the analyst. Removing the analyst from sight and asking the patient to lie on the couch invites the patient into a therapeutic regression and creates an atmosphere conducive to free associations. Positioning the analyst's chair behind the couch, outside of the patient's sight, also makes listening to the patient easier by minimizing the distractions and discomforting feelings that arise from being watched.

Practically, the couch should be comfortable and long enough to accommodate taller patients. The specific features of the couch vary; some analysts, for example, add extra pillows or blankets. Analysts also position their couches in a variety of ways. Some couches face blank walls, while others face something that might inspire associations, such as a window through which a patient sees trees that change with the seasons. Finally, analysts should take care to secure comfortable chairs for themselves, as they spend hours sitting every day and are vulnerable to back problems.

Personal Effects

Let me go back to Dr. Lamb's antique sword. It clearly had a negative effect on the therapeutic process, although he was initially unaware of its impact. Not only do the items in one's office reflect one's taste, but they also insinuate themselves into patients' treatments in the form of fantasies and associations. How, then, does one decide what to put in an office?

At the Freud Museum in London, one can see the kinds of things Freud had in his office; similarly, pictures of Freud's Vienna office are on display at the Freud Museum in Vienna. These are useful for us as we think through and make decisions about the physical aspects of the therapeutic setting. Freud, for example, was interested in archeology, and so kept many archeological artifacts in his office. I do not know if he consciously placed them there to invite the regression he sought, as if saying, "In this room you will regress therapeutically in order for us to understand the beginnings of your life." We do know, however, that Freud (1905a) often suggested a similarity between his approach and that of archeologists as he sought to make repressed material available. "I have restored what is missing, taking the best models known to me from other analyses; but, like a conscientious archeologist, I have not omitted the mention in each case where the authentic parts end and construction begins" (p.12). I do not suggest that all analysts should have archeological items in their offices, unless of course, they are genuinely interested in archeology.

Deliberately collecting things the analyst thinks of as symbolically useful items for one's office would be unproductive and a kind of manipulation of the patients. The analyst seeks a balance by creating an authentic, personal presence in the room, while not over-personalizing the space, which would threaten to distract the patient from the therapeutic task. Ideally, items in the office should be pleasing and familiar to the analyst, keeping in mind that any item can be imbued with symbolic meaning and become a representation, of either the analyst's or the patient's self- and/or object images. Consider the following illustrations.

Once I had a potted plant in my office. At one phase of her treatment, one of my patients felt that I was depriving her of needed love. She verbalized this; I remained silent, waiting to see what might develop. The next day the patient looked at the plant intensely while lying on the couch and declared that it would die since, in her estimation, I was not giving it the water it needed. I wondered if the patient's statement was another complaint that I was not providing her with the love she desired, but this time she was putting her "hungry" self-image onto an item in my office, the plant, which also was in need of "milk."

Freud had a Turkish rug covering his couch. Since I am of Turkish origin, having immigrated to the United States in early 1957, I also had a Turkish rug on my couch. As such, Turkish rugs would often appear in my patients' associations and sometimes in their lives outside of analysis. One patient who I will call Hamilton was fifty-eight years old when he started analysis and began lying on the Turkish rug covering my couch. He had experienced many traumas in childhood, including regular beatings from his father that were administered in a bathroom that Hamilton remembered as a "torture chamber." During his initial years in analysis, Hamilton often perceived me as a "terrible Turk with a scimitar." The patient put his image of his father onto his analyst. Later in the analysis, after Hamilton had firmly differentiated me from his childhood father, he imagined the analyst as a softer, more caring person. At the same time, he bought a new workplace and renovated its large bathroom, making it smaller, an act symbolically "shrinking" the torture chamber of his childhood. He also bought a soft-colored Turkish rug for the new space, aware that it was an extension of his analyst whom he now regarded as a caring and nurturing person (Volkan and Fowler 2009).

Aside from decorative items, the analyst also must decide whether to display things of a more personal nature, such as photographs of a spouse, child, parent, or national hero. My answer is no. During the analytic session, the patient will have fantasies about the analyst, contributing to the emergence of the analyst as a transference figure. In order to foster such a development, it is better not to include items representing the analyst's actual personal relationships. For example, pictures showing the analyst cuddling children might interrupt the patient's exploration of "sibling rivalry" issues.

Finally, once analysis is underway, any physical changes in the office may induce psychological reactions in the patient's mind. Sometimes, for personal unconscious reasons, the analyst might make a change in the therapeutic setting, as Dr. Lamb did when he bought the sword, and this may influence the flow of the analytic process.

In another example, a young analyst I supervised years ago changed the furniture in her office without preparing an analysand who consequently felt as if she had lost her mother and had been sent to a new mother. She had to mourn the loss of the old furniture.

The Analyst's Person

The analyst is the most important object for the patient in the therapeutic setting. Who is an analyst? He or she is a person who devotes considerable time and energy to arduous study in order to spend hour after hour sitting in a chair in an office undertaking what Freud (1937) called an impossible profession. What makes a person choose this path? Of course, there are myriad possibilities. A few analysts, such as Harold Searles (1979), L. Bryce Boyer (1983) and I (Volkan 1985), suggest that a common impetus behind this choice involves a sublimated "rescue fantasy," which has ties to particular childhood life-experiences. Olinick (1980), elaborating on this notion, posits that a depressive mother, in particular, can induce rescue fantasies in her receptive child. He explains:

For such relatedness of mother and child to be formative, it must be early, though the necessary duration is not clear. ... It seems that depression or sadness alone is not sufficient; in addition, the maternal character must be at least in certain aspects alloplastic. (pp.12–13)

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Excerpted from Psychoanalytic Technique Expanded by Vamik D. Volkan. Copyright © 2011 Vamik D. Volkan. Excerpted by permission of Pitchstone Publishing.
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