Acknowledging the “Analyst as Person”

Lessons from the Early History of Psychoanalysis

Some of our reluctance, perhaps, is a necessary disavowal (as Morris discusses in this issue)—necessary to do the work and necessary for the field to develop—and stems from our history as a field. If analysis is merely a “procedure” we employ, rather than an investment of ourselves, maybe we can avoid the emotional upheaval experienced by the first psychoanalyst. Whatever the actual outcome of the treatment of Anna O., we know that for Josef Breuer conducting it was overwhelmingly disruptive. In 1907, in a letter to Auguste Forel, Breuer wrote that while much of what he learned in the treatment of his now famous patient was of great scientific importance, he also learned that “it is impossible for a ‘general practitioner’ to treat such a case without his activity and the conduct of his life thereby being completely ruined. I vowed at the time never again to subject myself to such an ordeal” (Grubrich-Simitis 1997, pp. 26–27). What Breuer had discovered, in addition to the talking cure, is that being that involved with a patient takes its toll on the analyst. This toll can lead us to withdraw from patients, to resist involvement with them, or to disavow that involvement, preferring, perhaps, to pretend that the analytic relationship is not a “real” relationship.

Freud’s early papers provide an antidote to that kind of “all in” experience. The patient presents with symptoms, the analyst puzzles them out through his detective work and his method of free association, symptoms are relieved, and the patient is cured within a relatively short period. Of course, we know now it is not so simple; but that focus on the patient’s symptoms and the uncovering of the unconscious, uninfluenced by the person of the analyst, has had for me, and for many, a magnetic pull, no matter how often I am made aware that that neatness does not exist in my office. In my fantasies, I am the surgeon excising the diseased part; I am the mathematician solving the problem. In this model, the patient is the symptomatic one, not me. He has obsessional symptoms; she uses projective identification; he is masochistic. And I have the tools to help. The patient, who most likely has arrived in my office by chance, and in any event could not know what she is getting into, will emerge from the treatment unharmed by my aggression, unseduced by my charm, uninfluenced by my unconscious needs and conflicts. Particularly when I began analytic training, just starting my own analysis and afraid of the unconscious forces with which I was becoming acquainted, acknowledging that my personhood would affect the patient felt like more than I could bear in going about my daily work. It was much more comfortable to imagine that I was uninvolved, and to maintain what my superego would consider the ethical position.

With more clinical experience, Freud, too, seems to have recognized, and then become uncomfortable with, the role the analyst’s personhood plays in the treatment. In 1915, in “Observations on Transference-Love,” Freud begins to acknowledge that the analyst plays a role in promoting the erotic transference, but then he quickly steps back: “He has evoked this love by instituting analytic treatment in order to cure the neurosis. For him, it is an unavoidable consequence of a medical situation, like the exposure of a patient’s body or the imparting of a vital secret” (p. 169). The fault lies in the method, in the simple act of instituting analytic treatment, not in the analyst. In the Rat Man case, Freud (1909) similarly pleads innocent. In the third session, the patient struggles to tell Freud about the story the cruel captain told about the rat torture. He stammers and gets off the couch, begging to be released from having to recount the horrific details of the torture. But Freud does not yield. “I assured him,” he writes, “that I myself had no taste whatever for cruelty, and certainly had no desire to torment him, but that naturally I could not grant him something which was beyond my power” (p. 166). In both cases he is disavowing responsibility for the suffering the treatment might occasion the patient. Is this a conscious reluctance to inflict suffering or an unconscious resistance to acknowledging his sadism?

And then, to ensure that we check our drives at the door, in “Observations on Transference-Love,” in the same paragraph I cited earlier, Freud also denies the analyst any gratification. “It is . . . plain to him that he must not derive any personal advantage from [the patient’s love]” (p. 169). While he seems to be talking about sexual gratification, this dictum strikes the beginning analyst as a prohibition against getting anything from the patient, further inhibiting discussion, and likely thought, about how our desires affect the treatment. At the same time, we all know that we want something from our patients and that we get it, if only the feeling that we are working as analysts (Wilson 2003, 2013).

As the field matured, countertransference and even the analyst’s unconscious became more speakable. In “Counter-transference and the Patient’s Response to It,” Margaret Little (1951) addresses the ways our personhood may infect the treatment. She begins the paper with a clinical vignette. A patient has given a successful professional presentation two weeks after his mother’s death. The patient reports in analysis that he is feeling anxious. The analyst interprets this feeling as being due to the patient’s fear that he, the analyst, might be jealous of his success. “The interpretation was accepted,” Little reports, “the distress cleared up quite quickly, and the analysis went on” (p. 32). Two years later, now no longer in analysis, the patient realized that the interpretation of his distress “had in fact been the correct one at the time for the analyst, who had actually been jealous of him, and that it was the analyst’s unconscious guilt that had led to the giving of an inappropriate interpretation” (p. 32; emphasis added). In this case, perhaps, the interpretation led to symptomatic relief even if it was off target. Little suggests that the efficacy of the interpretation related to the patient’s “unconscious recognition of its correctness for his analyst and his identification with him” (p. 32). That is, the patient is so identified with the analyst that an interpretation appropriate to the analyst is mutative for the patient, even though the interpretation does not address the source of the patient’s anxiety. Heinrich Racker (1957) makes a similar observation: “What makes these happenings so important is the fact that the analysand’s unconscious is fully aware of the analyst’s unconscious desires. Therefore the patient once again faces an object . . . that unconsciously seeks to satisfy its own desires or allay its own anxieties rather than to understand and satisfy the therapeutic need of the patient” (p. 334).

Some fifty years later, Vincenzo Bonaminio (2008), writing about the analyst as person, reports on his treatment with Giovanni. The treatment feels stuck for a long time, until the analyst has what he calls, following Winnicott, a “healing dream.” From this dream, the analyst emerges with a metaphor for thinking about the patient. The patient is far away, as if on Mount Everest, and frozen. He begins to use this metaphor with the patient, and the patient responds in kind. This kind of language becomes part of the therapeutic dialogue and seems useful. With a different analyst, the language might have been different, the stuckness might have taken a different form, and the whole analysis might have been different. As Bonaminio writes, “Certainly, the analyst has a subjectivity of his own that leads him to reelaborate what the other narrates to him, and that makes his listening different from any other listener’s” (pp. 1140–1141).

These examples point to the iterative nature of identifications in the analytic process. The analyst identifies with the patient, through her own lens, and the patient identifies with the analyst. In Little’s case, which is based on her own analysis with Ella Freeman Sharpe, we have follow-up data. The interpretation was useful affectively but was not mutative; it sat like a foreign body in her mind until she was able to recognize its provenance. In Bonaminio’s patient, it appears that the commingling of unconscious content from each member of the dyad was useful therapeutically and moved the treatment along. But we don’t know, we cannot know, the impact that our personhood will have on our patients, for good and for ill.

Learning to be an Analyst

This realization is a bitter pill to swallow for analytic candidates (maybe even more so for those of us trained in the medical model, where “cure” and “sterile field” are appropriate aims). In some ways our analytic training system breeds a disavowal of the influence of the analyst as person on the outcome. Perhaps this is an area where the education of psychoanalysts is more aptly termed, as the French call it, formation, and perhaps the fantasy of learning a skill or a technique in American psychoanalytic institutes creates some of the issues I am describing. But as with the work in general, I can write only from within my experience. In what I assume to be standard American psychoanalytic education, candidates learn how to “do” psychoanalysis. They go to lectures, read papers, and get supervision regarding their patients. There they hear about how analyst X does things, as if analysis were a technical procedure, which if executed correctly will effect a good result. I don’t imagine that I am the only therapist to read a paper with a case vignette or listen to a case presentation and think: “This is beautiful. I will try that.” But, of course, I can’t try that. My patient is not that patient, and, perhaps more importantly, I am not that analyst.

Clinical examples are like buying clothes from a catalog: they look great on the models, but not always on us. What we don’t learn and can’t learn from these vignettes is who the individual analyst is and why that technique works for that person (and why it might not be such a good fit on us). We see a snippet of a treatment, massaged to fit a particular theory. The result for the candidate I was, and at times for the graduate analyst I now am, is a sense that I am doing things wrong, because my treatments don’t look like that. And when I try to make my treatments look like that, or take a theory or approach that my supervisor has suggested directly into my office with my patient, I generally miss the patient. My wish to fit a particular predetermined theory has led me away from my own immediate experience of the patient and his of me. Perhaps more importantly, however, in identifying with the supervisor, or the writer of the most recent paper I have read, I am taking on another persona that might fit me as badly as the theory fits my patient. The words I most dread hearing from a patient are, “I’ve been thinking about what you said last week. Can you explain it again?” Usually that means I have introduced some bit of theory that has come from without, in a bit of zeal to finally have “the answer,” something I have come to see as my retreat from the depressive position (Cooper 2016). I have lost the capacity to be myself with the patient where we are, rather than to know from on high.

This should not be understood as an argument against theory. I do wonder, though, if we do candidates a disservice by teaching theory as if it were the Ten Commandments, handed down as a truth with a capital T, devoid of historical and interpersonal context, rather than as the work of very particular men and women working in very particular social and intellectual milieus with very particular patients. Although I think that the search for capital T truth is a developmental phase in becoming an analyst, just as copying old masters is a way of developing skill as an artist, it can also serve as a retreat from our patients and ourselves.

Judy Kantrowitz has written extensively about the importance of patient-analyst match in treatment outcomes. She has also written convincingly about the impossibility of knowing, a priori, what will make a good fit (Kantrowitz 1986). Given this uncertainty—because we cannot know our unconscious, because we analyze in character (Kite 2008), because “it is what the analyst is rather than what he says that matters” (Nacht 1962 p. 207), because “no psycho-analyst goes further than his own complexes and internal resistances permit” (Freud 1910, p. 145)—we are confronted with an ethical dilemma when we engage a patient in an analytic process. We offer a treatment we believe will be helpful, with whichever model of therapeutic action we find most compatible or compelling. Following Freud, we approach the clinical situation with an ideal of stoicism (Kirsner 2006), a discipline that is necessary for establishing the frame and treatment contract, a necessary disavowal, as Humphrey Morris calls it. But this discipline may also blind us to the ways we as people are implicated as the treatment proceeds and in the outcome it obtains.

Conclusion

The ethics of the analyst as person lies in acknowledging just that. The analyst is a person. No one would say that we are not people, of course, and much of the more recent literature (e.g., Aron 1991; Renik 1993; Hoffman 1994; Wilson 2003, 2013) points to the way our responses to patients are intimately connected with who we are as people, particularly in our unconscious countertransference response, and these writers also encourage us to learn about ourselves from our patients’ understanding of us. However, I believe this attitude exists in tension with the disavowal of our personhood that runs through our literature and mythology. Even within the recent literature I have mentioned, there is an idea that we can be known, and that we can come to know, through our countertransference, all that is necessary for us to know about ourselves as analysts. I would argue that there are aspects of ourselves and of our contributions to the treatments we conduct that are unknowable, and the best we can do is to accept that. This is both a developmental achievement and an ethical imperative.