Coasting in the Countertransference: Conflicts of Self Interest Between Analyst and Patient (Book Review)

Author:  Hirsch, Irwin
Publisher:  Analytic Press
Reviewed By:  Maroda, Karen, Vol. XXVIII, No. 3 (Summer 2008) pp. 60-62/65

Irwin Hirsch has written a highly readable and courageous exploration of the conflicts of self-interest between analyst and patient. He is unrelenting in his honesty, exploring everything from seeing too many patients back to back, to avoiding their criticism and rejection. He says our decisions about how we practice are based more on financial concerns than any other single variable. Ouch.
If this volume were written by someone else, it could be unbearable to read. But there is something in Dr. Hirsch’s tone (and those of you who know him personally will recognize this immediately) that is so non-accusatory, so non-judgmental, that it allows the analyst reader to actually find relief in this confessional and cautionary tale. Hirsch is not railing about how others practice. He is talking about himself. But he writes from the perspective that most of his colleagues practice the same way. We are all in this together. He accepts that a certain degree of self-interest is simply the human condition. Yet he feels guilt.

Philosophical in its tone, Coasting in the Countertransference allows the reader to come to his or her own conclusions about what is inevitable and what is not. Reading this book may change the way some people practice. For others it will help relieve them of their own pain in the face of having kept too many patients beyond the time they needed to stay; or taken too many referrals of close associates that should have been handed off to others. A longtime interpersonalist, Hirsch also critiques the tendency for therapists to view patients as fragile, resulting in overly solicitous analyst behavior. He sees the two-person approach as often lacking in sufficient respect for the patient’s strengths and, ironically, the analyst’s weaknesses.

Coasting in the Countertransference is a theoretically and clinically provocative book that challenges us to face ourselves. When I finished this book, my mind was racing with questions I wanted to pose to its author. He agreed to an interview and what follows is a slightly edited version of the phone conversation I had with him.

Interview

Maroda: Coasting in the Countertransference is compassionate in its tone, while exposing a wide array of analyst behaviors and attitudes that frankly do not make us look very good. In fact, I think it would be easy for someone outside the field to go away from this book thinking that we are a pretty self-absorbed, greedy bunch.

Hirsch: One of the responses I received when I presented some of this material to an analytic group was this was bad for our profession. It never even occurred to me until this point. I never thought anyone outside this profession would read it. It’s my first book, so I wasn’t thinking about any outside audience. But I get it now. However, my feeling is that self-interest operates everywhere—in every profession. Psychoanalysts are no guiltier of it than other professionals. I try to make this clear in the book. My intention and feeling is that I portray the profession in a human way, “warts and all.” I believe that seeking comfortable equilibrium is normal and natural, and not something unique to our patients or those deemed pathological. I try to follow in the tradition initiated by Harry Stack Sullivan and his credo: we are all more simply human than otherwise. Like him and Harold Searles and Heinrich Racker, I try to narrow the distinction between the alleged healthy analyst and the alleged ill patient.

Maroda: Do you consider any of these coasting issues to be serious ethical concerns? And should we be altering our ethical standards to address them?

Hirsch: The biggest concern I had about publishing this book was concern that I would appear to be unethical. One case example I gave was of my most egregious performance in a long-term therapy. I was afraid this patient might sue me. I don’t always know where the line can be drawn between self-interest and unethical behaviors, other than what has already been written into the ethics code, such as sexual relations and violence. Since I believe that the various forms of self-interest I write about are part of our every day, or even every session engagement, reference to issues of ethics seems more background than foreground for my purposes. I’ll let the readers judge.

Maroda: Regarding clinical practices you said, “I am suggesting, however, that analysts’ avoidance of patients’ anger is a very serious and a ubiquitous current problem in our field.” You go on to say that we avoid conflict and over-emphasize notions of holding and containment long after the period of safety has been established.

Hirsch: I think that analysts sometimes embrace certain theoretical perspectives that lend themselves to warm, comforting relationships. All too often anger is avoided and theory is invoked to rationalize analysts’ personal discomfort with anger. This indeed, is self-interest personified, but easy for analysts to disguise by hiding behind theoretical premises.

Maroda: So what do you see as the remedy for this reluctance to confront anger in the transference?

Hirsch: I start and end with recognition and confrontation with oneself. The only solution to anything I write about is the personal discomfort that might arise as a result of the self-awareness that some of these practices are not in the long-term best interest of the treatment, and therefore the analyst. Change can only occur when we candidly face ourselves, though this does not mean that we will always elect to choose discomfort in preference to equilibrium.

Maroda: I was fascinated by your comment that part of why therapists avoid confrontation and the negative transference may be due to our attempt at recognizing the real relationship. Now that we can’t say that patients are really angry at their mothers, not us, we take the negative transference more personally. I think you are right. It seems like one of those important concepts that slipped through the cracks when we converted to two-person theory.

Hirsch: In the old days it was sex and aggression, and the downside of this was that it became formulaic—we saw it everywhere because we were told that all human experience could be reduced to those instinctual derivatives. However, as a result, nobody ignored sex and aggression in analysis. Since the recognition that the person of the analyst is part of the transference, a lot of the uncomfortable things that people say about us have to be taken at least somewhat personally. That is, since the concept of transference has been interpersonalized (see Merton Gill), patients’ perceptions of us are believed to have something to do with us, and are not solely projections of internalized past experience. I think that because of this analysts are now more inclined to attempt be “good objects” only, for example, holders, empathizers, etc.

Maroda: In supervising therapists I encounter enormous resistance to the idea that patients are not that fragile. And I find, as you state, that when patients are regressing, many therapists panic and become anxiously overly solicitous, and the patient worsens. Do you think this is addressed adequately in training?

Hirsch: I feel very fortunate having worked in a day hospital early in my training. I saw potentially decompensating patients all day long, and they went home at four o’clock. Some of them recently had psychotic breaks or made suicide attempts, yet they all went home at the end of the day and usually managed to return the next day. I developed an enormous tolerance for pathology as well as enormous faith in the resilience of people. Also, the element of agency and choice was part of my existentially oriented interpersonal analytic training. I don’t see disturbed patients as simply being victims of the past. I see them as agents in repeating often-miserable early experience. I can’t really comment on how others were trained, but I know this early exposure was invaluable for me. And yes, when analysts have not had this sort of exposure in their training they may communicate to more disturbed patients the sense that they are ill and weak and about to break. This may help an analyst to feel strong, but it is often disastrous for patients to be seen in this way.

Maroda: I was surprised by the entire chapter on baldness—noting that hair loss is both a narcissistic injury and reminder of mortality. You say analysts do not address this issue adequately. If the patient is not talking about it, what signals you that it needs to be brought up by the analyst?

Hirsch: Part of my evidence is when my research assistant did a literature search; there were virtually no articles that had ‘baldness’ or “hair loss” in the title or in major terms. So my strongest evidence for this being an insufficiently addressed issue was that the literature has not attended to the effect that hair loss has on many people. If this is not an issue that creates considerable anxiety, why is there virtually no psychoanalytic writing on the subject? The presence of some secretiveness with a patient, like wearing hats or doing “comb-overs” should be a sign that the patient perceives baldness as a very threatening issue to confront. However, I would suggest that any patient who is bald and/or balding and says nothing about this over time is likely to be avoiding something significant.

Maroda: You refer to “noisy” analysts who interpret the two-person approach as a license to talk too much in the sessions, interfering with the patient’s process.

Hirsch: I was trying to make the point that I have a preferred theory that I like more than I do other theories, but I also realize that my theory doesn’t necessarily lead to better results than these other theories. The theoretical perspective I am most comfortable with is where the analyst is free to make whatever observations he wants, but this can also be a license to overpower the patient with our point of view and/or our personal presence. My main point in this chapter is to convey that every theory has upsides and downsides, potential strengths and potential weaknesses. Each analyst works within a theory where he feels most at home, and of course this reflects analysts’ self-interest.

Maroda: Sussman (1992) has quoted Olinick and others who say that an important motivation for the analyst to enter into the regressive relationship is the presence of an early unconscious rescue fantasy involving a depressed mother. Might some of our maladaptive strategies with patients be based on this need to stay with and comfort the depressed mother rather than being motivated by money?

Hirsch: Certainly there are many motivations other than money. For example, Searles wrote about analysts needing to see the patient as more pathological than we are—as psychologically inferior to us. However when it comes to certain historical speculations that purport to explain everything and everyone, I think we run into trouble. There are so many different reasons why people become analysts. I don’t think that having a depressed mother can be the modal point. This is far too formulaic, diagnostic and reductionistic for my tastes.

Maroda: Was writing this book therapeutic? Have you changed the way you practice since you finished the book?

Hirsch: The patient I mentioned earlier whom I saw three times a week for eight years, and where I felt I had made some egregious errors, really stayed with me. I had young children at the time, felt a lot of pressure to earn a living, and he was not the only person I saw with whom I was far from optimally present. I kept notes on these people and thought that one day I might write about this period. It has helped me to come clean about the worst I’ve ever done. I believe that I am now much less likely to affectively disappear for the extended periods I did then.

Maroda: Donnel Stern mentions in his foreword to the book that he adopted your practice of calling patients who you felt you had shortchanged, to talk to them about it. Did you talk to this particular patient who you felt you had failed?

Hirsch:I tried to contact him a few times—he never called back. The others whom I called did, but not him. I think those who I was able to contact felt good about my efforts at post-mortem.

Maroda: Do you ever worry about what your past, current or prospective patients might react to what you said about yourself and the profession in this book?

Hirsch: Yes, it makes me nervous. Not current patients, because current patients can talk about it. What I’m most nervous about is previous patients reading this and recognizing their composites. I changed all the circumstances of their lives, of course, but I still worry they might see themselves in the emotional content. They do not have the medium to address their feelings about this on a regular basis, and I worry that it might be hurtful to them to see aspects of themselves in my clinical illustrations.

Maroda: You talk about taking referrals from current patients to build your practice. Do you still accept referrals of close associates?

Hirsch: I never did see people who are intimate—immediate family, best friends, lovers, spouses, etc. One of the many complications of seeing these people is that we might feel compelled to be nice to them because they will be talking about us with each other. Their respective treatments are more likely to be compromised because they may be less likely to express their unique individuality, especially if they fear that their analyst may like their lover, friend, etc., better than them if certain aspects of self are displayed. However, I always have accepted referrals from patients when the person referred is not an intimate acquaintance.

Maroda: You stated earlier that you don’t see us as being different than any other profession in terms of self-interest. Yet it seems we feel that we should be different.

Hirsch: We are supposed to be self-reflective and analyzed. This makes it more difficult to rationalize our flaws and recognize that our personal analysis has not left us as ideal human beings. Analysts often suffer the illusion, or delusion that they are nicer and better human beings than, for example lawyers, bankers, or business people. This to me is patently absurd. All we need to do is to look at our colleagues and ourselves honestly, and this myth should be blown away immediately.

Maroda: That brings us to an interesting point. If we are more self-aware as a group than other professionals, why don’t we pursue self-interest less?

Hirsch: Because self-awareness doesn’t necessarily lead to change. Self-awareness leads to choice. I am fully aware that many of the things I do are not ideal, but I do them anyway. All analysts regularly choose self-interest in priority to uniform concern for patients. We either cop to this or we do not, and if we do we then have the opportunity to do something different.

Maroda: Is there any question about the book you were hoping I would ask or anything else you would like to add?

Hirsch: The only thing I want to add is that this book was written in the spirit of discussing the relatively neglected area of certain personal features of the analyst. I believe that the wishes and desires of the analyst play much more of a role in our work than we have acknowledged in the literature. My thesis seems to me a logical extension of a two-person psychology conception, and an effort to highlight often-unattended selfish aspects of the analyst, whom I perceive as one of two flawed participants in any analytic dyad.

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