Safety For the Analysand,Safety For the Analyst,Safety For the Dyad

Joseph Lichtenberg opened the panel by posing the question, “Is safety a feeling, an emotion, or an atmospheric something?” He pointed out that Joseph Sandler (1960), the first author to specifically explore the concept of safety, referred to the feeling of safety as the gateway regulating the movement of content from the preconscious into consciousness. Lichtenberg noted that the greatest attention to the issue of safety is to be found in the attachment research of John Bowlby, in which seeking safety and a secure base is shown to be central to the attachment process. Lichtenberg referred also to the contributions of Emmanuel Ghent, who wrote about homeostatic safety; to Jay Greenberg, who views safety and effectance as primary organizers of the mind; and, finally, to his own work, in which he refers to safety as an inherent aspect of the frame, one that applies to the entire domain of how we interact within an analysis.

Lichtenberg charged the panelists with the task of exploring how safety affects the analysand, how it affects the analyst, and how it plays out in the dyad. The panelists began with short presentations of their views on the question of safety in analysis; following their responses to one another, they presented case examples to illustrate their views. For reasons of confidentiality, this report will include only a brief summary of the material actually presented.

James Hansell began his presentation by acknowledging that despite its now frequent appearance in discussions of psychoanalysis, the concept of safety is still quite slippery and ill-defined. He made three points regarding safety: (1) the patient’s subjective experience of emotional safety has become increasingly important as the goal of psychoanalysis has evolved from catharsis in the pre-psychoanalytic era, to self-knowledge in the classical era, and now, in the contemporary era, to self-acceptance or integration, where it serves as an important bridge between self-knowledge and self-acceptance; (2) that because our patients often come to treatment with an internal sense of danger regarding the analytic project of getting to know themselves, safety has a paradoxical quality of being both a requirement for conducting the treatment and an outcome of treatment; (3) that safety provides a pathway for integrating one- and two-person psychologies as an internal sense of danger becomes externalized into the interpersonal process between patient and analyst.

Estelle Shane, taking a systems approach that allows the consideration of multiple psychoanalytic models, began by pointing out that emotional safety, as a concomitant of secure attachment, is a significant element in the intersubjective system and a fundamental criterion for change in both patient and analyst. For both, safety can permit exploration, inquiry, play, assertion, and the development of positive new experiences or newly revised organizations of experience. She pointed out that only in an ambience of intersubjective security can the patient risk the “un-safety” inherent in the recovery of long-forgotten traumatic experiences. As both a complex emotion and an essential aspect of the psychoanalytic milieu, consistent empathic attunement to the patient’s subjective experience provides the patient a continuing sense of being held in safe hands through the inevitable travails of the psychoanalytic process. Shane said that her work with insecurely attached patients had taught her that though a sense of security is a prerequisite for successful treatment, it may not always be an outcome of such treatment.

Evelyne Schwaber then spoke of a show she’d seen on TV about students in a drama school. Teaching them, the director in the play states, “Acting is about revealing the truth in someone else by first finding the truth in yourself.” (Schwaber commented that she has a son who is an actor, with whom she discussed this parallel.) “The truth,” Schwaber stressed: “not a pretense, not an act.” As in the case of gifted writers, she went on, so too, “at our best, that’s what we do as psychoanalysts. . . . we find our patients by finding something of ourselves—not in our countertransference, but our resonance (not what we would do in their shoes, but how we would feel). We find ourselves in seeking the innermost feelings of the other, conveyed in words or in tone—communicated from the body—the nonverbal, often another ‘royal road’ to what lies unconscious. . . . and that is where safety comes in.” To help the patient feel safe, “we must feel safe enough to enter her or his path, however dark (or bright), no matter how uncomfortable, fearful, or strange—even if about us—and seek its inherent legitimacy.” She then quoted a patient: “When you find the way my mind works without saying it should work another way—that lets me experience more about how my mind works.”

Commenting on an article in the New England Journal of Medicine by David Watts (2012) on the coldness and distance that advanced medical students or physicians may come over time to feel regarding the pain and suffering of patients—and how to prevent that—Schwaber noted what Watts calls the “doubleness factor,” a state of assurance that one can hold on to both worlds—of safety and of danger. “The loss of personal safety,” Watts states, “is worth the risk. It means we have to rethink danger. The cure for the malady of distance is to enter danger and come back alive.” Schwaber continued: “As in a physical condition, it means we (as psychoanalysts) must enter the patient’s pain—enter what may be horror, conflict, rage, shame, note the defensive manifestations, and find resonance in recognition—so to seek the possibility of our own culpability in evoking it.”

Arietta Slade next spoke to the issue of safety from her perspective as both a clinician and an attachment researcher. Citing Bowlby and his groundbreaking work on separation and attachment, Slade pointed out that seeking safety when threatened is an essential aspect of our humanity, one that is evolutionarily privileged. For the human infant, it is the trusted ability to seek proximity to the “stronger and wiser caregiver” who provides a haven of safety and security that promotes exploration and engagement with the world. In a world where threat is normal and ubiquitous, fear activates the attachment system, exploration ends, and the child seeks proximity and comfort from the caregiver. In this way, fear is a mediator in the delicate balance between attachment and exploration; only in proximity to a safe and secure attachment figure can the child venture out to explore the world. When fear is not effectively regulated by the caregiver or, more problematically, if fear emanates from the caregiver herself, both exploration and the quality of the attachment are disrupted. Over time, patterns of fearful arousal, the threat at hand, and the child’s adaptive solution are internalized, leading to the development of psychic structure and, at a neurological level, the architecture of the brain, hardwiring these attachment patterns into the child’s brain. Noting the likelihood that many of the patients who enter analysis evidence insecure attachment patterns, Slade drew parallels between, in the child-caregiver relationship, the impact of fear on exploration and, in the analytic situation, fearful arousal and its potentially inhibiting effect on exploration within the analysis. At a clinical level Slade brings this understanding into the analytic work by associational attention to moments of fearful arousal from the analysand’s past: when the child sought safety from a caretaker, what happened in that moment, and what did the child see in the caretaker’s eyes then? Reinforcing the comments of the other panelists, Slade pointed to the operation of this fear-induced inhibitory effect on exploratory process for both patient and analyst.

In the panel’s discussion, this reporter reflected on some forms of potential danger that often operate in analytic situation for both patient and analyst: the potential danger of actual physical or sexual assault; the danger associated with an intrusive psychological assault; the danger in having feeling states, reactions, or behavior misunderstood, or misconstrued in a shaming, blaming manner; the danger associated with potential breakdown and dissolution of this important relationship; the danger of allowing oneself to feel hopeful and then seeing that hope collapse in the face of a perceived setback or rupture in the analytic relationship. These and other potential dangers operate in both directions, often impacting an analysis implicitly and with a complex bi-directionality.

The panelists next presented their case material.

Estelle Shane presented the case of a man she described as depressed and profoundly angry who refused to make eye contact because of his intense shame and a fear of what would be found if they looked into each other’s eyes: a mutuality of anger and hostility, desire and lust. This patient experienced her as alternately sad, helpless, or grieving but was most troubled, even enraged, by his belief that despite his rage-filled, hateful, even threatening behavior aimed right at her, he could see that his analyst was not afraid of him. This was experienced as evidence that she really didn’t understand him, so how could he possibly feel safe with her? He reported never feeling safe with anyone and that no one has ever truly understood him. Carefully acknowledging her real need to regulate and steady herself in the face of his rage-filled, threatening behavior, she admitted, as he had suspected, that she was not actually afraid that he would do her harm. This admission, risking even further rage and despair from this already desperate patient, would allow this dyad to begin to repair the rupture produced by this enactment and work toward establishing the kind of safety needed for the analytic work to proceed.

James Hansell presented the case of a women who experienced “excruciating” anxiety and anguish related to physical and sexual trauma at the hands of her father. Her sensitivity to safety in the treatment, or its felt lack, was pervasive throughout their work, and Hansell posed the question what it could possibly mean to provide this patient a sense of safety in the treatment. To address this question he detailed a “safety-related” incident that occurred two years into the analysis. This patient, having just returned from a trip to her hometown, came to her analysis and abruptly announced that this would be her final session. Careful exploration of the feelings behind this sudden shift led to an incident (a seemingly innocent hug that she was told she needed) with a local healer she had seen during her trip home. This event had stirred up the patient’s fear that continued treatment with Hansell would lead to a sexual violation. Rather than interpreting the oedipal implications of this fear, Hansell chose to address the safety concern directly, telling the patient that their work would never involve actual touching or hugging, just talk. This clear, direct reassurance allowed the patient to process her feelings surrounding this event and ultimately get to the internal terrors, including her oedipal conflicts, activated by the event with the healer.

Following his presentation of this case, Hansell cited three paradoxical truths about all analyses: (1) it is naive to think that the analyst can do much more than make the patient feel externally safe to explore how endangered she feels, but that this can be doing a great deal; (2) for the patient a feeling of safety is both absolutely necessary and quite impossible; (3) some level of safety is required for analysis to occur, but this has to be achieved within the analytic relationship. He summarized his presentation by saying that in contemporary psychoanalysis the analyst’s provision of real interpersonal safety (empathy, caring, commitment, etc.) creates the conditions under which the analyst can begin to explore the subjective internal dangers that alienate the patient from herself.

Responding to Shane’s and Hansell’s cases, Joseph Lichtenberg made the point that safety is both a condition we hope to establish in our work with patients and an issue that comes up in the work. Referencing the unexpected and bewilderingly intense arousal of Hansell’s patient in response to being hugged by a “healer,” Lichtenberg noted the results of infant research and the significance of touch as a self-soothing behavior. This kind of self-touch can elicit arousal connected to the internal experience of safety, a self-regulating behavior that often operates completely outside of awareness. Conversely, for some individuals the arousal associated with this unconscious self-soothing touch can become frozen in self-conscious awareness of this arousal in the presence of the analyst, leading to the loss, at least temporarily, of safety within the analysis.

Speaking to Shane’s case, Lichtenberg noted that rapid and uncontrolled swings between dissociative states can give a patient the feeling that he or she is unsafe because of an inability to regulate these swings. Lichtenberg noted also that sometimes our patients need to react to their feeling that they cannot move or affect the analyst emotionally and will respond by escalating their efforts to penetrate the analyst’s contained and managed emotional presence. Shane responded by clarifying that although she did not feel afraid of actual physical harm from her patient, she was clearly reacting emotionally to the patient’s efforts to express his rage and convince her of his dangerousness.

In later reflection on the panel discussion, Schwaber (personal communication) noted the “distinction to be considered between the clinical illustrations of the psychic aftermath deriving from external threats to safety having occurred in the patient’s life and history, and those illuminating the vicissitudes in the sense of safety (or danger) deriving historically as an intrapsychic matter, further conveyed within the psychoanalytic situation. The examples differed in highlighting the question of safety or danger felt from within, or that of danger originating from without. Of course, psychic life has its origins in each place, inside and out. But the distinction in these examples was quite notable, and may warrant further commentary.”

Speaking to the case presented by Shane, in which the patient got very close to threatening the physical safety of his analyst and constantly attacked the analyst in a shaming, belittling manner, this reporter questioned whether the analysand, not just the analyst, has a responsibility for “providing, maintaining, and re-equilibrating” the sense of safety in the analysis.

Arietta Slade next presented two cases, each illustrating a different aspect of safety. The first involved a mother whose experience of “mothering” was defined by fearful, traumatic arousal stimulated by her young child’s “way of being.” This patient’s feelings of “helpless aloneness” vacillated between a “stony (hyper-regulated) facade of self-efficacy and that of a dsyregulated and overwhelmed child.” Despite a history of sadism at her mother’s hands, which ultimately led to severing contact with her, this adult patient became the traumatized child; looking for comfort and safety, she sought to reconnect with her mother. Despite the likelihood that she would be threatened and attacked by her mother, for this traumatized patient “safety and violence were one.”

The second case presented was that of an adult, first seen by Slade years ago as a child, who returned to treatment at age thirty-two suffering from crippling anxiety, panic attacks, and an obsession with dying. This patient, who experienced an unacknowledged and dissociated childhood trauma, was able through treatment to reconnect with her experience of fearful arousal during the traumatic event and recover memories she had long denied herself. Slade used this case to demonstrate the process of “listening for and thinking about patterns of fearful arousal” and the importance of connecting these patterns to how fear was regulated in early experience. Building on Bowlby’s ideas about fear and patterns of response within psychoanalytic theory, Slade pointed out that putting the search for safety and its sequelae into words can be both liberating and enormously soothing: “I believe that our ability to imagine into moments of fearful arousal, both from the past and the present, provides a vital sense of safety to these traumatized patients.” She concluded by saying that in order not to become an object of fearful arousal ourselves, “we must regulate our own fears to see the danger that is felt—tolerate it and resonate with it.”

Evelyne Schwaber began her clinical presentation by citing a patient’s words, a reflection that has stayed with her for years: “Not recognizing the legitimacy of the hurt is a far worse hurt than the hurt itself.” Citing a case example from her published work (as discussed in a paper by the late Japanese psychoanalyst Takeo Doi [1993]) that illustrated the discovery of a rupture brought on by a missed recognition in the analyst’s search, Schwaber spoke of finding her way back to hearing the essence of the patient’s experience (described by Doi as illustrating the occurrence of amae, the Japanese word for a core connectedness). She explained that she was able to regain this connection in pursuit of further inquiry, learning thereby of her participation in evoking the rupture, and finding its meaning to the patient in the “depth of his mind.” Thus, “entering the danger” permitted the discovery of a deeper level of experience, allowing the dyad—in accord with Doi—to restore amae and together come back safe and “alive.” Underscoring this point, Schwaber highlighted this stance of inquiry to “find what had not yet come into view, the reality of the patient, its inherent legitimacy, and how we may have been a part of it.” Finding the way his mind works, seeing it recognized, the patient may now feel safe to see more—as we, feeling more safe to do so, deepen our own experience. From this position of discovery, “what had been unconscious coming forward to awareness, the past remembered, . . . history becomes almost self-explanatory.”

In sum, the panel, and the audience, agreed on the importance of thinking about and discussing the various permutations of safety in the clinical setting—for the analysand, for the analyst, and for the dyad.