Analysis Begins in the Analyst’s Mind

Analysis Begins in the Analyst’s Mind

In my own work and in observing the work of others, I have concluded that the analyst must do a great deal of internal work every step of the way—from the initial contact with a prospective patient to the time the patient actually begins analysis—in order for an analysis to begin. In other words, a helpful analysis begins in the mind of the analyst. ³ It is the analyst’s emotional engagement and capacity to think psychologically about the patient during the consultation that launches the therapeutic process within which the patient can begin to have greater access to her own mind and her own capacity for psychological mindedness. What I am suggesting here about the beginning therapeutic process resonates with the developmental perspectives offered by both Winnicott and Bion.

Winnicott (1960) compellingly describes how the infant’s ability to develop “a separate personal self” depends in great part on the mother’s care and capacity for awareness and empathy. The mother’s emotional investment and abilities guide her to respond in a good-enough way to her baby’s needs and temperament. Bion (1959, 1962) similarly suggests that it takes the mother’s mind and her capacity to feel and process her child’s feelings to allow the child to begin to have his own mind—to perceive himself, the mother, and the world in a realistic way. Bion suggests that it is the mother’s ability to receive and process mentally the infant’s incomprehensible experiences in the form of normal projective identifications that allows the child to develop the capacity to eventually tolerate and emotionally understand his inner experience, especially his distress. Bion extends this idea, suggesting that two minds are needed to think and feel one’s most disturbing thoughts at any age (Ogden 2008)

In an effort to illuminate the nature of the analyst’s engagement and capacities for psychological work during the consultation and the beginning of treatment, I have identified six distinctive yet interrelated aspects of the analyst’s internal work. All six are requisite to facilitating the patient’s engagement in the analytic process: (1) Being receptive to the patient’s need for intensive treatment. (2) Identifying and imagining the patient’s strengths and potential. (3) Envisioning the patient in analysis with oneself. (4) Generating a realistic sense of confidence that analysis is the most useful treatment for this patient. (5) Recognizing the patient’s wish for analysis. (6) Considering as analytic data the patient’s and one’s own reservations about analysis. ⁴

Technical Considerations

I will now describe how my analytic mindset guides my participation in a consultation and facilitates the patient’s engagement. I will then move on to the specific issue of recommending analysis. When a prospective patient contacts me, I suggest that we meet for a consultation, typically two to three appointments, in order for her to tell me about herself. If it is agreeable to her, we set up times to meet. At the end of the consultation, I share with her my understanding of what she is struggling with and what she is hoping to achieve. I also offer my recommendation about how best to proceed. If feasible, I try to have the consultation appointments as close together as possible, preferably on consecutive days. Doing so allows for continuity and a chance for the patient to get a feeling for what several sessions a week can offer. This way the patient can begin to experience rather than just imagine the potential benefits of daily analytic meetings.

From the first moment of the initial phone contact with a patient, I search for meaning in everything the prospective patient presents and in everything I think and feel in relation to him or her. I am particularly attentive to any sign of discomfort our encounter engenders, in my patient or me, even if minor. I work to register and articulate to myself my reservations about working with this patient and how I might be identifying with the patient’s defenses and rationalizations. This awareness often increases my capacity to imagine more fully the pain and disturbance that bring the patient to treatment but are not consciously available to him or her.

Reith (2010), reporting on a ten-year study on initial psychoanalytic interviews, writes that the most robust finding about analytic process in initial interviews was the power of unconscious or preconscious transference-countertransference dynamics: “Whether or not the analyst and/or the patient became consciously aware of them at the time, the unconscious transference and counter-transference dynamics could be so potent, and their effect on both protagonists (as well as on others later on in the investigative process) so destabilizing, that we have found Bion’s (1979) idea of an unconscious emotional ‘storm’ that arises whenever two persons meet, to be a particularly apt way of describing them” (p. 70). I believe that the analyst’s anticipation of the storm within herself, and her openness to it, allows her to be more receptive to its often subtle manifestations during the consultation. By registering and making sense of her difficult feelings in relation to the patient, the analyst can begin to understand the patient’s turmoil.

During the consultation I try to ascertain which aspects of the patient’s difficulties relate to problems that are “internal, longstanding and portable” (Bernstein 2000). I also assess her level of motivation to change. I want to know what solutions she has tried and how they worked out. I am especially interested in any history of past treatments and her history of relationships. If I can find a specific example, and I believe it will be compelling, I point out to the patient how a feature of her response to me during the consultation parallels a dilemma or difficulty she has outside the consultation room. Doing so provides an opportunity to demonstrate to a prospective patient how analysis works, to demystify the process, and for me to get a preliminary sense of how the patient will respond if analysis proceeds.

Given the crucial importance of studying analytic beginnings for our practices and the future of our profession, it is noteworthy that comparatively very little has been written about the dynamics of the initial sessions and even less on how and what exactly analysts recommend. Notable exceptions can be found in the work of Ogden (1992), Busch (1995), Schlesinger (2005), and Wille (2012), who describe persuasively the richness and dynamic complexity of the initial sessions. A recent international collection of papers on launching analysis assembled by the Working Party on Initiating Psychoanalysis of the European Federation, Initiating Psychoanalysis (Reith et al. 2012), includes contributions from diverse theoretical perspectives on the dynamics of initial interviews. Although this collection usefully describes the complexity and intensity of the initial sessions and the analyst’s frame of mind, it does not focus on the technical aspects of recommending analysis. For technical considerations regarding the recommendation of analysis and the resistances that typically follow, the writings I have found most useful are Brenner (1990), Busch (1995), Hall (1998), Bernstein (1990, 2000), Rothstein (1994, 1995, 2010), and Levine (2010). ⁸

While what one actually says to a patient at any time, including the recommendation, depends on one’s beginning understanding of that patient’s difficulties and experience of self and others, I still believe it is useful for analysts to share with each other our characteristic ways of recommending. Further, though every authentic analytic moment is unique and what I say, how I say it, or when I say it varies depending on each patient and each individual interaction, I have found that there are certain important elements that I include in my recommendation when I have concluded that analysis is the treatment of choice. I try to convey to the patient my understanding of her life goals and the obstacles she has encountered in her efforts to reach them, as well as my understanding of her attempts to help herself. I offer her my view of possible options for how to proceed: to wait and see if time will help, to try again some of the solutions she has tried before, to try medication or short-term therapy, etc. I share with the patient my estimation of the advantages and disadvantages of each option. I then offer my recommendation that we meet with the goal of understanding the reasons she has been unable to achieve some of what she wants. I add that we can achieve this by listening together to her thoughts and feelings and trying to understand them. Depending on how the patient responds to the first part of my recommendation, I offer the second part: the conditions necessary if the kind of treatment I am proposing is to work. I suggest that we meet as often as possible, preferably daily and in an open-ended way, until we decide that we have accomplished our goals. ⁹

What about patients who need analysis but are not ready to consider a recommendation for daily meetings even if they are suitable? I see it as my professional responsibility to recommend what I think the patient needs. At the same time, however, it is neither helpful nor empathic to make a recommendation the patient cannot make use of. If I think a patient needs analysis but is not ready to hear this, I do not suggest daily meetings. Instead I recommend that she come as frequently as she can arrange. In some cases, when I feel strongly that a patient needs higher frequency immediately, I explain my thinking and suggest that she come at least three times a week from the outset.

There are various ways of recommending analysis. Rothstein (2010), like Freud, recommends a trial of analysis: “Recommending a trial of analysis derives from my belief that for most prospective analysands the analyst cannot know, without a trial, with whom she/he can successfully collaborate. For this reason, I often say to a patient: we can give it a try and we will know in three to six months if it is for you” (p. 789). Although I agree with Rothstein’s notion that we cannot predict the outcome of any relationship, including analysis, I do not think of the initial stages of analysis as a trial, nor do I frame it that way to a patient. Instead I proceed with the assumption that we can work out a rich, constructive analytic relationship. When I think back to the beginning of every analysis I have engaged in, I recognize that for me thinking about a particular beginning as a “trial” was an indication that there was something in that consultation that was especially disturbing to me. In other words, thinking of the beginning as a trial was a signal of my reservations about proceeding and of engaging more fully with that patient.

After I recommend analysis, I listen for what my recommendation has meant to the patient. I assume that the recommendation acquires multiple meanings but listen for the meaning most accessible to the patient at any given time. To the patient the recommendation might signify punishment, criticism, seduction, being chosen, an invitation for regression, an offer of help, or being understood, among many other meanings. It is inevitably a seduction, gratifying and scary, both a compliment and an insult. I work to understand these fears about the idea of analysis and then, if possible, help the patient recognize how her trepidation about analysis relates to fears that brought her to seek a consultation in the first place.

What about patients who receive but do not accept the analyst’s invitation to be in analysis? Rothstein offers to see such patients on their terms only if they explicitly agree to work to understand the obstacles to their accepting what he believes are the optimal conditions for their treatment. I differ from Rothstein in that I accept the patient’s preference for less-than-optimal conditions as a starting point without making an explicit contract with the patient to explore his reservations further. If the patient decides he cannot proceed at an analytic frequency and suggests a lesser frequency, I accept it. I do, however, tell the patient that although I understand that this is what is possible at this time, I hope that together we can discover what stands in the way of his being able to come more frequently and that possibly he will feel differently as our work progresses.

I have found that even if patients turn down my offer of analysis, once the recommendation has been made, and as long as they are in treatment with me, they continue to wrestle with their wishes and fears about engaging more deeply. Thus, regardless of whether we make an explicit contract, we inevitably encounter and explore their reservations. When I look back at the treatments I have been engaged in, I see that exploration of the patient’s fears has often led to an analysis, but that sometimes it did not. Whatever frequency a patient chooses, the analyst’s recommendation for daily meetings remains on the table and serves as a residue for the patient’s associations. When I hear allusions to frequency in the patient’s associations, I address them only if they are close to the surface of the patient’s awareness. I attend first to the patient’s resistance to the awareness of thinking about it by asking if he has considered adding a session. I then interpret the fear that is contained in the patient’s reservations about increased frequency.

What do we look for in patients’ thoughts that alerts us to the possibility that they might be ready to intensify their treatment? Among possible indicators are allusions to frequency (often in displacement to activities other than therapy), complaints about time, increased frustration with symptoms, and my own impatience and dissatisfaction with the existing frequency. I also listen for patients’ increased sense of trust and comfort in the treatment and their wish for deeper engagement.

I have had the repeated experience that patients ask for additional appointments in indirect ways. For example, I have found that when patients ask to reschedule on a day we are not meeting, it often turns out that they are actually considering adding a session but are afraid to know it or ask for it. For one patient, asking to reschedule was a way to find out indirectly whether I was available and willing to meet with him more intensively. Afraid of wanting something he might not be able to have, he wanted to be assured that I was available before even letting himself know that he wanted more.

I have found that Rothstein’s technique of asking patients to agree explicitly to examine the obstacles to beginning analysis runs the risk of fostering externalization. In other words, patients might perceive the wish for analysis as coming from only the analyst, not the patient. By not asking for an explicit contract, analysts increase the possibility that patients will experience conflicts about beginning analysis as internal: patients want analysis and, simultaneously, are afraid of it. When patients experience their conflicts as internal, we have a better chance of understanding their many fears about engagement, whether they enter analysis or not.

Given the expense of a several-times-weekly treatment, I am often asked how my patients can afford my fee. I began my practice many years ago with the assumption that the frequency of treatment would be determined by the patient’s finances. I have found that to be true in some cases but not all. Although finances might determine frequency at the beginning, I have found that if analysis is helpful, patients often become increasingly capable of supporting the treatment they need. I have many examples of patients who began treatment unable to afford daily sessions. As they progressed—felt less inhibited, for example, or less guilty—they were able to find a way to pay for additional sessions.

I have found it essential in order to maintain my analytic equilibrium not to feel underpaid. At the same time, I do not want to feel that the patient is paying more than she can afford, at the expense of maintaining a reasonable lifestyle. As with many matters in analysis, interactions involving money (in other words, setting, negotiating, and collecting fees) present many opportunities for helping the patient understand and integrate disturbing feelings such as greed, entitlement, guilt, and longing to be taken care of. However, interactions involving money can also lead to destructive enactments such as analysts taking advantage of patients by overcharging them or enticing them into analysis by undercharging them, ending low-fee treatments prematurely, or turning patients into annuities (Hirsch 2008).

Interactions around fees highlight the tension between the analyst’s self-interest and desire and the patient’s interest. This is a tension that bears on the analyst’s recommendation for analysis. To explore this topic in depth goes beyond my scope here. Nonetheless, I will share a few thoughts at this point and will address it later in my clinical example.

Doing analysis at a daily frequency is deeply gratifying to me. It is also how I make a living. How, then, do I distinguish whether my wish to see a patient more frequently is primarily in my patient’s interest or is primarily serving mine? ¹⁰ I have found that this question remains in my mind from the consultation until the end of any treatment and constitutes an ongoing tension. This internal tension increases or decreases depending on many factors (e.g., my assessment of the patient’s needs, my assessment of the usefulness of the analysis for the patient, my confidence in my skills or the healing power of the analytic process, the state of my practice, whether exploitation is prominent in the patient’s dynamics and therefore is being evoked between us). I am less worried that I am inadvertently privileging my own interests when I am clear in my mind that the patient needs the analysis and will likely benefit from it, and that no other treatment will likely help her reach her goals. I am more tense when the patient’s dynamics are such that she is prone to being exploited, and when I am especially ambivalent about engaging with this patient. I believe the worry about exploiting patients is a necessary burden that each analyst carries throughout each analysis. I recognize that my awareness of my capacity to privilege my interests over a patient’s does not guarantee that I will not unconsciously act it out. Though there are no easy assurances that one will not inadvertently exploit patients, there are several measures that analysts can take to decrease the chances of destructive enactments; these measures include self-analysis, reanalysis, frequent peer consultation, ¹¹ and working firmly within the ethical standards of our profession.

Finally, it might be useful to the reader to address my diagnostic criteria for recommending analysis. This topic merits a paper in itself, so I will discuss it only briefly here. I do not think that every patient who consults with me needs and would benefit from an analysis. I see patients on a once- or twice-a-week basis who benefit from treatment. I recommend analysis at the outset when the patient’s emotional difficulties are long-standing and particularly entrenched and/or disrupt the patient’s life in profound ways; when his or her treatment goals are ambitious quality-of-life goals; and when I think that the patient will benefit from analysis and that no other treatment will help the patient achieve his or her goals.

In trying to decide whether to recommend analysis, I have several considerations during the consultation: the patient’s level of suffering and its duration, the primary ways the patient deals with that suffering, the quality of his or her current relationships, his or her capacity for work and for rest and pleasure, the kind of help the patient has sought in the past and how it worked out, and whether I have a sense that I can relate to the patient’s pain and can work with this person. I wish I could say that my criteria always have served as accurate predictors of outcome, but that has not been the case. One of the people that I have been able to help the least, in my opinion, was an obsessively defended woman with a neurotic character structure who I thought would benefit greatly from analysis. Despite both of our efforts, though she made some changes in her life, she remained quite limited in her capacity to make emotional contact with others and retained many of her symptoms. On the other hand, I think about a young man who told me during the consultation that he sold and used drugs daily. He had been involved in drug-related violent altercations and two car accidents. I was very wary, but I thought he needed the intensity of an analysis. During the course of his treatment, we were able to engage in a rich, close, and deeply meaningful analytic process. Over eight years, he became able to better know and empathize with himself, to use his many talents and inner resources to create an intimate relationship with a loving mate, and to enter a highly competitive and demanding profession.

Some analysts believe that patients in the neurotic range benefit most from analysis. My experience has been that less neurotically put-together people benefit from analysis just as much. I have found that intensive work is as necessary to addressing the effects of trauma and early developmental disruptions as to understanding profound guilt. I have treated two critically suicidal patients in analysis: one who became suicidal after the sudden death of a spouse during the analysis and another who suffered from chronic suicidal fantasies and had made suicidal gestures. Seeing them daily was vital, in all the senses of the word, in keeping a connection with them and trying to help them with the depth of their pain and despair, even at times their psychotic states of mind.

Clinical Example

Ms. B. was referred to me by her divorce attorney. My initial impression was of a strikingly beautiful woman in her thirties who carried herself with an air of self-assurance tinged with aloofness. Ms. B. had recently separated from her third husband, Jonathan, who was also her business partner. Cautiously, she disclosed that Jonathan had caught her having an affair. Although the affair had ended and her husband still wanted the marriage, she could not decide whether to remain married. Unhappy with Jonathan and yearning for independence, Ms. B. wanted the divorce. At the same time, doubting her capacity to support herself and their three young children, she felt incapable of proceeding with it. Ms. B. thought her husband had been doing all the “heavy lifting” in their accounting firm and that she was “just the bookkeeper.” She believed that without him she was “nothing” and would be left with nothing. Ms. B. felt desperately caught. She felt deep affection for her husband and greatly admired his business acumen, his confidence, and his love of life. However, she also saw him as judgmental, domineering, and self-involved, even oblivious to others. She felt lost without him but suffocated by his presence.

Ms. B. grew up the middle child in an Eastern European immigrant family with seven children born a year apart. During her childhood, while her mother worked during the day and went to school in the evenings, Ms. B. had a large share of the responsibility for cooking, cleaning, and taking care of her younger siblings. She described her mother as self-involved and unavailable, but praised her father for being interested and loving. Her father had acquired and lost in quick succession several businesses. Because of the father’s business troubles, the family had at times experienced great financial hardship. During those times they had furniture repossessed, lived with the threat of losing their home, and worried about their next meal.

Apprehensive about relationships and new to therapy, Ms. B. came to see me thinking that we would meet briefly and I would help her decide whether to divorce. I experienced palpably her pressure for answers and her urgency to arrive at a quick decision concerning her marriage. Given that she was in the midst of a life crisis, I considered privately whether short-term or couples therapy might be the treatment of choice for her. As I thought about her treatment needs, I wrestled with many considerations. During the consultation it had become apparent to me that Ms. B. was deeply unhappy with herself and dissatisfied with most aspects of her life (her relationships, her work, her sense of herself) and had been so as far back as she could remember. In addition, I thought, although she wanted to know whether to continue her third marriage, Ms. B. could not make an informed decision until she understood more about herself and her motivations. Given the long-standing nature of her difficulties and the fact that she did not want to work on her marriage, I decided not to recommend short-term treatment or couples therapy. As I grappled with whether she could make use of an analysis, I registered my observation that Ms. B. responded to the consultation quickly by seeming less depressed, more hopeful, and less urgent. This initial reaction gave me an optimistic sense about her ability to engage in and benefit from intensive treatment with me.

At the end of the second session, as I imagined myself recommending analysis, I became aware of some additional doubts. Given Ms. B.’s naiveté about therapy, I thought to myself that she might be scared of the analytic frequency or the open-endedness inherent in an analysis. I also wondered if, as a businesswoman, she was too practical and focused on clear cost-benefit considerations to undertake analysis, an uncertain venture from a business perspective. Would she think that I was out of my mind to suggest frequent meetings?

Before my third meeting with Ms. B., I reconsidered my reasons for recommending intensive treatment. I thought about how Ms. B. had told me of her hopes for her future: to have a close and loving relationship with a man without turmoil and drama, to take good care of her beloved children, to achieve financial independence and stability, and to feel good about herself. Although I registered that despite her presentation she experienced herself as helpless and brittle, I also saw a different version of Ms. B.: a determined, resourceful, capable, and likable woman. Also, though she looked self-composed and self-assured, I sensed much uncertainty, fear, and private suffering. I envisioned that analysis would help her become better able to use and appreciate her strengths, become kinder to herself about her vulnerabilities and more aware and understanding of her self-destructiveness and unconscious rage. Given her account of her history, my contact with her and with her deep pain, and my analytic experience, I reestablished in my mind that Ms. B.’s capacity to achieve her ambitious goals depended on her resolving deep, long-standing conflicts about intimacy and success and appreciating the effects of early deprivation and disruptions in her experience of herself and the world around her.

Letting myself think back to our initial meetings, I was able to recognize several unpleasant feelings in relation to Ms. B., feelings that I had barely registered before. I recalled that I reacted to her poise and aloofness with some unease and had passing thoughts throughout the first meetings that either she was so well put together that she might not need an analysis after all or, alternatively, that she might be difficult to reach. I also recognized that I responded to her mention of having had an affair with apprehension and concerns about her propensity for acting out and possible impulse control problems. I also felt uneasy about a theme of exploitation and misuse in her description of relationships and my prediction that once in analysis this unpleasant emotional climate would sooner or later infuse our relating. In addition, I noticed that I was reacting to her appearance with barely registered discomfort, a mixture of admiration and slight anxiety. In retrospect, these relatively tame feelings foreshadowed the emotional storms to come a few months into the analysis.

Despite not knowing the meaning of my uneasy feelings at the time, recognizing my anxiety and thinking that it had meaning freed me enough to proceed. At the end of our third meeting, after explaining my sense of her difficulties and my understanding of her goals and reviewing treatment options with her, I recommended that Ms. B. come as often as possible, optimally daily, and stay in treatment as long as she would need. Not directly responding to the recommended frequency but referring to the demands on her time, given her work and her parenting responsibilities, Ms. B. decided she could manage two times a week. I agreed to start on those terms.

In the next days, I realized that I had mixed feelings about starting therapy with Ms. B. I felt disappointed that we could not start more intensively. At the same time, I noticed a sense of relief that she had decided to proceed slowly. This relief was another signal to me that I had more worries in relation to her than I was consciously aware of.

In the first weeks of treatment, Ms. B. alternated between eagerly looking for immediate solutions and appearing inhibited and ill at ease. During this time, she focused on a list of the pros and cons of pursuing a divorce. When not attending to this concern, she spoke of worrying that she did not have anything important to talk about and that perhaps the twice-a-week schedule was “too much.” I felt, and worked to contain, great pressure to be useful and provide her with parenting advice and answers about her marriage. When she looked painfully self-conscious, I felt an equal amount of pressure to put her at ease and reassure her that I was interested in what she had to say. I felt a sense of urgency to engage her and had the perception that she was about to flee.

When I was able to recognize these reactions to her as signs of my anxiety, I began to consider its meaning. Realizing that I was identifying with Ms. B., I was able to register more clearly the extent of her anxiety and the pressure she seemed to feel to provide me with what I wanted. After I shared these impressions with her, Ms. B. was able to speak directly about her discomfort during the sessions and described how she searched her mind in vain for what she imagined an interesting patient would talk about. Slowly she recognized that this was a familiar worry, a long-standing distressing feeling that who she was would not be interesting enough to others, that she did not have what it took to hold someone’s interest for long. Together we began to discover that Ms. B. considered herself responsible for not having gotten the attention and interest that she needed from the important others in her life, most recently her husband.

By looking closer at her thoughts during her self-conscious silences, Ms. B. and I discovered how disparaging she anticipated me to be. Little by little, we came to understand that seeing me as a harsh critic reflected her own self-criticisms, and she began to recognize that she was an unforgiving judge of herself. As she became a bit less worried about my judgment, Ms. B.’s self-consciousness eased some and she shared more freely her thoughts and feelings. I noticed that at the end of sessions she made passing remarks about how she had more left to say or how fast the time had passed. Or, at the beginning of sessions, she would comment on how long it seemed since our last meeting. I heard these remarks as an indication of her wish to have more time. I sensed that Ms. B. was beginning to find the twice-a-week meetings frustrating. With several areas of concern on the table, I also started to feel that we needed more time together to allow us to go beyond the surface. I asked Ms. B. whether she had considered adding a session. She replied that, although it had occurred to her, she was concerned about lack of time and finances, especially about how her finances might change if she proceeded with a divorce. When, after exploring it further, it turned out that it was unclear to her whether her finances would be an issue in the future, I offered that her concerns about money at this time might also reflect some other worry related to adding a session.

At this juncture, I found that I had to tolerate and grapple with my concerns about my motivation. Given the uncertainty about her marriage and her finances, I wondered if it was prudent for her to increase. Why was I encouraging her? Was it primarily self-interest? In considering my motivations, I privately reviewed my reasons for recommending analysis and looked at the progress we had made. I had recommended analysis because her long history of failed relationships, work dissatisfaction, and disturbing feelings about herself indicated long-standing, multilayered conflict around intimacy and success, and possibly trauma. From experience I knew that short-term measures could not address the layers and complexity of her difficulties. I concluded that although she was using the twice-a-week meetings well and we were moving along in our understanding of her (by beginning to identify her fears and wishes), for our work to deepen she needed increased frequency. My additional knowledge about her (her profound insecurity, her sense of deprivation, and the harshness of her judgment toward herself) further supported my rationale for recommending analysis. Ms. B.’s increased capacity to think freely and psychologically as a result of being listened to analytically supported my assessment that she could make good use of intensive work.

As she imagined adding a session, Ms. B. experienced a new wave of apprehension about how I might perceive her. She spoke of worrying that coming more often would make her “deficiencies,” which she worked so hard to hide, more obvious. She worried about not being able to speak intelligently or make sense of her thoughts. Other than her looks, Ms. B. disclosed, she believed she had nothing to offer. She felt she was not well-educated, well-traveled, or particularly bright. I observed her dilemma that although she was aware of wanting more help with these very disturbing feelings, she worried that increasing her sessions would make her feel worse. I shared with her that I understood that she felt painfully deficient regardless of how frequently we met, but having more time together would allow us a better chance of understanding these disturbing feelings that led her to keep her distance in relationships. Soon thereafter, Ms. B. added a third session.

With the increase in frequency serving the dual function of giving us more time to explore her feelings and of reassuring her of my interest, Ms. B. brought more of herself into her sessions. She began to examine her feelings about her marriage in a deeper way and to consider her motivations for having married and for staying married. She understood that in her husband she looked for someone who could provide her the comfort and security she lacked as a child. Sorrowfully, Ms. B. recalled feeling deprived and alone as a child in a home where there was never enough: food, attention, or affection. She identified a similar feeling within her marriage. With much regret, Ms. B. slowly realized how she and her husband had made an unspoken agreement to remain distant. In the early years of the marriage, when they were building their business, he traveled all week and came home only on weekends. She recalled how relieved she felt when he was leaving again at the end of the weekend and how apprehensive she had felt just before he was due to come home.

As we explored her memories further, she began to reconsider: perhaps what she feared most were his departures, not his arrivals. She recalled the time when he first began his travel and how she missed him when he was away for days at a time, month after month. Knowing that it was a necessary sacrifice for the future of their business, she tried to ignore her building anger and resentment and pretended, even to herself, not to need his presence or his help. Ms. B. and I came to see that trying to ignore her distress and need for help and relying on herself had been her characteristic way of coping with deprivation since she was a child. After noticing that she appeared more distant and guarded on Mondays and in sessions after an off-day, I suggested to Ms. B. that a similar process might have been taking place between us: she had been bracing herself to not feel that she wanted or needed help. Ms. B. confirmed that often on days we didn’t meet she questioned her need for treatment and thought she might be better off meditating or doing yoga. Thinking that meeting more often would allow us to help her better tolerate her longings and become acquainted with her defenses against them, I shared my thought with her that adding a session might be helpful at this time. I also suggested that as with her husband, her fear of relying on others might be keeping her from recognizing her wish for more help. Ms. B. revealed that she had been thinking about adding another session. Yet she felt worried that it was an indication that she was too dependent on others and feared that were she to come more often, she would become too dependent on me. Some months into the treatment, after realizing that her fear of dependency was another old, recurrent worry that she was trying to manage by staying distant and aloof, she added a fourth session and started to use the couch.

Once on the couch, Ms. B. felt as if she had been “made to do it,” as if she had submitted to my will. I found myself irritated by Ms. B.’s view of me as forcing her and considered it her projection. Over the next sessions, as I thought about my irritation, I gradually realized that she was not simply projecting but was also picking up accurately that indeed I wanted her on the couch. I then recognized that I was invested in her continuing to use it. I resolved that although it could be useful for the analysis for her to lie on the couch, it would be even more useful to explore her conflict about it. This reminder helped me become less invested in her remaining on the couch and allowed me to help her further explore her feelings.

In response to my invitation to tell me more about her feeling that she had to continue to lie on the couch, over a number of sessions we recognized that she was importing an old and familiar experience in relationships: feeling forced and having no options. At the same time, lying on the couch evoked Ms. B.’s fears of a lack of connection or engagement. Not being able to see me, she expressed fears that she would lose touch with me or, alternatively, that I would get lost in my own thoughts, lose track of her, and neglect her.

I think in part because I had mentioned in my initial recommendation that five times a week was the best treatment for her, Ms. B. soon began to allude to a fifth session. I say in part because I expected that wanting more contact would have come up sooner or later regardless of whether I had actually mentioned it. She first introduced the topic by referring to her wish to be a better tennis player and concluding that in order for her to play tennis well it was important to play five times a week. Although she was not aware of these reactions, she nevertheless anticipated Tuesday, her weekday off, with sadness or aloofness and showed visible relief when we resumed on Wednesday. At this juncture too, I registered my own disinclination to raise the issue with her. I wondered to myself if four times was good enough and whether it was my therapeutic zeal that was motivating me to want to raise the issue of a fifth session, rather than a consideration of Ms. B.’s best interest. I privately questioned if, by adding a fifth hour, Ms. B. would be overextending herself. Yet thinking back on my experience with other patients and examples from the work of colleagues, I determined that, if it was possible, the fifth hour would increase Ms. B.’s opportunity to consider her disturbing feelings and thereby her chances of coming to terms with them. When I thought about it further, I realized that my own fears of increased involvement with her had led me to think about limiting our contact rather than picking up on her interest, exploring it with her, and recognizing her autonomy to decide how she wanted to proceed. In addition to considering my own motivations, I thought about whether Ms. B. was ready to go deeper and, if so, how to give her the chance to explore the issue without pushing her beyond where she was.

When I shared with Ms. B. that her alluding to the importance of frequency in getting a job well done led me to wonder if she had given any thought to coming a fifth time, she responded that indeed she had been imagining what coming every day might be like. However, she felt concerned about her propensity to be self-indulgent and often did not allow herself to have what she wanted in order to counter that trend. Ms. B. recognized that five sessions felt like a privilege: allowing herself to have the most of what she could have. Yet the recognition that she wanted to come a fifth time brought with it fears of losing control and wanting even more, worries that she would lose her autonomy and her capacity to think for herself, and concerns that she would exhaust all of her resources or me. I believe in part because she was aware by now, eight months into the treatment, of the benefits of time and continuity, Ms. B., despite her fears, asked for a fifth hour.

In the course of the analysis, I gradually understood some of the sources of my initial apprehension. In retrospect, this apprehension was an indication of the unconscious storms that Ms. B. and I were immersed in but were not in a position to fully register. As we began to work together, we came to experience more directly and fully the stormy transferential and countertransferential feelings that were preconscious during the consultation and to begin to understand their meanings. Shortly after Ms. B. began daily sessions (and I believe in part because she felt safer and more contained), she disclosed a “secret.” In a circuitous and halting manner, she described a period of weeks, in December of the year before she came for the consultation, when she felt increasingly depressed and overwhelmed. With thoughts of killing herself by overdosing on her husband’s sleeping pills, she called the police for help and was hospitalized for three days. I felt alarmed by her disclosure and worried that I had underestimated her level of disturbance. Was she indeed more troubled than I had allowed myself to know? What was I getting myself into? Reeling, I reached in my mind for the thought that the timing of her disclosure, as well as the feelings that she engendered in me, had meaning. I managed to suggest to her that being in analysis five days a week might be very frightening to her, for reasons that we had yet to understand.

Ms. B. hesitantly acknowledged that she had been feeling terrified that the frequency of our meetings would reveal her “craziness,” which most of the time she kept under wraps. She further disclosed that she felt scared of the unpredictable outbursts of rage or despair she had occasionally experienced since she was an adolescent. Ms. B. worried that the more time we spent together, the more opportunity there was for her to experience, and for me to learn, the extent of her mental trouble. She anticipated she could become overwhelmed and would overwhelm me. I shared with Ms. B. my thinking that she must have reasons that we had yet to understand that caused her to anticipate that she would be left alone with overwhelming feelings. I further suggested that there must be some basis in her past experience that led her to worry that no one was sturdy enough or caring enough to tolerate and help her with the intensity of her feelings of powerful anger or extreme disappointment.

Not having made it clear in her initial recounting, Ms. B. described that what precipitated her hospitalization was a period of intense marital conflict culminating in an argument with her husband and his threatening to move out. Eventually we came to understand that fear of rejection and profound shame regarding her needs were some of the important reasons that Ms. B. had kept her hospitalization secret, as well as other matters she eventually disclosed (that she was still sucking her thumb at night, that she occasionally slept wrapped around one of her children, that she had had multiple affairs).

As we continued our work, more elements of my initial apprehension became understandable. I slowly came to realize that my initial sense of unease with her aloofness was the leading edge of my fear, at times terror, of feeling profoundly alone, inferior, and rejected in our relationship. I had hesitated to engage with her in analysis in part because, in identification with her counterdependent stance, I preconsciously and accurately anticipated that in getting to know her I would have to tolerate and contain feelings of dependency and neediness that would be profoundly difficult for me. Later in the analysis (when she left me a phone message unilaterally changing the frequency of our meetings or in a remote and dismissive tone announced at a session that she had decided to end her analysis “by the end of the week”), I understood my initial apprehension about her impulse control as in part my preconscious identification with her characteristic style of preemptively rejecting others.

In the course of our work together we understood that Ms. B. had felt neglected by both her parents. As a young child she had felt inadequately held and attended to by her busy and overwhelmed mother. She had also felt “dropped” each time her mother gave birth to a younger sibling and when her mother preferred her father’s company to hers. In addition, Ms. B. felt disregarded and teased by her father, who, while seemingly favoring her among his children, used her as a cover for his affairs. Ms. B.’s father often brought her along while visiting his mistresses, which included one of her elementary school teachers. As she did with all relationships, including her marriages, Ms. B. entered our relationship assuming she would be mistreated by me and imagining that her only protection against neglect or misuse was to drop me first by involving herself with others or by leaving.

Much later in the analysis, when she came to an analytic appointment with a plunging neckline or wearing skin-tight clothes or when she recounted in evocative detail and in a breathless, husky voice her most recent sexual encounter, I began to understand some of my initial reactions to Ms. B.’s appearance as a reflection of my competitive and erotic feelings toward her. My discomfort foreshadowed intensely shameful feelings of arousal and envy that I had to contain and make sense of in my interactions with Ms. B. She and I came to appreciate that from quite a young age Ms. B. had had to rely on herself and develop ways to get what she needed. We learned that having been noticed and admired for her appearance, Ms. B. used seduction to meet her needs for nurturance and affection. Having been at once underparented and overstimulated, including being sexually teased by relatives, Ms. B. conceived of relationships as mutual stimulations and offered herself sexually to others partly in the hope that she would be taken care of. This highly sexualized mode of relating protected Ms. B. from painful feelings of helplessness, rage, unfulfilled want, and shame.

Ms. B. had felt used by both her parents: by her mother to help with younger siblings and the household and by her father to help him cover up his affairs and feel desirable and virile. Thus, she approached our relationship expecting to be used and thinking that the only way to get what she needed was to allow me to use her or to look like she did. My preconscious perception of her expectation of being used by me dovetailed with and fueled my preconscious fear of exploiting her. Although we do not talk about it often, we clinicians need our patients for many reasons: to earn a living, to exercise our professional skills, for professional advancement, and of course for our own deep-seated emotional reasons. Our ability to keep the patient’s treatment needs primary is crucial to the patient’s welfare. Ms. B. was to become one of my first analytic patients post-graduation. Although I was not fully aware of it at the time, I felt I needed Ms. B.—to be a five-times-weekly analytic patient who came regularly, lay on the couch, and paid my fee—in order to prove to myself that I was a “real” analyst. Looking back, I realize that because I needed Ms. B. to be in analysis, I worried at a preconscious level that I would be exploiting her by recommending analysis and increasing her frequency. I now understand these thoughts and feelings in part as a manifestation of my uncertainty about engaging with her more intimately. I also see them as role-responsive feelings—a response to what she evoked in me and a necessary part of relating to her and understanding her. ¹²

Is this case report an example of analysis beginning in the analyst’s mind or an example of the deepening of a psychotherapy that led to an analysis? It is both. Whether Ms. B.’s analysis started at an analytic frequency or built up to it was not consequential for her well-being. What was crucial in helping Ms. B. with her suffering was the emotional work that I, as her analyst, had to do to deny neither her pain nor the tremendous effort that would be necessary on both our parts to provide her the help she needed. During the consultation and the deepening period, it was crucial for this patient’s life that I, as her analyst, be able to generate and maintain (and regain when I lost it) a vision of what was needed and trust in both of us that we could accomplish it. I have tried to illustrate that the work that took place in my mind—both my initial and my ongoing assessment (conscious and preconscious) that Ms. B. needed psychoanalytic assistance and my willingness to engage with her at an analytic frequency and intensity—was a prerequisite for this patient to get the help she greatly needed. I chose this case example because Ms. B. is the kind of person (given her initial presentation, life circumstances, and therapeutic naiveté) to whom an analyst might not have offered an analysis. She could very easily have been seen for years at a twice-a-week frequency without her unconscious storms being fully manifested, identified, or understood. Ms. B. is the type of patient who could easily have just been given medication, or sent for couples work. She would never have come to recognize and come to terms with the depth or sources of her pain or to understand that her ways of protecting herself prolonged, even compounded, her suffering.

Concluding Remarks

In this paper I have shared my thinking and experience of the conditions that have facilitated the beginning of the analyses that I have been part of or have observed closely as a peer or supervisory consultant. I have described how I find it useful in my clinical work to consider analysis as beginning in the analyst’s mind. Although patients and analysts affect and shape each other from the outset, I think it is the analyst’s responsibility to initiate intensive treatment. Patients depend on the analyst to recognize their need for analysis, recommend analysis, and facilitate their engagement.

The analyst’s emotional investment and capacities allow for the beginning of a back-and-forth between analyst and patient that allows the latter to engage in a useful analysis. These capacities include the ability to identify the patient’s pain and fear; the capacity to envision how the patient could develop as a result of understanding conflicts and traumatic experiences; the capacity to envision working helpfully together with the patient; a realistic confidence in analysis; and an awareness that most patients want to know the truth about themselves and to engage deeply and intimately. Recognizing from the outset how much apprehension and fear a close encounter with another’s inner world can engender within me (and keeping in mind that this fear is crucial in understanding the patient) has been a central aspect of my development as an analyst. This recognition has enhanced my ability to listen, engage, and stay the course.