Book Review: Creative Analysis: Art,Creativity and Clinical Process

“I sometimes think you could be more creative as a therapist.” ¹ I’ve never forgotten this comment from a gifted supervisor, made in the course of a positive yet otherwise unremarkable evaluation. It made me see how concerned I had been with “doing it right,” and how this might distract me from creative aspects of the work. I came to medicine from art history and was happy to think of psychiatry as creative. But as a new therapist, I was a dutiful pupil in the École des Beaux-Arts, bent on the mastery of established technique, with little sense as yet of innovation or personal style.

What is creative analysis? George Hagman’s new book is a gallery tour of the subject, opening with a brief survey of what analysts have said about creative processes: Freud’s comparison of creative writing to daydreams and the child’s imaginary play, Kris’s regression in the service of the ego, Klein’s attempt to repair internal objects, and Winnicott’s transitional space between the inner life and the object world. The book goes on to offer a description of the creative process that applies especially well to the analytic endeavor. This is then elaborated, with particular attention to the creativity of both participants.

Following Winnicott and influenced by self psychology, Hagman considers the work of art a type of transitional object, invested with fantasy and experienced as part of the self (p. 4). To begin, the artist makes a mark (in her chosen medium) and then responds to the mark she has made—a Squiggle Game played with herself. I am reminded here of Winnicott’s colleague, the analyst and painter Marion Milner (1950), who described the reciprocity of hand and mind in the process of making free drawings. She would begin in a dreamy state, though not a dreaminess that shuts itself off from the world. Her hand “talked” at random; the watching part of her mind made running comments (for more on Milner as a creative analyst, see Olson 2013).

As the process continues, notes Hagman, “inner and outer subjective elements interact and change each other—gesture follows and builds on the previous gesture, the artwork gradually crystallizing as a network of gestures” (p. 10). Thus “internal and externalized aspects of self-experience enter into a dialectical relationship that transforms both” (p. 8). In this way, subjectivity is externalized, worked on, and perfected (p. 1).

Psychoanalysis can be seen as another such process. With “readiness wrapped in anxiety and self-protectiveness,” the patient comes to us seeking to feel better about herself and her life (p. 21). Hagman favors Adam Phillips’s description of patients as “failed artists of their lives,” their creativity inhibited or blocked. Notes Hagman: “The goal of the process is not just any change, but the improvement of the subjectivity of the patient, the creation of new ways of feeling, thinking and acting which the patient experiences as better than the past” (p. 23). I am reminded of Donald Schön’s The Reflective Practitioner (1983), in which he compares the practices of architecture and psychoanalytic therapy, both based on what he calls “reflection-in-action.” We are designers, where to design means “to change existing situations into preferred ones” (p. 46).

In analysis, notes Hagman, the patient’s subjectivity, rather than being directed at an object or medium, “is externalized through its impact on another person, the analyst. The patient speaks, directs a comment or gesture toward the analyst who is thus changed, perturbed, excited, curious, enraged. . . . interpretations help to give words to the patient’s experience and organize his or her meanings, fantasies and intensions. [They] give the patient the opportunity to reflect on his or her subjectivity, now somewhat changed by the analyst” (p. 24).

In the creative process “is a feedback loop in which the new object influences the artist even as the artist refines the object—an aesthetic resonance. This responsiveness has its roots in the mother’s response to the infant’s spontaneous gesture” (p.14). Likewise the gestures exchanged in therapy derive from early parent-infant interplay. Our gestures are unique to us, a signature, based on our subjective qualities, akin, I would add, to what Samuel Ritvo (1993) calls the child’s “play signature” (pp. 240–242).

One might thus expect Hagman to be sensitive to nonverbal and nonspecific factors in the treatment situation; indeed he is, in coauthoring a chapter, “Aesthetic Interaction,” with Carol Press, at once choreographer, dancer, and scholar. They direct attention to Daniel Stern’s work on vitality affects (1985)—e.g., surging, fading, fleeting, drawn out, bursting, crescendo—and to value affects (understood as aesthetic, not moral—our likes and dislikes). They refer to our musical colleagues (Steven Knoblauch, Frank Lachmann, Gilbert Rose) who discern things from acoustic properties such as voice quality and the rhythms of sound and silence. To such examples I would add the contributions of M. Robert Gardner (1983, 1984), who has studied his visual images and kinesthetic sensations and gestures during or following analytic hours; and Elizabeth Danze (2006), an architect who views the consulting room as a participant in the process.

Our gestures compose our aesthetic sense of self, which is not-conscious (though not repressed) and forms an important part of procedural knowledge and memory. In psychotherapy this includes what the Boston Change Process Study Group terms implicit relational knowing, our intersubjective, experiential understanding of how it is to be with others. The BCPSG (Stern et al.1998) hold that “something more” than interpretation is needed for therapeutic action, something they call “now moments” or “moments of meeting.” Similarly, Hagman sees the exchange of gestures as creating reorganizations in the treatment dyad and in the partners’ ways of being with others. I find this consistent with Morton Reiser’s view that experience is registered in the mind/brain in the form of perceptual images, arranged in nodal memory networks organized by affect. Reiser (1999) notes that “both analytic participants bring to the very first hour their own Nodal Memory Network and leave with significant affectively charged segments of the hour’s dialogue appended to or incorporated within it. And so it goes with each and every subsequent hour. The memory system of each participant and hence of the ‘analytic instrument’ is continuously expanded in this way as the analysis progresses” (p. 491).

Just as we need interpretation and procedural memory, we need the contributions of left and right hemispheres. In the chapter “Creative Brain” Hagman critiques the work of Alan Schore, who contends that parental neglect, misattunement, and trauma can adversely affect development of the right hemisphere, making it harder to regulate affect, relate words to feelings, or decenter from self in order to empathize with others. Schore sees therapeutic technique as having relied too much on left hemisphere functions, thus perpetuating the distinction between creative and analytic thinkers as right and left hemisphere dominant, respectively (p. 35).

Hagman prefers the “balanced brain” approach of Ian McGilchrist, who views creativity as residing in the interplay of hemispheres. In brief, the right hemisphere needs the left hemisphere to step back and think about things, while the left needs the right to feel connected. The therapist needs the left to make sense of the right and needs to help the patient bring both hemispheres on line as an integrating system in which the right gives the left emotional values and meaning. The result is therapeutic and creative. Hans Loewald, I think, says something similar, but in terms of mind: “Psychoanalytic interpretations establish or make explicit bridges between two minds, and within the patient bridges between different areas and layers of the mind that lack or have lost connections with each other. . . . What is therapeutic, I believe, is the mutual linking itself by which each of the linked elements gains or regains meaning or becomes richer in meaning—meaning being our word for the resultant of that reciprocal activity” (1977, p. 382).

In a chapter devoted to the “creative analysand,” Hagman observes our tendency (e.g., in case reports) to present ourselves as the agent of change in the treatment, with less to say about the patient’s contributions and capacity for self-repair. A more passive account of the analysand’s role may tend to perpetuate itself and fails to convey what is needed for change to occur. In line with this, he prefers Roy Schafer’s use of action language (1976) to describe mental experience. Of course, Hagman notes, disclaimed action and apparent victimization are frequent responses, perhaps once adaptive, to trauma, which tends to impair our capacity for creative living. In this familiar clinical setting, creating agency where passivity has been may be a therapeutic aim.

To this end, Hagman sees the patient’s selfobject transference as a creative way to use the analyst to repair and grow. Some transferences test the analyst to see if she is something new or just another old traumatogenic object. (This is the more traditional view of transference as a repetition and expression of “stuckness.”) But there is also hope: “In this potential space . . . of the analytic situation patients seek to externalize their subjective experience in hopes that something might be done with it” (p. 92). Sometimes it takes a while before the patient risks using the analyst as a selfobject, with the longings and dependency entailed. Hagman notes that “this way of using the analyst may depend on the maintenance of an illusion that the analyst is [perfect, attuned, powerful, admiring, encouraging, etc.]. . . . These illusions are only useful for a time, and must be given up” (p. 69). Elsewhere he adds: “What makes analysis so powerful is the introduction of a new person into the plot. This person, the analyst, exists outside the imagination of the analysand, and the omnipotent control of the analysand’s fantasy life. He or she is thus in a position to introduce ‘not-me’ elements . . . into the analysand’s experience. The analyst has been auditioned and assigned a role by the analysand. However they are a different type of character whose role is to enter into the rhythms of the piece, and disrupt the familiar structure of the analysand’s self-construction” (p. 28).

In a companion chapter, “Creative Analyst,” Hagman finds creativity in the analyst’s “struggle to preserve, enhance and restore self-experience, specifically the sense of the analytic self as it emerges during the treatment process” (p. 74). The analytic self seems analogous to the sense of oneself—one’s identity—as an artist. It may also be a counterpart to the patient’s subjectivity. A work in progress, the analytic self is subject to permutations. It depends on colleagues, mentors, students, and especially patients. Doing analysis both validates and challenges our analytic self. We are “on the line,” subject to the vicissitudes of the process, to anxiety, self-doubt, and disorganization. As Hagman observes, “Self-crisis is essential to most forms of creativity and likewise the creative analyst must welcome the disruption of the analytic self . . .” (p. 80). Just as the artist is repeatedly disillusioned regarding the artwork’s perfection, so too the analyst, who must allow the work to unfold with developments that can be confusing, sloppy, disappointing, or painful. Like the artist, the analyst must manage the resulting anxiety and depression to reassess the work and resume the creative process. Clinicians will take courage and encouragement from this chapter.

Throughout the book there is a tendency to repetition, with some resulting loss of focus. Nonetheless, Hagman’s slender volume inspires us with examples of creative reciprocity. Responding to gesture with gesture, the reader cannot help but add examples of her own. Mine include Otto Isakower’s analyzing instrument, a working model in which the analyst’s evenly suspended attention is attuned to the patient’s free association and to her own thoughts, images, fantasies, and emotions (see Balter, Lothane, and Spencer 1980; Wyman and Rittenberg 1992). The instrument is a joint venture, put together for and disassembled each hour, perhaps like a flute taken from and returned to its case. As Reiser (1999) has noted, “Isakower considered it the analyst’s task to process and understand those comings from within and to apply this self-understanding in the ongoing effort to understand the analysand. . . . Note well that this is an interactive model that functions within a subjective analytic space rather than at the surface of one of the two participating minds” (p. 489).

Others may recall Jacob Arlow, who puts it in visual terms: “The joint search by patient and analyst for a picture of the patient’s past is a reciprocal process. In a sense, we dream along with our patients, supplying at first data from our own store of images in order to objectify the patient’s memory into some sort of picture. We then furnish this picture to the analysand who responds with further memories, associations, and fantasies, that is, we stimulate him to respond with a picture of his own” (1969, p. 49).

Lastly, readers familiar with Loewald will think of his essay “Psychoanalysis as an Art and the Fantasy Character of the Psychoanalytic Situation” (1974), in which he writes: “patient and analyst—each in his own way and on his own mental level—become both artist and medium for each other. For the analyst as artist his medium is the patient in his psychic life; for the patient as artist the analyst becomes his medium. . . . In this complex interaction, patient and analyst—at least during some short but crucial periods—may together create that imaginary life which can have a lasting influence on the patient’s subsequent actual life history” (p. 369).

Hagman’s account of the psychoanalytic duet is valuable and useful. New and experienced clinicians alike will find his book good guidance to the creative nature of our work.