The analyst communicates certain associations of a personal nature even when he does not seem to do so. These communications begin, one might say, with the plate on the front door that says 'Psychoanalyst' or `Doctor.' What motive (in terms of the unconscious) would the analyst have for wanting to cure if it were not he who made the patient ill? In this way the patient is already, simply by being a patient, the creditor, the accuser, the `superego' of the analyst; and the analyst is his debtor [pp. 145-146].But is a reparative motive, which is, after all, relatively benign, the only kind that the patient can plausibly attribute to the analyst for assuming this rather peculiar role? It seems to me there are others that are much more threatening to the patient's sense of safety. Is the analyst not the person who has detected a certain need in the society for understanding, for love, for an idealized object; the one who has scanned the culture (usually with special attention to the white, urban middle class and upper class) and thought, "why shouldn't I take advantage of this hunger, this craving that a lot of people have for this kind of attachment"? Is the analyst not also the one who has found a way to feed his or her narcissism without being subjected to very much personal risk, or, perhaps, one who fears and craves intimacy and has found a way to have it while still maintaining a good deal of control and distance, or one who enjoys his or her sense of power over the people (if business is good, the many people) who want to be his or her special or favorite one? Finally, what could be better than to have all of this hidden under the guise of being the "good-enough parent" who provides, "objectively," a secure holding environment, armed against whatever protests might arise with knowing interpretations of the "neurotic transference"?
These motives, and others like them, comprise the dark, malignant underside of the analytic frame. It is a side that I think we commonly deny. It's rather astonishing, I think, how ready we are to compare ourselves to rather ideal parents, not perfect perhaps, but surely "good enough," and how prepared we are to see the influence of the pathogenic aspects of the patient's past upon the entry into the analytic space of the so-called "bad object" (cf. Slavin and Kriegman, 1992).
The rituals that constitute the frame are undoubtedly essential to the process, and deviations from them are certainly as open, if not more open, to suspicion regarding their self-serving nature as is their religious observance. What I'm questioning is the neatness of the dichotomy: adherence to the frame creates safety, deviation from the frame creates danger. Even if the frame is mostly beneficial, it does not create a perfect sanctuary because, as I have said, it cannot eliminate the analyst's personal participation as a coconstructor of reality in the process and because its defining features are, in themselves, suspect.
Psychoanalytic rituals provide usefully ambiguous grounds, not only for new experience and development, but also for neurotic repetition. Acknowledging this reality has at least two important clinical implications. First, the patient's conscious and unconscious objections to analytic routines, even his or her rage about them, must be taken seriously. By that I mean more than that we have to get into the patient's world and see it from his or her point of view. That attitude can be subtly patronizing, to the extent that we consider the patient's perspective to stem from deficits or even from unresolved conflicts originating in childhood, and to the extent that we hope that the patient will eventually come to see things from a more developmentally advanced perspective. Instead, I mean that we recognize what may be objectionable about the frame, even from the point of view of a mature, "healthy" adult, so much so that we may wonder what kind of pathology would result in a person being willing to go along with it at all! The one in need is the one who may be driven to accept an invitation to be exploited, and the analytic arrangement can be construed, quite plausibly, as extending such an invitation. A second clinical implication of acknowledging the malignant aspects of the frame, in addition to recognizing a place for an unobjectionable negative transference (cf. Guidi, 1993) and for reasonable resistance, is that such acknowledgment provides theoretical grounds for considering the benign potentials of momentary deviations from the standard routine. A readiness to deviate in certain limited ways may offset the exploitative meanings that can get attached to maintaining the frame in an inflexible manner. There is no way for the analyst to know, with certainty, what course to pursue with respect to the balance between spontaneous, personal responsiveness and adherence to psychoanalytic rituals at any given moment, nor can the balance that is struck be one that the analyst can completely control. The basis for the patient's trust is often best established through evidence of the analyst's struggle with the issue and through his or her openness to reflect critically on whatever paths he or she has taken, prompted more or less by the patient's reactions and direct and indirect communications.
With these ideas as background, let's take a closer look at a piece of clinical experience.
CONFRONTING A PHOBIA WITHIN THE ANALYTIC SETTING: A SERENDIPITOUS OPPORTUNITY
A patient, Ken, is in my private, downtown office on the 21st floor for the first time. For about three years we had met four times per week at my office at the university, which was on the seventh floor. In that office there was one small window at the foot of the couch. Here, there are two enormous windows on the wall across from the couch to the patient's right, about 6 or 7 feet away. The patient is terrified of heights. The theme of high places is at the center of a complex knot of symptoms, an amalgam of depression, anxiety, obsessional tendencies, and phobia. Ken has had full-blown panic attacks just contemplating certain situations that involve heights, not to mention being in them. On one occasion, he traveled to another city for a meeting where he was to make a presentation on a subject of great interest to him. At the last moment, to his dismay and embarrassment, he had to back out, because to get to the room where the meeting took place he would have had to walk across a corridor with a railing overlooking an atrium. But his reactions are variable, and sometimes he has managed very well in situations that could have been disabling. In general, he is a very competent, resourceful person, a mental-health professional himself and a psychotherapist. Ken is also a devoted husband and father of three young children.
At the university office, Ken had generally felt comfortable. He had rarely felt anxious during a session. Sometimes he would get anxious after a session while waiting for the elevator, which was next to a window. Often he would take the stairs rather than wait. He had told me of a fantasy of coming back to the office to ask for some ill-defined help. He had thought of my comforting him or perhaps waiting with him at the elevator, but he never acted on that impulse. In general, he had always been respectful of the conventional limits of the analytic situation and had made good use of it as a context for expressing and exploring the things that troubled him. In many ways he was an ideal analysand, reporting many dreams and experiencing and reflecting upon transference issues in the here and now and in terms of genetics.
Changes in my schedule and Ken's made it more convenient to have first one, then two of our four sessions in my downtown office. The idea of meeting there was broached for the first time by me, anticipating a day when the university would be closed because of a holiday but when I would be working in my practice. Ken actually declined that invitation, but he subsequently brought up the possibility himself because he wanted to take advantage of the opportunity to tackle his fear of heights within the context of the analysis. We did, however, discuss the fact that once the option was made available, Ken felt some internal pressure to try it, along with a sense that I might want him to. And it is true that I thought this might be a serendipitous development. The combination of the two locations could provide the opportunity to confront the phobia directly, as Freud (1919) suggested was necessary with such symptoms, but with the advantage of having that confrontation woven into the analytic routine itself. The latter would include alternation between the "safer" and the more "dangerous" settings.
So, here we are at the end of this first session on the 21st floor. Ken has managed to get through this hour without a major attack of anxiety or vertigo. He was quite anxious at the beginning, although it was not as bad as he had anticipated, especially with the window shades pulled down, something I had done in advance at Ken's request. He said, "I was afraid I would be drawn to the windows and I would become like a robot or an automaton, unable to control myself. And then what would you do? Would you stop me? Of course, I feel that you would." I say that he may have a wish for an experience in which I stop him physically from doing something selfdestructive. He says he feels that would be a demonstration of will and strength for his benefit. He reports a dream. "There is a truck with long boards of wood. Somehow I go underneath all the wood boards. They started to slide out of the truck on top of me and I realized I could be crushed. But I got out and I didn't panic. I don't remember whether there was anyone else helping. I think I just got out myself." He spontaneously thinks of the unloading of a truck as a metaphor for the analysis. Then he associates to his father. He thought of him as husky and strong physically, but he always felt threatened by him rather than comforted. He says his father "always wanted to win," whereas he, as a father himself, enjoys roughhousing in a playful way with his own children. I say, "Meeting with me here has a lot of meaning for you I think. It's probably not just the height as such that is affecting you." The patient says, "I could get into resenting it, having to put myself through this. But I do have a sense that we are in this room together and that in general we are in the process together, and that helps." Now this much-anticipated and dreaded first time is over. I say it's time to stop. Ken sits up. He seems a bit shaky. Then he looks at me and, rather to my surprise, he says, "I don't feel too bad, but I wonder if you'd mind walking to the elevator with me?"
MOMENT OF TRUTH: THOUGHT IN ACTION
I think it's good to stop at points like this to consider the analyst's position, because, as an exercise, it's useful to consider the kinds of attitudes the analyst may have toward the patient's request without the benefit of hindsight.
The instant the patient's question is posed I am called upon to act. There is no way that I can "call time" to think it over. If I hesitate or if I say, "Well, wait, let's think about this for a moment," or "maybe you could say a little more about what you're feeling," I am of course acting in a particular way. There is no way to just think about it without acting, and however I act will have some sort of complex meaning to myself and to the patient. The commonsense idea, one that is highly valued psychoanalytically, that I should think before I act is of little or no help in this respect. It certainly will not do to say "let's think about it and talk about it more tomorrow and then we'll see." The moment of truth is now. What I do will express something about me, about our relationship, and about the patient. While it cannot be action following thought in a linear way, it might, nevertheless, be action that is saturated with thought or thought-full.
Does it make any sense to ask what is the right thing or the best thing for the analyst to do? Many would say, "it depends." More needs to be known about the patient, his history, his dynamics, the status of the transference, and the nature of the process in this very session. I have told you so little, after all, of what I know or knew, so little, one might say, of what was "going through my mind." But even if I could explicate all of the issues pertaining to that list of considerations about the patient, to what extent would that put us in a better position to decide what I should have done and with what attitude? Is an accurate assessment of the patient's state of mind possible? And if it were possible, would it be enough?
The alternative to the view that the analyst should act simply in accord with an assessment of the patient takes it for granted that the analyst acts in relation to a complex, only partially conscious, organization of his or her own thoughts and feelings. In the moment of action there is no sharp split between what is personally expressive and what is in keeping with one's technical principles or diagnostic assessment. Expressive participation and psychoanalytic discipline are intertwined (chapter 7). If there is a "right" or best thing for the analyst to do, it might be something that is integrative of as many considerations about the relationship as possible. From the point of view of a supervisor or consultant, for example, the information that is relevant would have to include the nature of the analyst's experience. And the suggestions that a supervisor would make would take account of the analyst's involvement in the process. The supervisor might say, "Given that the patient was apparently experiencing such and such and that you [the analyst-supervisee] were experiencing such and such, might it have been useful to do or say this or that?" Let me emphasize that I'm not saying that this "given" in the analyst's experience should be immune from criticism. After all, there are certain attitudes and perspectives that we try to cultivate so that the probability will be higher that our experience will at least include certain properties: empathic listening, for example, theoretically informed understanding, critical reflection on our own participation, and so on. In fact, part of my purpose in this paper is to convey my own sense of the optimal analytic attitude, one that allows for a range of countertransference experiences that can be used constructively to promote the process.
SOME BACKGROUND: A CHILDHOOD OF SCARCE LOVE AND DREADED IMPULSE
Certainly, as I said, I have conveyed only a small fraction of the information about the patient that was relevant to my action at that moment. In fact, what I could formulate to myself at that time, not to mention what I can recapture from memory, is probably only a fraction of the information I was processing. Considerations of confidentiality limit even further what I can convey to you accurately. Finally, whatever information is selected and however it is organized constructs a story line of some kind, a particular narrative account among the many that might be pertinent and even compelling (Schafer, 1992). With those qualifications, here are a few more highlights from the patient's history.
Ken was an only child. His mother was alcoholic, estranged from her unsympathetic, self-centered husband, painfully lonely, and often depressed. When the patient was 15 years old she killed herself, using a combination of drugs, a plastic bag over her head, and gas sucked in from a Bunsen burner from the patient's chemistry set. The patient came home from school one day and found the house locked. A note on the door suggested he go to a neighbor's house until his father came home. Later, the father and the patient descended the winding stairs to the basement where they found the mother's body. There was a note addressed to the patient that read: "I had to do this. I couldn't take it anymore. You go on and have a happy life. You're great." In this act, the mother constructed, not a "good enough" ending, surely, but a catastrophic one for her son to carry with him for the rest of his life.
The patient's father was a salesman. He was very narcissistic, full of a kind of bravado, a macho style that was decidedly unempathic in terms of its responsiveness to the patient's needs and sense of vulnerability. The father's "competitiveness" was so extreme it often deteriorated into virtual abuse. Here's one telling story. In playing one-on-one basketball when the patient was in his early teens, the father, who was much taller, was happy to block all the patient's shots and win the game ten to nothing. Indeed, Ken, who was a quiet, sensitive type and something of a bookworm, often felt his father didn't particularly like him. In fact, Ken thought his father preferred two of his nephews, both of whom liked hunting and fishing, activities that were quite abhorrent to the patient.
Ken had only scant and fragmentary memories of his mother. What was particularly striking was that he had vivid memories of parts of her body, distinct images of them in the bathtub, for example, especially her breasts, which he admired. He had more difficulty remembering her face, not to mention difficulty recapturing a sense of her as a whole person. Toward the end of the first year of the analysis the patient recalled a moment in his early teenage years when, looking at his mother passed-out drunk in her bed, while his father was out of town on one of his many business trips, he thought to himself, "Why don't I just have sex with her and get her pregnant. Maybe that will enliven her and make her happy." Ken also had conscious wishes that his mother would die, which were countered, in part, by his realizing that her death would leave him alone with his father. Many times he fantasized wishfully and anxiously about his father being killed in a plane crash and not returning from one of his trips. At times, he was also very afraid of his father. On one occasion he refused to go on an amusement park ride with him for fear that his father would push him out of the elevated car to his death.
Thus, perhaps an important aspect of the atmosphere of the patient's childhood could be characterized as one that was full of the dangers of eruption of incestuous, patricidal, matricidal, and infanticidal impulses. We developed a picture of his environment as one in which he felt that he was left alone with dangerous temptations. He had a sense that it was all too easy for him and others to act on impulses that were destructive to him, to them, or to both. It felt like he had only his own will to prevent an action that could be disastrous, and his own will often did not seem up to the challenge. He had his parents as models, after all. In the end, through an act signifying the ultimate abdication of responsibility, his mother left him with a terrible choice. He could try to demonstrate that one could be moved by forces beyond one's control to do oneself in. If he threw himself out the window, or more precisely, if he succumbed to what he experienced as a force drawing him out the window, he could say, "This must be how it was for her; she loved me but could not stop herself." But if he stopped himself with thoughts like, "what will become of those I care about, including my children?" he was left with the agonizing question as to why she couldn't or wouldn't have done the same for him.
A WALK TO THE ELEVATOR: AN EXPERIENCE IN "LIMINAL" SPACE
It is as though there are two major "models" for human interrelatedness, juxtaposed and alternating. The first is of society as a structured, differentiated, and often hierarchical system of politico-legal-economic positions with many types of evaluation, separating men in terms of "more" or "less." The second, which emerges recognizably in the liminal period, is of society as an unstructured or rudimentarily structured and relatively undifferentiated comitatus, community, or even communion of equal individuals who submit together to the general authority of the ritual elders.... For individuals and groups, social life is a type of dialectical process that involves successive experience of high and low, communitas and structure, homogeneity and differentiation, equality and inequality [pp. 96-97].And further, very much in keeping with my view of the analytic process, Turner writes that "wisdom is always to find the appropriate relationship between structure and communitas under the given circumstances of time and place, to accept each modality when it is paramount without rejecting the other, and not to cling to one when its present impetus is spent" (p. 139).
So when the time is up we enter that peculiar, liminal zone that is "neither here nor there." I think it's useful to consider it not only for its own sake, but also because it exposes more clearly the dialectic between ritual and spontaneity within the process as a whole. The strategy is analogous to learning about so-called normal mental processes by studying psychopathology. In this instance we have not only the period in the office after the time is up, which, after all, is ironically a part of normal analytic routine, but the prospect of time spent with the patient outside the office. In these two liminal zones, the one more outside the ritual than the other, the personal-egalitarian aspect of my relationship with Ken is highlighted and partially extricated from the role-defined hierarchical aspect, so that the tension between the two is felt more acutely than usual.
I responded to Ken's request immediately, simply by saying "sure," and we walked to the elevators. My immediate feeling was that it would have been extremely stingy of me to decline or even to hesitate, since it had been such an ordeal for Ken to tolerate the session in this office. I knew, after all, that the idea of meeting at this location was initiated originally by me. Also, the patient's request, an aggressive initiative on his part, was out of character. It was a risk for him to make it, and I thought he might well feel not only disappointed, but also humiliated if I said no. I certainly didn't want to be like his father blocking his shots in basketball. That danger seemed greater to me than the dangers of complying. Also, because the request was so unusual, I felt inclined to give the patient the benefit of the doubt and respect whatever creative wisdom might have prompted it. Another consideration might have been that I felt that, over time, I had conveyed enough of an impression of personal availability to contribute to the patient's readiness to make the request. In any case, as Ken and I waited in the hallway we made a little small talk about the elevators, the express type versus the local type, which stopped at which floors, which he came up on, and so on. After a couple of minutes, one opened up and Ken stepped in. We shook hands just as the doors began to shut. It was not our customary way of parting. I'm not sure which of us reached out first.
Before getting to the patient's retrospective view of the experience the next day I want to stop to talk a bit more about the episode at the elevator, an example of an "extra-analytic" interaction. How do we conceptualize the nature of the interaction in the hallway? On the surface it could hardly be more mundane. Just a little, rather uninteresting small talk. But as we are waiting there is a little tension in the air, a touch of awkwardness, and a feeling that what's happening has a little extra "charge." Would we say that the analyst, ideally, would feel entirely comfortable in that situation? Would we say that the patient, too, would be comfortable the closer he was to completing his analysis? My own view is that regardless of the specific personalities of the participants, and regardless of the amount and quality of analytic work each has under his or her belt, there is a residue of tension that is likely because here, in the hallway, outside the psychoanalytic routines of time, place, and role-defined interactions, the analyst emerges out of the shadows of his or her analytic role and is exposed, more fully than usual, as a person like the patient, as a vulnerable social and physical being. At this moment, in Turner's terms, "communitas," a sense of equality and of mutuality, moves into the foreground while role-determined, hierarchical structure shifts to the background. This reversal of figure and ground is likely to feel conflictual because both parties have much invested in the analyst's relative invisibility. The analyst's capacity for an encompassing perspective and for constructive use of his or her special expertise is enhanced by the protections against narcissistic injury that a position of relative anonymity affords. This aspect of the ritual provides some rational ground for the analyst's authority in relation to the analysand. Beyond those rational grounds, however, there is an irrational component to that authority, a certain element of mystique that gives the analyst a special kind of power. Only with that magical increment of power does the analyst stand a chance of doing battle with pathogenic object relations that were absorbed before the patient was old enough to think, or most importantly, to think critically. And only the analyst's relative anonymity can allow the patient to invest him or her with that magical power, one that represents, in more or less attenuated form, the power of the longed for omniscient, omnipotent, and loving parent.
So, it's not surprising that there is a little tension and a little awkwardness accompanying the small talk as we wait for the elevator. But it would be misleading to say that the special authority of the analyst, both its rational and its irrational components, are dissolved in these circumstances. Let's not forget that a reversal of figure and ground does not mean that one side of a dialectic is sacrificed in favor of the other. Rather, the two poles, that of spontaneous, egalitarian, informal participation and that of authority-enhancing, role-related, formal participation, continue to work in tandem, synergistically, the one potentiating the impact of the other. On a personal level, many relational themes are being played out, more than I can mention here, and more, indeed, than either participant could be aware of back then, or even now in retrospect. For one thing, this is a kind of transgression that I am joining the patient in, a bit of mischief in relation to the psychoanalytic "authorities," the tribal "elders," but also in relation to those authorities as they are internalized as part of my own (and maybe the patient's) psychoanalytic conscience. There is also a sense, however, that the transgression is a minor one, a forgivable one, even, perhaps, a constructive one. We both know that we will be back inside the analytic frame the next day and we both fully expect that this very interlude of escape from it, this relatively "frameless" experience, as Grotstein (1993) calls it, will probably be subjected to routine analytic scrutiny. We will then be able to explore the latent meanings of our interaction in the hallway as though it were part of the manifest content of a dream (cf. Kern, 1987).
Aided partly by this expectation, at the very moment that I transgress I am aware, implicitly, that the patient and I are also trying to construct a noncatastrophic transgression, a nonincestuous, nonsuicidal, nonhomicidal violation of the rules. We are trying to differentiate this illicit act, stepping out the door together, from stepping out of the 21st-floor window, from being drawn into an incestuous abyss with the mother, from killing the mother, from killing the father, from being killed by the father, from the mother killing herself. In these scenarios, the patient may be either in the parent's or in the child's role, casting the analyst into the complementary position. All these potential differentiations--in which, hopefully, something new will emerge out of the shadows of something old--all these possibilities have special power, not only because they have been or will be understood analytically, but also because in the background it is the analyst who is participating in them and authorizing them. By making more vivid the patient's sense, as Ken puts it, "that we are in this together," by being, for the moment, a person conspicuously like the patient himself, by trusting the patient's conscious judgment, by extending myself beyond what is most comfortable for me (which reciprocates the patient's extension of himself in coming to my private office), by spending some time with the patient that is not paid for, by all of these simultaneous actions and others, I have at least a fighting chance, as the analyst, operating with the mantle of authority that is uniquely mine by virtue of my ritually based position, of overcoming the soul-murdering impact of the parents' conduct. I have a chance of reaching the patient with messages such as, "You are a person of worth; you have a right to be fully alive; you don't have to be buried alive under those wood boards; your feelings matter; you deserve respect as a unique individual; you can have concrete impact on me without destroying me or yourself; your desire, even when it runs counter to what is conventionally sanctioned, is not necessarily deadly; indeed, that desire has the potential to do more good than harm."' In sum, I am in a position to offer the patient a profound kind of recognition and affirmation. What is transformative, however, is not this action alone, but a continual struggle with the tension between spontaneous responsiveness and adherence to psychoanalytic ritual and a continual effort, in Turner's (1969) words, "to accept each modality when it is paramount without rejecting the other" (p. 139).
Now let's return to the particulars of the process and consider the patient's experience of the episode as he reported it the next day, now in the relative comfort of the university office.
THE PATIENT'S REFLECTIONS: COCONSTRUCTING NEEDS AND WISHES
FRAGMENTS OF A TERMINATION
I was down in the basement. Someone was trying to get in with a drill. The basement in the dream is like a fortress. There is a big door with a deadbolt and a key lock. Somebody is drilling a hole in it. And I am standing there by the door thinking I can almost see the point of the drill coming through. And I think it was you out there. And I have the idea that if I can put my finger on the point of the drill you'll know I'm in there and that I'm alive. And I'm thinking that it's dangerous.So here is the patient identified with his mother and yet struggling to differentiate himself from her. He's in the basement where she killed herself, and there I am outside, perhaps like he was outside when he came home from school that awful day when he found the door locked. But now there is some kind of rescue operation going on. In order to be saved, to make contact, he has to touch that phallic object, he has to let himself be reached and touched by my own attempts to break through to him. To do this he has either to overcome the sense that the contact is necessarily sexual, or better, to be less threatened by whatever sexual and aggressive dimensions there may be in our encounter. Finally, he has to let me reach him, despite his having felt impotent to reach his mother. Here he has to overcome a need he feels to absolve himself by proving that such "awakenings" are simply impossible.
And apropos of my theme in this chapter, the moment of contact in the dream occurs in a moment of trespass. Someone is breaking into the basement of Ken's home. An intruder is entering where, presumably, he has no place, where he does not belong. The law is being broken, the patient's private space is being violated. Surely this cannot be a precedent, a prescription for a way of living. Locks on doors are there for safety, there to create environments in which we can live with some semblance of security, even environments in which we can create illusions of security, in which we can hide from the terror of annihilation. But there are times when our "security systems" reach a point of diminishing returns and they need to be deactivated, if only temporarily. So it is with the analytic frame. It's there to protect us, to create an environment that is especially conducive to both exploration of meaning and affirmation of worth. But it has its dark, suffocating side, especially when it is taken too seriously and adhered to too zealously. Thus, the ideal holding environment becomes one in which the frame itself is fully understood to be a construction, a set of ritual activities that are enriched by their integration with the analyst's personal, spontaneous participation. Such participation sometimes takes the form of limited departures from the frame, excursions into liminal space, although more commonly it involves qualities of naturalness and spontaneity that are mingled with the ritualized, roledetermined aspects of the process. Analysis then becomes a model for living, a rich dialectic between plunging into experience and reflecting on its meaning (Becker, 1973, p. 199). It entails for the analyst an integration of being with the patient as a fellow human being, sharing the same kind of personal vulnerability, and being, ironically, the very one who is idealized and authorized by the culture and by the patient himself or herself to bestow upon the patient a sense of personal significance and worth, the kind that stands a chance of overcoming the most profound kinds of childhood injuries, even as they are joined by the inexorable insults of the human condition.