How Analysts Think and Why They Think the Way They Do: Reflections on Three Psychoanalytic Hours (Book Review)

Author:  Rothstein, Arden Aibel and Abrams, Samuel (Editors)
Publisher: Madison CT, International Universities Press, 2005
Reviewed By: Edwin Fancher, Fall 2005, pp. 62-63

This volume is the partial record of a meeting to celebrate the fiftieth anniversary of the NYU Psychoanalytic Institute at New York Medical Center as a functioning affiliate of the American Psychoanalytic Association. The very title of this small paperback perhaps promises more than can be expected from one all-day conference on such a broad topic.

To demonstrate how the mind of the analyst works Dr. Claudia Lament, a recent graduate of the Institute, presented a brief case summary and process notes on three consecutive analytic hours with a young male patient. Her presentation was followed by extensive commentaries by panelists Kathleen Lyon, Shelley Orgel, Nasir Ilahi and Peter B. Neubauer, all faculty and members of the NYU Institute. Later there were extemporaneous remarks by members of the audience and follow up questions and answers. Several months after the event the participants were queried about the issues that had been central to the discussions, and this record was added to the volume. Numerous introductions and commentaries by the two editors were featured throughout.

The case presented was that of Mr. A., a 30-year-old writer and businessman, who suffered from a writer’s block and a failed love life. The hours presented in detail occurred during the third year of a four time per week analysis, at a time when he was particularly depressed and resistant. In these three reported sessions the patient attacked the analyst with invective, defiance and periods of sullen silence. The analyst showed great courage in reporting her feelings of frustration and confusion, and her doubts about whether to intervene or not at certain times, and if so, in what way: “Perhaps I should have left myself out of my interpretations and simply stayed with his feelings about Rebecca or with his dreams” (p. 15).

At one time she felt that she had interpreted too much. At another point she describes her decision not to interpret because she felt that “…he was just waiting for an opportunity to lash out” (p.14). She reported countertransference reactions and how her patient’s turmoil induced her to associate to her own traumatic childhood experiences. By the end of the third reported hour the patient seemed to have re-established trust in the analyst and he was able to respond to her expression of concern for his loneliness: “Then in the recognition of these feelings, he appeared able to share with me, in a genuine way, his despair and hopelessness. It felt to me that in so doing, the walls had come down, if only a little.”

She responded to him, “It feels beyond words” (p. 21), a Kohut-like ending of the third hour

Kathleen Lyon, the first discussant, reviewed the contents of the three hours, pointing out the neglect of the sexual and masturbatory material, but she did not follow up on these issues, but instead supported the analyst’s decision to shift from defense interpretations to a more empathic stance. She saw the patient primarily in terms of separation-individuation issues: “for him any closeness is experienced as overwhelming, and any distance as destructive to both parties (p. 32).

The second discussant, Shelley Orgel introduced the issue of annihilation anxiety. He speculated that the analyst was a transitional object to the patient, or a Kohutian type “self object.” He saw fantasies of merger as central. He regarded the ending of the third hour as “a moment of breakthrough, a smashing of walls.” and speculated “…their shared language may create a bridge of love from and toward him as a separate, unique being” (p. 42).

The third panelist, Nasir Ilahi, emphasized repeatedly that he represented a very different analytic point of view because he was trained in the British object relations school of Klein, Winnicott and Bion. He noted that Sandler felt that since the 1970s “…there has been a growing process of dialogue and mutual interaction between the proponents of different theoretical points of view” (p. 45). However, his experience of “…such dialogues, especially between viewpoints that at a deeper level diverge widely from each other—has also alerted me to how incompatible understandings of clinical material, and technique and interpretations that arise from them, can sometimes be” (p.45).

Ilahi critiqued the views of each of the other panelists in detail and implied that there could be no rapprochement with their American ego psychology orientation, (a designation that was disputed by some).

He presented his own version of Mr. A: “Mr. A now feels very excluded by the analyst, presumably over his inability to have emotional access to her. He deals with this internal state of affairs by denial and splitting off of his very needy child part. He projects it onto the analyst in such a way that the analyst experiences a mixture of being shut out, tantalized and frustrated which Mr. A identifies with the rejecting parent. All this takes place unconsciously and is vividly lived out in the transference. However, it is at a level that is beyond words and beyond his individual associations.” (Italics in original). (p. 47).

He felt that one of his major differences with the other panelists is over the issue of transference: “I find that transference, as I understand it, is seldom recognized or thought about by analysts in the United States, irrespective of the school to which they belong. This arises from the differences in our training” (p.124). He tried to describe how projective identification informs on the pathology of this patient, but his point did not seem to be absorbed by the other panelists.

Peter B. Neubauer’s contribution started with a short lecture on the history of developmental psychoanalytic theory, from Freud’s Three Essays through Mahler, Winnicott and Anna Freud’s developmental lines. He then reverted to the traditional principles of ego psychology: “…the psychoanalyst relies on the synthetic function and the integrative function of the ego to achieve new psychic structures,” (p. 61). In spite of the absence of a developmental history in this case, he speculated that Mr. A. represents “…an unchanging developmental fixation and regression with wishes for early unity with primary object” (p.63). He understood this patient in preoedipal terms, as did all the other panelists.

During the question and answer period, only Harold Blum, from the audience, questioned whether oedipal issues were being neglected in this case, a point that I am in agreement with.

During the periods when the panelists responded to each other, the main issue was Ilahi’s insistence that his point of view on this case was the only correct one, and was basically different from the others because it was based on his different training in Britain. He felt that the other panelists saw the patient as “…psychologically a whole person, a unit, while I hear him mostly as deeply split” (p.116). Despite this, the other panelists kept trying to deny that their differences were significant. Typical of this trend was Orgel’s statement about Ilani: “ While he claims differences with Dr. Lament, he nevertheless expresses views not too distant from those of the other discussants” (p.99). Similar attempts to paper over the differences were made by Neubauer.

The last part of this book consists of an Appendix of written comments made six months after the conference by the five participants addressed to each other about the issues that had emerged at the conference. No one seemed to have changed his point of view.

One of the problems with this kind of presentation is that the data on which judgments may be made is usually very limited. The analyst did not describe in enough detail the themes of the first two years of treatment, nor the kinds of interpretations she had been making during that time. Also, rather than rehashing in writing the disputes between the participants six months after the conference, a follow up report on the progression of the case would have been preferred. This; would have allowed the reader to decide if the third hour did represent a “breakthrough” as some predicted, or not, and might have shown us whether Mr. A’s regressive behavior was a temporary phenomenon or was a reflection of more serious pathology, as others thought. The four American analysts did try to justify their views by reference to the clinical data. I did not think that Ilahi did that. Nor, did he tell us what kind of interpretations he might have used to reach this patient.

How does this book answer the question of how analysts think and why they think the way they do? The book supports Mr. Ilahi’s thesis that analysts think the way they do because of their unique training at their particular institutes. All the discussion about the case did not lead to an agreement between Ilahi and the four American analysts about the pathology of this patient, or of a technique for treating him. I had the impression that the Americans didn’t really follow what Ilani was saying. The dispute at the conference reminded me of the Freud-Klein Controversies of 1941-44 (1991) except that at that time the two opposing camps each knew the other’s arguments, were deeply committed to their positions and were arguing over which version of “truth” would prevail. In a way, it is refreshing that Mr. Ilahi is so certain and passionate about his approach to analysis and that he is convinced that he knows the best treatment for this patient. But it is discouraging that he seemed unable to document his clinical judgments in specific data from the case report. In our contemporary world where there are more schools of psychoanalysis than we can count, adherents of each theory, presumably, believe that their approach is the most scientific or most adequate, and certainly the most effective in helping patients. Contrary to that stance is another popular conception of psychoanalysis where diversity or pluralism are dominant and all psychoanalytic theories and techniques derived from them are regarded as equally valid (Wallerstein, 1992). Both positions reflect profound contradictions in contemporary psychoanalysis and are found in this work.

On the positive side, I can recommend this book as a fresh and open picture of how the minds of some American psychoanalysts, trained in the mainstream traditions of ego psychology, Mahler, Winnecott, and Sandler and one British Kleinian, responded to very complicated clinical material of a disturbed but challenging patient. That in itself should provide enough intellectual stimulation to cause the reader to examine how his own mind works as an analyst and ask himself why it works in that particular way.

King, P., & Steiner, R. (1991). The Freud-Klein controversies 1941-45. London: Tavistock/Routledge.
Wallerstein, R. S. (1992) The common ground of psychoanalysis. Northvale: Jason Aronson, Inc.

Edwin Fancher is a member of the faculty and training and supervising analyst at the New York Freudian Society. He is also president of the New York School for Psychoanalytic Psychotherapy and Psychoanalysis. He can be contacted directly by email.

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