Talking with Patients: A Self Psychological View of Creative Intuition and Analytic Discipline, Revised Edition (Book Review)

Author:  Shapiro, Sanford
Publisher: Jason Aronson, 2008
Reviewed By: Marilyn S. Jacobs, Vol. XXIX, No. 1, Winter 2009, pp. 33=34

, By . Lanham, MD:
The revised edition of Talking with Patients: A Self Psychological View of Creative Intuition and Analytic Discipline is a gem of a book. The work is an updated compendium of the author’s reflections, insights and instincts about psychoanalytic work. It is also an autobiographical narrative of how one highly gifted and deeply intuitive psychoanalyst evolved in his approach to psychoanalytic practice.

The original edition of this book, first published in 1996, considered the theoretical turn in psychoanalysis to self psychology from classical psychoanalysis. This revised volume includes more recent theoretical developments. Dr. Shapiro’s years of practice of psychoanalysis have taken place concomitant with the seismic shift of the profession from classical ego psychology to the theories of self psychology and then to intersubjectivity theory, relational psychoanalysis, control mastery theory and the cognitive neuroscience related integration of neurobiology and psychoanalysis. The author has culled the most essential aspects of these orientations and summarized them succinctly. He then illustrates these with clinical material. An added dimension to the narrative is the link to the wider realm of intellectual ideas by the inclusion of aphorisms and quotations in the chapter headings.

Dr. Shapiro believes that the practice of psychoanalysis is challenged by the need to maintain “a balance between analytic discipline and creative intuition” (p. 1). This “creative intuition” influences his view of psychoanalytic practice and is a major theme of the book. His analytic work using creative intuition is, well, quite creative! Dr. Shapiro, a psychiatrist psychoanalyst, reveals his creative intuition with elegance and parsimony. In doing so, he deepens the understanding of what it means to be a psychoanalyst.

The author details the path taken by use of classical theory and then charts how the turn to self psychology and beyond changed these aspects of psychoanalysis for him. This thread runs through his discussion and is an important and valuable quality of this book. The distinctions between classical and contemporary psychoanalysis are often misunderstood; and as a consequence contemporary theories can be overlooked by those who wish to pursue psychoanalytic training.

The pervasive influence and reductionism of Freudian metapsychology in the culture as well as in mental health domains has often obscured the recent exciting theoretical and practical advances. In particular, the idea of working with patients in analysis in a two–person system is a departure from what is commonly believed about psychoanalysis. The one–person system more closely reflects traditional hierarchical social structures. Thus, the juxtaposition of classical and contemporary views as taken from the author’s own experiences is very valuable. Moreover, the author’s voice, resonant with compassion, empathy and intuition, mirror what transpires in psychoanalytic therapy.

The essential elements of the “analytic attitude” (Schafer, 1983), that lens from which a psychoanalytic therapist approaches professional practice, are considered. These include issues in evaluation and diagnosis and with the question of “analyzability” (see Freud, 1964/1937 and Stone, 1954); the varying levels of therapeutic intensity (psychoanalysis versus psychoanalytic psychotherapy), as well as transference, countertransference, resistance dreams and termination.

Dr. Shapiro describes a model for supervisory consultation derived from contemporary practice. In one example, he agrees to participate in the treatment of the patient of a therapist whom he is supervising to provide additional containment of the patient’s seemingly intractable mental turmoil. He also provides a self psychological approach to couples therapy. The pitfalls of psychoanalytic practice such as isolation and the risk of litigation also are considered.

Dr. Shapiro has made this work compelling by liberally integrating the discussion with patient encounters which demonstrate the difficult aspects of clinical work. For example, in discussing an impasse during his work with “Jill,” the following account is provided:

When I did not know what to say, I remained silent, and she felt I was not there. It did not occur to me to tell her I didn’t know what to say so she would at least feel I was present. At one point, her feeling of disconnection led to a breakdown.

It happened during an hour where she was unable to talk, and I felt anguish and confusion as I watched her struggle and I felt helpless as she became more agitated. I thought that something would eventually occur to me, but she couldn’t stand it any longer, and without a word, she got up and started to walk out.

I have had patients walk out, come back the next day, and talk about it; but this scared me. If Jill walked out I expected I would never see her again. As she opened the door, I said, “Wait, please.” None of my rules was working, and I was operating on pure intuition. Jill returned and sat at the foot of the couch with her back to me. I felt I had only a moment to act before she would leave again.

I was in turmoil, I wanted to be helpful, yet I feared I would make a technical error and ruin everything. My reasoning processes failed me, but my intuition came to the rescue. I suddenly had a strong image of myself sitting next to her on the couch. Without thinking, I got up and went to her, sat next to her, and put my arm around her.

I had never before touched a patient during a session. For one thing it was against the “rules,” and for another it was foreign to my reserved nature, but I held Jill and she relaxed. Neither of us talked, but I felt out connection was reestablished. Five minutes later the hour ended, and I said, “We’ll continue next time.” She nodded and left, and the next day she resumed the analysis as if nothing had happened.

Over the next six months we talked much about the experience. We both felt that my reaching out to her and holding her helped us get through a difficult period when neither of us had the words to connect with each other. That situation never recurred. (p. 77)

This poignant clinical moment reminds of us the poetry of clinical intuition in psychoanalytic work and the benefits of applying a two–person phenomenology. It also demonstrates how a psychoanalyst will struggle to understand herself as well as the psychological processes within the patient. This dimension derives from philosophical subjectivity and not scientific objectivist reductionism.

In the decades since Freud created psychoanalysis, the psychoanalytic literature has expanded logarithmically. Paradoxically, the many diverging voices of this expansion have oftentimes obscured explanation of what psychoanalysis actually is about. The revised edition of Talking With Patients is an addition to the literature that explains psychoanalysis clearly and concisely (examples of this trend are: McWilliams, 1994, 1999, and 2000; Mitchell & Black, 1996). We are indebted to Dr. Shapiro for taking the time to revise the previous edition. This book will be of interest to both those entering the field as well as seasoned practitioners who seek a jargon free and user-friendly understanding of the practice of contemporary psychoanalysis.

Marilyn S. Jacobs
Los Angeles, CA
mjacobsphd@gmail.com

References

Freud, S. (1964). Analysis terminable and interminable. In J. Strachey (Ed. & Trans.), The standard edition of the complete psychological works of Sigmund Freud (Vol. 23, pp. 216-253). London: The Hogarth Press. (Original work published in 1937)
McWilliams, N. (2004). Psychoanalytic psychotherapy: A practitioner’s guide. New York: Guilford Press
McWilliams, N. (1999). Psychoanalytic case formulations. New York: Guilford Press
McWilliams, N. (1994). Psychoanalytic diagnosis: Understanding personality structure in the clinical process. New York: Guilford Press
Mitchell, S. and Black, M. (1996). Beyond Freud. New York: Basic Books
Schafer, R. (1983). The analytic attitude. New York: Basic Books
Stone, Leo. (1954). The widening scope of indications for psychoanalysis. Journal of the American Psychoanalytic Association, 2, 567-594.

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