Impasse and failure in psychoanalytic treatment.
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Adult↗
Biomedical subjects
R D Chessick
Publications and source records attributed to R D Chessick.
The application of postmodern thought to the clinical practice of psychoanalytic psychotherapy.
The purpose of this article has been to acquaint psychoanalysts and psychoanalytically oriented psychotherapists with some of the most current ideas in philosophy and psychology, which have crucial implications for our professional organizations and our clinical work. The basic stance of this postmodern thinking constitutes a challenge to what is called foundationalism, which dominated scientific and philosophical thought until recently. In place of foundationalism, even in the production of scientific or philosophical works, we could hope for an ongoing dialogue between a king or queen who states the basic theoretical orientation, the loyal opposition that looks for inconsistencies and kinks in it, the jester who deconstructs the whole thing and introduces parenthetical digressions, and finally, a secret society of organization that functions to hold the adherents of the theory together and provide them with a unifying ego ideal. Postmodern thought is described and there is some discussion of its "four horsemen," Derrida, Rorty, Foucault, and Lyotard, who in general question the possibility of whether any form of interpretation can be thought of as related to reality or the truth. My own point of view is that an intermediate position is necessary rather than a binary opposition between nihilism and foundationalism or more specifically, postmodernism and traditional psychoanalysis. That is to say, within certain horizons and with an understanding of the cultural and historical referents that always affect and delimit both the patient and the therapist, it is still possible to reach conceptions about what is going on both in the psychoanalytic process and the psyche of the patient that have at least a tentative "truth." Careful attention to the patient's material following an interpretation can provide clues about the validity of our conception at the time. But the horizons and historicity that delimit all "truth" reduce the authority and the stature of the analyst, make the analyst less of an arbiter of what is "reality," and focus greater attention on the therapist-patient dyad, which is consistent with the modern trend in psychoanalytic treatment anyway. The notion of social constructions as constituting the psychoanalytic process was discussed and it was suggested that this notion suffers from the lack of sufficient attention to the historical determinants of how a given individual reacts in a given situation. A patient will react differently to different therapists, depending on the transference or projective identifications that the patient brings to the treatment, regardless of the interpersonal interaction. This is in opposition to the idea that transference is primarily an effect of the therapist-patient dyad, and preserves a major aspect of traditional Freudian theory. The dangers of postmodern thought disintegrating into nihilism are described, and the limitations of so-called postmodern thought are discussed, including the intrinsic paradoxical nature of any postmodern proposition. At the same time, postmodern thought is useful in calling attention to the "space of the Other" in human affairs, to the tendency to form binary oppositions in which the second element in each binary pair is part of the Other and is depreciated, and to remind us that there are always further interpretations of the narrative that emerges from the psychoanalytic situation. The feminization of psychotherapy and its relationship to feminism are important current issues. Postmodern thought is valuable in responding to the common complaint of feminists about Nietzsche's attitude toward women; postmodernist approaches emphasize the ambiguous and the allegorical aspects of Nietzsche's thought, to the extreme orf Derrida's contention that Nietzsche is not really interpretable at all. At the same time feminists legitimately object to postmodernist erosion of the grounds for political action. (ABSTRACT TRUNCATED)
Female↗
Who does he think he is: remarks on the psychology of Jesus.
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Delusions↗
The application of phenomenology to psychiatry and psychotherapy.
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Humans↗
Psychosis after open heart surgery: a phenomenological study.
This brief self-reflective phenomenological study attempts to throw light on the inner mental processes that go on immediately following open heart surgery. The combination of organic assault, medication, post-traumatic stress, and psychological injury involved produces an abnormal mental state that can better be treated if it is understood from the point of view of the patient.
Atrial Fibrillation↗
Poststructural psychoanalysis or wild analysis?
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Borderline Personality Disorder↗
The psychoanalytic treatment of ulcerative colitis revisited.
A review of the literature indicates that very little is known about the role of psychological factors in the etiology, exacerbation, and treatment of ulcerative colitis. Most phenomenological consensus seems to take place around recognizing that the patient has great difficulty in expressing aggression and is frightened of loss of control. Episodes of ulcerative colitis are often related to the sudden loss of an important love-object and/or severe narcissistic wounding. Chronic narcissistic rage is not at the center of the psychological phenomena as I (Chessick, 1985) have described it in narcissistic psychosomatic disorders. In ulcerative colitis, acute episodes of object loss, narcissistic wounding, or bitter disappointment, along with a sense of entrapment and helplessness, produce the threat of an explosion of uncontrollable rage. Such an explosion would result in disruption of the patient's life and expulsion from significant and needed relationships. This produces an acute internal conflict, hopelessness, and despair, with the danger of resolution by paranoid projection. Why in these patients these events seem to be followed by changes in the colonic mucosa is simply unknown, nor is it clear whether they are related to these changes directly or indirectly. The defensive inability to feel the archaic rage at early significant caretakers or their later life substitutes is clearly an important determinant of the psychosomatic condition. I believe that the treatment problems raised by the patient presented here are fairly typical of what will be encountered in any effort to psychoanalyze a patient with ulcerative colitis. Perhaps because of the failure of Alexander's specificity hypothesis, there has been a loss of interest in the psychoanalytic treatment of such patients, and this is regrettable because at least some of them, like the present case, respond well and it makes a vital difference in their future. One certainly cannot say that psychoanalytic treatment represents any sort of "cure" for ulcerative colitis, but it seems clear that resolving underlying psychopathology to whatever extent is possible lessens the chance for ulcerative colitis to be exacerbated by stressful events, such as severe narcissistic wounding or substantial unexpected object loss, because the ego has been strengthened and the patient has an improved tension-reduction capacity. Psychoanalysts should not be afraid to consider the treatment of such patients as long as they are not in the acute phase of the disease. Acute manifestations require active medical, pharmacological, and supportive psychological intervention.
Adult↗
Nothingness, meaninglessnes, chaos, and the "black hole" revisited.
In the present article some clinical material involving complaints of nothingness, meaninglessness, chaos, and the "black hole" is presented and discussed. The purpose of the discussion is to illustrate that it is not possible to interpret this material solely as representing the reemergence of psychosis or early infantile catastrophic states. It is necessary to analyze this material, along with all other material, on at least five channels of therapeutic listening that I have described in previous work on the subject. These channels are the traditional Freudian, the Kleinian, self psychology, the phenomenological, and the interactional channels of listening. They are based on utterly incompatible premises. In this article I reviewed them briefly and then tried to illustrate how they may be applied to the same clinical material. One hopes that it has been demonstrated that the emergence of this characteristic nothingness, meaninglessness, chaos, void, and black hole material should not be automatically attributed to any one underlying intrapsychic situation, but can have many meanings in one patient as well as a variety of different meanings in different patients. Because this material is so dramatic when it emerges and is relatively common in the patients we see in our clinical work today, it is very important not to be misled by preconceived notions of what it means; one might even argue that the insistence on certain preconceived interpretations of given material represents an unfortunate form of countertransference.
Adult↗
On corruption.
This paper begins with the premise that in most individuals and in most cultures there is an inevitable force that presses toward the production of corruption as time passes, a force that requires vigilant resistance. Corruption is here defined as a falling away from the ego ideal of the individual or the ideals of the culture, which results in certain unfortunate and maladaptive changes in attitude and behavior of both the group and the individual. Support is given to the premise by a brief review of the work of Robert Hutchins and of Oswald Spengler, both of whom were eloquent and learned advocates of the premise, although, perhaps for personal reasons, they were too pessimistic. There follows a discussion of the metapsychology of corruption both in individuals and in cultures, both from an ego psychology point of view and from a self psychology point of view. Freud's paper on narcissism and Kohut's "psychology of the self in the narrow sense" are taken as starting points. Using the terms of the former, a divestment of the ego ideal of narcissistic libido is described, along the lines of, and somewhat parallel to, Freud's concept of secondary narcissism. Using Kohut's early concept of a separate line of development for narcissism, it is suggested that a similar separate line of development can exist for "corruption" in both individuals and cultures. At the root of this development are the repeated narcissistic wounds inevitable in the course of individual life and in the life of a culture as it tries to live up to its ideals. Resistance to the demoralizing effects of the vicissitudes of life is an important function of the ego, and depends on the strength of the ego, of the cohesiveness of the sense of self, and of a conscious awareness of the dangerous pressures toward corruption that pervade our civilization and resolve not to be swept up by these pressures. This leads to the main point of the paper, focus on the status of the ego ideal of the psychoanalyst or, conversely, his or her level of "corruption," whether conscious or unconscious. It is maintained that this level and the particular value system of the analyst, as well as the level of energy invested in living up to his or her value system, is communicated subtly to both one's students and patients, and has a vital role in the treatment process.(ABSTRACT TRUNCATED AT 250 WORDS)
Cultural Characteristics↗
What brings about change in psychoanalytic treatment?
The development of two general points of view regarding what brings about change in psychoanalytic treatment is traced in this article. One set of conceptions emphasizes interpretation, especially of the transference, and historical or narrative reconstruction. The other set emphasizes the experiential and transactional aspects of a new and better human relationship. Various current versions of this difference in emphasis are discussed. Future investigation is needed to distinguish the role of correction of expectations generated out of actual infantile experiences through the new relationship to the analyst, from the role of interpretation of early fantasy activity and reconstruction of how this was generated and congealed in the patient's childhood. The danger of avoiding the analysis of core infantile fantasy activity and its effect on the patient's current perception, thinking, and behavior, by a premature termination of the treatment when the relationships of the patient seem to be more successful, mature, and realistic, is stressed. One must be careful not to utilize self psychology or object relations theory beyond foundational repair in psychoanalytic therapy without considering the consequences. One must ask oneself always if one is utilizing such theories and practices and the interpretations based on them defensively, in a collusion to avoid facing the patient's core unique childhood oedipal and preoedipal fantasy activity and the reverberations of it in the analyst's core fantasy activity. Continuing self-analysis is required in each and every treatment process, which is why the analyst also learns and matures from every case. The openness of the analyst permits insight through interpretation, meliorative noninterpretive aspects of the new object relationship or experience, regression due to the analyst's reliability which gives the opportunity to undo developmental arrests through the analysis of core fantasies, a symbolic holding environment, and the collaborative creation of a narrative, all of which are known to have therapeutic effects and work together to produce change in psychoanalytic treatment.
Fantasy↗
Studies in feminine psychology 6: Kundry.
The problem of feminine rage, feminine psychology, and feminine self-destruction must be understood as multiply determined and not merely an appropriate manifestation of social inequality in a male-dominated culture. This is illustrated by a study of pathological and borderline women, in the present paper represented by Wagner's creation from Parsifal, Kundry. Kundry suffers from pathological splitting, in which she oscillates from mature nurturing service to hatred, seduction, and destruction of men. What is most emphasized is her misery and guilt, which is a consequence of her reality testing being sufficiently intact for her to be aware of this splitting and its consequences for her. She receives no understanding from the men around her; even the hero or "pure fool" Parsifal at first attempts to strangle her like an animal. But Wagner's intuition emphasizes her conflict and guilt rather than the splitting and deficits, making her redemption possible. This approach to borderline psychopathology has a more hopeful prognosis, given the presence of a dedicated, determined, and competent psychoanalytic psychotherapist.
Borderline Personality Disorder↗
The outpatient psychotherapy of the borderline patient.
This paper discussed common problems in the outpatient psychotherapy of borderline patients, especially their rage, seductiveness, and abrupt negative shifts. The definition of "borderline" is not settled. Even DSM-III-R mixes it up with other personality disorders. There are no pathognomonic symptoms, no specific personality constellations, and no compelling evidence for a definitive stage in infant development when this disorder is fixed; all stages are involved, from faulty foundational to oedipal periods. It is a descriptive diagnosis and typical presentations of such patients are reviewed. In the psychotherapeutic approach, limits must be set first, but these must be flexible and reasonable. Medications are used rarely and with care. We attempt to form an alliance by (a) getting the patient to join us in a study of himself or herself, especially a study of when rage and maladaptive behavior emerges, and (b) providing a consistent and reasonable ambience. The ultimate aim is uncovering and interpreting when the patient is ready for it, more and more approximating psychoanalytic treatment as the patient's pathology permits. The special phenomena of the self-object (Kohut), transitional object (Modell), and disruptive extreme erotic or raging (Kernberg) transferences were reviewed, as well as the pitfalls of therapist anxiety and impatience in dealing with them. While archaic transferences predominate, we serve as an auxiliary microscopic ego and appeal to the rational adult part of the patient's ego in a phenomenological investigation. We interpret early only if we cannot get the patient to examine what has led to the explosions and when distortions or projection without insight continues to predominate. The dangers of early transference interpretations are discussed. Therapy is long, tedious, and requires the willingness to patiently catalyze the patient's resumed development and endure the periodic disruptions. Countertransference problems and what to do about them are reviewed.
Ambulatory Care↗
What constitutes our understanding of a patient?
A number of approaches to the search for methodology in the human sciences are reviewed. Heidegger's use of Husserl's phenomenology led to his exploration of the background practices on which he believed all our understanding is based. This use of phenomenology was adopted by Sartre and R. D. Laing, and existential psychiatrists and psychoanalysts in their emphasis on the here-and-now encounter between the patient and the therapist, along with various embellishments and emendations on Heidegger's notion of what it meant to live authentically or inauthentically. Foucault maintained that there is a politics embedded in all the human sciences such as psychiatry and psychoanalysis, and this politics revolves around the use of power and its operations, including the actual use of the human sciences in the culture and what the different theories imply in the way of an ideology. Lacan emphasized this when he challenged the prevailing ideology of United States psychoanalysis, in which adaptation was seen as the crucial task of the ego. The existence of background practices and outer horizons required for any understanding in the human sciences leads to a situation that questions the use of empirical methods to establish what is accepted as "truth" in the human sciences. A predominant alternative, that of hermeneutics, has gained acceptance by eminent analysts such as Gill and certain interpersonal theorists. But the term hermeneutics is used in many ways by many authors and runs the danger of a relativism and a nihilism. This leads to a discussion of the value of various philosophical positions in throwing light on our search for a methodology in the human sciences. A review of arguments invoking the "end of philosophy" such as those of Rorty reveals that they are paradoxical and based on premises which in turn represent a philosophy. This debate remains unresolved. In general the postmodern view sees "truth" as more relative and emphasizes the role of social and cultural aspects of prevailing ideologies in constituting and determining what we call truth and understanding, including the "understanding" of a patient in psychotherapy. An example of the postmodern blend of philosophy and psychoanalysis is presented by Arlow's emphasis on unconscious fantasies and his insightful comments on how these unconscious fantasies organize and determine what we experience from the very beginning of life. This I believe is most consistent with Rescher's philosophical notion of "conceptual idealism," also briefly reviewed in this paper.(ABSTRACT TRUNCATED AT 400 WORDS)
Empathy↗
What grounds the transference-countertransference interaction?
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Adult↗
The death instinct revisited.
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Aggression↗
On falling in love and creativity.
This paper discusses the ego functioning and self psychological aspects of falling in love and passionate love. These universal and extraordinary phenomena are conceptualized as representing the activity of the creative imagination in solving problems related to coping with intense narcissistic and libidinal pressures. The work of other authors is reviewed and recast into a metapsychological framework involving ego and superego contributions to the experience, and focused on self cohesion. An illustrative clinical psychotherapy case is presented in an effort to understand what has traditionally appeared to be a mysterious and disjunctive life experience, and to explore the creative surge that can be generated by falling in love both in and out of the transference.
Adult↗