Roger Buckle, 2009
These reflections are around and about the things necessary for the serious business of assessment for psychoanalysis. I hope to touch on the ingredients for clinical assessment which I think are the most enabling, and which I think get to the heart of the matter. I offer nothing new, other than an indulgent account of my own experience.
The question is – how to assess someone for the journey that is psychoanalysis. Intuition and innate psychological flair is comparable to what we call talent in an artist. It is something to admire and, perhaps, to envy.
For example: not long ago, reading Michael Ondaatje (2007), I came across the following. “For we live those retrievals from childhood that coalesce and echo throughout our lives, the way shattered pieces of glass in a kaleidoscope reappear in new forms and are songlike in their refrains and rhymes, making up a single monologue. We live permanently in the recurrence of our own stories, what ever story we tell”.
Another example quoted by Ondaatje: “Everything is biographical” says Lucian Freud. “What we make, why it is made, how we draw a dog, who is it that we are drawn to, and why we cannot forget. Everything is a collage, even genetics. There is the hidden presence of others in us, even those we have known briefly. We contain them for the rest of our lives, at every border that we cross”.
However, we are not artists; we must learn our craft over and above what ever innate flair we do, or do not have.
My story begins 35 years ago when I had been in analysis for some time. I assessed the first of my three training cases. My patient essentially asked me to restore her health. She was a young single woman in her early thirties, referred because of panic attacks.
She came willingly because she was suffering and had a desire to get better, indeed to overcome her disabilities so that she could get on with life. She was a vice-principal in a primary school and loved children and her work.
I liked her approach to me and learnt that she had repetitive difficulties with her principals, male and female. She was afraid of intimacy. Her immediate idealisation of me revealed the primitive within, but nevertheless facilitated our making arrangements for an analysis. I learnt a lot about being an analyst over the ensuing 5 years that we worked together. She made considerable gains from her experience……..and I never heard of her again.
I was fortunate to begin with this patient; she enabled me to learn, discover, and work with such things as transferences of love and hate, and with countertransference and reverie; I was also helped by my own analyst who understood (among many things) the value of the “felt experience”.
In retrospect I was lucky that the simplicity of this assessment suited my style, in that I did not want to convey myself as an inquisitor, but rather (as I learnt later to call it) a container. The preferred method of the time was to take a careful and detailed history that culminated in the diagnosis.
We were encouraged in seminars to use a lengthy assessment to explore details of life history and development, such as our patients could recall.
We made formulations which were supposed to give meaning to the internal dynamics. Choosing a patient was sometimes put in terms of the ego and super-ego, sometimes drives and resistances, and sometimes defence mechanisms. Some leaders could talk about projection, but rarely projective identification.
However, the Australian Society was beginning to argue and change. It was as if the Controversial Discussions (1991) had reached the Antipodes in the 70’s.
Further development, and indeed maturation, was facilitated by many colleagues returning from analysis and psychoanalytic training in London. Senior, talented analysts from overseas visited regularly and contributed to the maturation in our Society. Dr Linnane and Dr Blomfield introduced Infant observation for our students who were encouraged to sink into their analysis in order (at least) to have a feel for that which they had chosen as a career.
This matter of our personal development and that of the Society needs careful consideration.
One hundred years ago Freud was changing his thoughts on technique. His recommendations elaborated the dynamics of the relationship between the patient and the analyst. It was determined by the patient’s unconscious memories, of fact and phantasy, and the analyst’s task was to understand and interpret the immediate significance of this relationship.
Freud’s statement in ‘Remembering, repeating and working through’ (1914) that we have to treat the patient’s illness as active at the moment, and not an event in his past life, implies that the analytic relationship represents the stage on which the patient re-enacts his symptoms, memories, dreams, and current experiences. This made the transference the field on which all conflicts must be fought out. This crucial change and development in the concept of the analytic situation cleared the way to new discovery of difficulties, this time on the part of the analyst, a new instrument was forged, the analysis of the analyst. As we have experienced, and so will our students, we are exposed to the violence of primitive instinctual impulses, the terror and despair of early infantile conflicts in our patients, and we can best deal with them if we have experienced and worked through, and continue to work with, the same problems in ourselves.
From this point we can easily trace the development of psychoanalysis through to Rosenfeld and Bion and the impact of projective identification.
Of all the discoveries within psychoanalysis since 1946 (Klein), the process which is projective identification is the one which has changed the way analysts throughout the IPA work with their patients. We now understand what it means ‘to put parts of oneself into an object, so that the object becomes identified with the unwanted aspects of the self’. We are clear that we are talking about a phantasy; a patient has an unconscious phantasy that he has put a part of himself into his analyst; the picture he then has of his analyst is altered. We, as analysts, are forced to feel feelings which unconsciously our patients cannot tolerate. We are affected and we try to understand; we try to think about them, to put them in some kind of order, to take in, to hold onto, to metabolise, and think about all the stuff of the patient; to put our minds to it.
We also know that projective identification can be a valuable, if not indispensable, means of communication. Rosenfeld (1987) was often to stress that containment can only be helpful if the analyst can relate to the communicative element in the projection and can transform these into a form that the patient can accept as helpful.
I believe this is what the patient wants; an analyst with the capacity to tune into the patient’s need to be understood even if the patient seems more obviously to be intent on evacuation, attack, or manic denial.
The difficulty is, of course, to be sure that what we experience as coming from the patient is actually coming from the patient and not from our own responses to something the patient has stirred up.
This has been the stuff of my development which in many ways parallels the maturation within our Society, and indeed, in all of psychoanalysis.
On the subject of development and maturation, I was reading the paper of Gabbard and Ogden (2009) in the recent International Journal entitled “On becoming a psychoanalyst”. They say we know that the maturation of the analyst has much in common with psychic development in general. One’s lived experience, whilst often disturbing, is the basis for learning from experience which we use to further and maintain our psychological growth. Gabbard and Ogden place emphasis on the intersubjective conception of the development of the analyst. From Bion (1987) they quote “it takes (at least) two people to make one. The analyst requires another person to make the unthinkable thinkable”. They say that person is most often the patient, but maybe the supervisor, colleague, peer group and so on.
They are reminded of Bion and the “container”, the process of doing psychological work with our disturbing thoughts.
They go on in their paper to discuss a number of types of maturational experiences that have played an important role in the development of their identities.
They include, the development of a voice of one’s own, the presenting of clinical material to a consultant, using one’s analytic work as a principal medium for self analysis, and, discovering what one thinks and who one is in the experience of writing.
They talk of daring to improvise, and a self-imposed need to be original, but deny that this is a sense of narcissistic display.
I found the rest of the paper somewhat over-cooked and lacking in depth, eg,”it has been our experience that, when the analyst is off balance, he does his best analytic work”. However, to my pleasure, they did read a book review in the American journal JAPA (2000) of John Steiner’s, and they borrow Steiner’s phrase “we must remember that, as much as we love analysis, a part of us hates it as well”.
This makes us think.
Now, I make these observations because I know what it was like to be a beginning-analyst. I did not have my 35 years of experience; I had not conducted more than 30 analyses. I had, though, spent some valuable time in analysis. In the beginning I struggled to have the mind to offer to the patient in order to fully understand the unconscious thoughts, dreams, and feelings required of me. Slowly I gained confidence with my felt experience, and was able to use this in thinking about the patient’s mind, and subsequently, use this to inform the patient of who he is, and what belongs to him.
This causes me to reflect, with some concern, about beginning-analysts in general. Today, in Melbourne, they are admitted to the training and proceed with 6 months of infant observation and seminars, and supposedly 12 months minimum of analysis before likely as not, galloping on to take on a patient which they have assessed.
Some are wiser and they pause, as if to catch their breath.
How equipped are they to do an assessment for analysis? What do they think analysis is, and how are they to know what they are offering?
It is nonsense to think they have matured much; and nonsense to think that they do not need help, if we think that assessment is a serious business.
How considerable is their need and reliance upon a supervisor for support and help, particularly in assessment?
We are, after all, responsible for their training, and hence their work with their patients. They do not know what we now know; and they have not yet the developed the minds to offer to their patient. What will they do if they get it wrong?
I have recently taken four seminars on this topic. I gave out a reading list some weeks prior. In the first two seminars the students presented their assessments of patients from their practice. We had very good discussions. In the third seminar I presented an assessment of mine, and we continued the good discussions. In the final seminar we had discussions from the reading list.
I think these seminars might have oriented the students to the subject a little, but they certainly were not able to feel confident as they wondered about going forward. Their identities as analysts had not yet moved on from intellectual and imaginary thoughts and images.
Incidentally, the reference that they responded to best was Isca Wittenberg’s lovely informative paper, with two beautiful case stories, from the J.Child Psychotherapy, in 1982. In talking of these references, I would like to bring your attention to the paper by Judy Kantrowitz from the International Journal, 1995, on “The beneficial aspects of the patient-analyst match”. The Boston studies took patient-analyst couples and observed them over a five to ten year period.
Each patient and analyst pair has its own unique interaction, in which the resonances and affective attachment play their part in the analytic process.
In the Boston studies of the patient-analyst match the fit was found to be facilitating for some and a handicap for others – and, not surprisingly, facilitating at some point in an analysis and impeding at another. These results have considerable support from our own experiences in our clinical work, and indeed from caretaker-infant studies.
Since a particular match influences which aspects of the patient develop, so too do analysts develop, not only from their work, but from the helpful honesty of their patients. These thoughts are not unknown to clinical psychoanalysts and they provide a cautionary note for assessment.
It is possible to think about the match of a patient with an analyst in assessment; we may know that we work with some impediment with certain people. It would be an intelligent analyst who referred this patient to a colleague. This thinking also points to aspects of assessment in the supervising of beginning- analysts.
Now, it is obvious that in an assessment we cannot know, or find out, everything about the person. And, what use would we put all this detail and information to? The question is: what is it that we want to know? This is a different question than: what is it that the patient wants to tell us?
I think I want to find out something about the core of the problem that brings the patient to see me. I want to find out if we can communicate, and, to find out if I have the capacity to work in analysis with this person. I like to feel that the person is seeking something from me: perhaps relief, maybe protection and security, or maybe a solution – whatever.
I have become used to, and indeed prefer, to start a consultation with a high degree of ignorance. This is what whets the appetite of curiosity. Although the patient is in a highly anxiety laden situation, I want to find out if I am able to provide the patient with the opportunity to be listened to and to share in thinking about his or her state of mind. This task of exploration is a mutual one. The setting has to be provided which offers the possibility of an interaction which will reveal the nature of the patient’s relationship to himself and to other important people in his life. As well the setting also invites his attitudes towards me, someone from whom he seeks help.
In addition I can observe a great deal. The person’s mental state will be manifested in every aspect of his behaviour and therefore available in the here and now. Every item of behaviour is taken in the context of the interview: his expression, his clothes, movements, his conscious attitude, phantasies, dreams, or the absence of, will all be noted.
I pay particular attention to the transferences and the ability to receive conscious and unconscious infantile feelings which in turn helps the patient to communicate to me further in phantasies, words, reactions or enactments. I study the impact on myself – subtle disturbances in mood, my reactions, can I think easily and digest?
Further, several important things tend to happen – the patient may get some feeling of being understood; they may have an experience of destructive or frightening aspects being contained; or, I may have an opportunity to have a dynamic effect on the interaction by using an interpretive comment.
Now, I want to give a brief story of an assessment interview.
I, more or less, ask very little other than to ask the person to tell me about themselves and why they have come.
This is a story about a young woman psychologist who sounded remarkably normal.
It is funny about first impressions – it is a strange feeling to be confronted with an experience of someone (with no apparent insight) putting things about herself – love, work and play – as though things were normal. I felt that she wanted me to know this about her, above all else. Not why she had come; not what she thought analysis for her was for.
I know from experience that many so-called normal personalities who are realistic, adaptable, and seem to have a well ordered life, can use this as a defence; what we have learnt to call the “the manic defence”.
When there was a pause, I said to her that I felt strangely dislocated with what she has been giving me.
To my surprise she did not directly take exception; she seemed anxious yet genuinely interested.
I went on to say that I felt she needed me to know how satisfactory things were for her, and yet, here we were with her enquiry about analysis.
The mood changed.
She then told me a story about a film she saw that had disturbed her. Essentially it was about a family with a distant mother that could not comfort her disabled daughter. She cried softly when she told me.
I felt there was more to this person than meets the eye. This was an honest response and I think she had empathically understood my comment. That is, she understood the reality of the comment, and the aggression of it.
I looked at her enquiringly. She must have heard me – so to speak, for she went on to tell me more stories which related to her feelings of why she had come. She did not say so directly, but, she seemed perceptive and I accepted her messages.
At this point I felt I knew enough to know whether analysis was wanted and could be of use. I thought the patient had some felt idea of her pain; she was empathic enough with her attitude towards herself, and had found a way to communicate this to me. I thought the patient had a real wish for reparation, as well as to use, and also to show me, her destructive pseudo-maturity.
Also, she had made the appointment, and in the session she could communicate and respond.
This recalls a paper of Irma Brenman Pick’s (1995), “Concern: Spurious or Real” and her beautifully clear account of two patients in which she refers back to Klein’s “Anxiety and Guilt” (1948).
To quote from Klein – “There appear to be transitory states of integration even in very young infants…….which give rise to depressive anxiety, guilt, and the desire to make reparation….......………As an alternative method, very likely a simultaneous one, of dealing with these anxieties, the ego resorts strongly to the manic defence”.
At this point with my patient, I had some idea of her internal world, and some clues about why she had come. I also knew something about her precocious defences, and her phantasies about the quality of the nurturing experience she thought she had received.
I knew little of her family, or the organisation of her parents and siblings – relationships, depressions, violence, or what – and, only had a glimpse of the society she lived in and the effects upon her.
I felt that she did not have intense persecutory anxieties, nor did she show a low tolerance of frustration. She was not passive or negative. She was able to gather herself towards the end of the interview and ask about the way forward.
In this matter of assessment I have found a position in which I can be myself. I hope I offer the patient the opportunity to experience an interaction with me, such as to achieve a mutual assessment, so that if analysis proceeds it will be experienced as a continuation from the assessment into the analysis. I am not afraid to share with a patient my opinion if I do not want to proceed, or if I recommend a second opinion be sought.
Mistakes can be made. Both the external and the internal lives of patients can change a great deal from the little we know of them from an assessment. I find it is comforting to know that the patient has some external supports, such as some friends and colleagues, and a good GP.
There is no road map for this adventure, that is, assessing patients for analysis, nor for analysis itself, but there are talented colleagues one can call upon.
Bion WR (1987) Clinical Seminars. In: Clinical Seminars and other works. London: Karnac.
Brenman-Pick I (1995) Concern: spurious or real. Int. J. Psychoanal. 76: 257-270.
King P, and Steiner R, Eds. (1991). The Freud-Klein Controversies 1941-1945. London: Routledge.
Freud S (1914) Remembering, repeating, and working through. SE 12 145-156.
Gabbard GO, and Ogden TH (2009). On becoming an psychoanalyst. Int. J. Psychoanal. 90: 311-327.
Kantrowitz J (1995) The beneficial aspects of the patient-analyst match. Int. J. Psychoanal. 76: 299-314.
Klein M (1946) Notes on some schizoid mechanisms. In: The writings of Melanie Klein Vol. 111 (1995) London: Hogarth.
Klein M (1948) On the theory of Anxiety and Guilt. In: The writings of Melanie Klein Vol. 111 (1995) London: Hogarth.
Ondaatje M (2007) Divisadero. London: Bloomsbury.
Rosenfeld H (1987) Impasse and Interpretation. London: Tavistock.
Steiner J (2000) Book review of A Mind of one’s own by R. Caper. JAPA 48: 637-643
Wittenberg I (1982) On Assessment. J. of Child Psychother. 8: no. 2.