Abstract
We are publishing these five contributions together, under the rubric “A Patient Returns,” because they reflect the experience of a group of experienced, highly respected senior analysts—major contributors to our field throughout their long careers. While there are important differences among them, we also note important similarities. Perhaps the most important similarity is the one alluded to by Shelley Orgel in his paraphrase of Mark Twain. “When I was a boy of fourteen,” Twain wrote, “my father was so ignorant I could hardly stand to have the old man around. But when I got to be twenty-one, I was astonished at how much the old man had learned in seven years.” While Twain’s comic irony relies on the fact that it is the son who changed, not the father, the emphasis of our authors is on how much they, the analysts, have changed. It is to these changes that we wish to call readers’ attention.
We are most interested in changes in the analysts’ technique, the ways they behaved with their returning patients. What we read repeatedly (but not universally) is that they are today more “relaxed,” more flexible, and more demonstrative of their own emotions. They disclose more about themselves and their feelings toward their analysands. There is more of a sense of the importance of “the relationship” than in the first treatments. Self-reflection is more often and more successfully used as a means to access the analytic process. The analysts may be less reliant on making the “correct” interpretation than in the past. They speak more about the analytic dyad, even the analytic “couple,” and only much less about doctor and patient, analyst and analysand. Use of the couch is rare, analysts and patients now preferring once- or twice-weekly sessions facing one another. Much of these analysts’ thinking about their therapeutic work today is redolent of the increasingly accepted analogy between the therapeutic situation and the very early one between mothers and their infants, especially their positive valences: caring, nurturing, mirroring, holding. Our authors rather naturally find themselves comparing their modes of being analysts today with that of twenty, thirty, even forty years ago. How much have they learned?
Using the analytic time machine, let us go back even further. Here are two returning patients of the same analyst:
In April, a nineteen-year-old girl returned to see her analyst. She was back for two reasons. First, to finish her story, incomplete when she left analysis fifteen months earlier. Second, to seek relief from day and night facial pain. In his notes on her case, her analyst referred to this as the girl’s alleged facial neuralgia. He noted that it took but “one glance at her face” to decide that she was not in earnest. He dismissed her, offering only that he forgave her for her not having permitted him to cure her with analysis. In November, a thirty-three-year old man returned to his former analyst for “more work.” It had been ten years since terminating an analysis of more than four years. He, too, had a recalcitrant symptom, one that appeared to have been cured by the first treatment. Constipation had in fact been his chief concern when beginning his first analysis. In his notes, the analyst noted “an obstinate hysterical constipation.” He took the patient back into analysis, observing with satisfaction that after some work on the residual transference, the symptom “yielded for good.” Between the two analyses, the patient had suffered a drastic financial reversal and was now virtually penniless.
In contrast to his stance with the returning young woman, the analyst took this returning patient’s request for help very seriously, began a second analysis, and treated the man for free. Moreover, he collected money from his colleagues for the patient’s living expenses.
Of course, there’s no disguising Freud and his famous patients, Dora and the Wolf Man. Surely we have come a long way and, as our authors show us, learned a lot. Imagine if Freud in 1900 had been able to mine his own reactions (“one glance at her face . . .”) for clues to what was going on between them? What if he could have been aware of his deep resentment of this nineteen-year-old girl and how it influenced his management of her return? Think, too, about the Wolf Man—and Freud’s formulation (“a bit of residual transference”)—a formulation that left little room for what we might today recognize as Pankieff’s need for continuing contact in order to maintain a stable equilibrium. Observe, too, that in both cases Freud thought of the return as motivated by transference. Today we might add many more reasons.
Our point is this. Yes, we have learned a lot over the past forty and one hundred years. Some of what we have learned reflects our highly personal, idiosyncratic histories, but it also reflects sweeping changes in our field, psychoanalysis. These latter changes, largely brought about by pressures from the relational and interpersonal schools, have emphasized the analyst’s subjectivity, its use as a therapeutic instrument, the importance of supportive measures, and the value of self-disclosure. Interpretation seems no longer to enjoy pride of place; the tracing of aggressive trends is minimized; abstinence and neutrality are less valued than in the past; the consulting room has been democratized. In certain ways these may be important advances. But we must recall that analysis, like everything else, is in a state of constant change. Future psychoanalyses may bear but the shadow cast by our current ideas, ones that seem so important and so correct today.
We feel we are obliged not only to make new and useful discoveries but also to be mindful of the techniques and ideas of past analysts that may still have unparalleled value, for example, free association, listening for and interpreting unconscious fantasy, the analyst’s right to remain silent, and the analyst’s legitimate authority (not infallibility, but legitimate authority).
Our authors were not tasked with describing the theories and techniques they still find usable even after many years. They describe—elegantly, we believe—how they behave today, what has influenced them, and who they have become, all refracted through a unique lens: work with the returning patient. This collection of papers not only documents the personal evolution of these analysts; it also reflects continuing evolutionary trends in our field. Is the work with returning patients typical of analytic work in general? Clearly not, neither for the returning patient nor for the analyst. What can work with returning patients tell us about patients who do not return? We cannot know. How can we situate the accounts of these analysts, including their oftentimes sheer delight in the fact of the patient’s return and their understandable wish that their earlier work produced favorable results?
These reports are necessarily subjective. They are therefore to be read mindful of implicit biases. Yet in that sense they do not essentially differ from other analytic case reports. These have been offered in the spirit of the best.