Clinical Values: Emotions That Guide Psychoanalytic Treatment (Book Review)

Author:  Buechler,.Sandra
Publisher:  Hillsdale, NJ: Analytic Press, 2004
Reviewed By:  Gregg Johns, Winter 2005, pp. 63-65

This text is the first volume in a series entitled, Psychoanalysis in a New Key. Dr. Buechler’s contribution provides a stimulating discussion of her perspectives on the role of emotions and life experience in psychotherapy. The writing style clearly conveys the voice of a seasoned, pragmatic, and flexible therapist.

Theoretically, Dr. Buechler draws guidance from the writings of Fromm, Sullivan, and contemporary thinkers espousing an interpersonal analytic approach. She further supports her position by providing quotes and excerpts from a rich source of literary and poetic inspirations. She lovingly refers to these influences as her “inner chorus” which resonates with guidance and validation of the experiences she encounters within the therapeutic process. Her therapeutic discussions examine the benefits and contributions associated with an interactive stance on the part of the analyst. This style is in contrast to the traditional analytic role of remaining strictly objective and anonymous to the analysand.

The text is comprised of an introduction and nine chapters, which highlight specific emotional and personal values that enhance the therapeutic relationship for both analyst and analysand. These include: evoking curiosity, inspiring hope and kindness, promoting courage and a sense of purpose, maintaining emotional balance, bearing loss, developing integrity, and emotional uses of therapy. These topics are further explored in the context of challenges and triumphs encountered by the analyst across the career span. An additional emphasis is placed on professional vitality and the prevention of burnout. Dr. Buechler provides both survival tips for the neophyte therapist and professional validation for the experienced therapist.

The first chapter emphasizes how curiosity about the unfamiliar can be a motivating factor in therapeutic progress. Buechler identifies six aspects of curiosity as a clinical resource: 1) Selective focus by both participants to prevent material from becoming overwhelming; 2) Establishing a context where interchanges can occur; 3) Promoting the integration of self-states in each treatment participant; 4) Noticing what has not previously registered; 5) Expanding the material; and 6) Reflecting on the countertransference. The author illustrates how instilling open-minded curiosity in the analysand is important in breaking down closed-minded paranoid defenses. This is further accomplished by the analyst’s comfort and acknowledgement of his or her limitations within the therapeutic relationship. Buechler states:

“We must manifest our commitment to life by responding sometimes when it would be safer to be silent. To be of help to the paranoid aspect of the patient, I must be comfortable with the subjectivity, limitedness, and lack of clarity of my impact (p. 29).”

The salient point here is that silence and avoidance of affect-laden material may propagate paranoid defenses when the analyst is uncomfortable with his or her limitations and refrains from appropriate self-disclosures. The working through process may be anxiety-provoking for analyst and analysand. However, progress is achieved when uncomfortable affects are identified and managed. This prevents a sterile or “play it safe” therapeutic process which maintains the status quo.

In the following two chapters, the role of kindness and hope for the patient in psychotherapy is explored. Buechler writes, “I would suggest that, regardless of the setting, if the patient can believe in the clinician’s good intentions, the patient can retain hopefulness” (p. 32). Buechler indicates that hope is needed for the analysand to consider change. Kindness and hopefulness on the part of the analyst communicates to the patient that he or she is a worthwhile individual, that they deserve a better quality of life, and that therapy can help in achieving these goals. Buechler provides personal and case examples illustrating how therapeutic acts of kindness can have their greatest impact years after they occur and that these acts demonstrate that the patient was worth the analyst extending him or herself. Further, she states that acts of kindness may have as much impact on the analysand as other analytic strategies.

Buechler identifies four important elements for inspiring hope; 1) the willing suspension of disbelief, 2) an acceptance of mystery, 3) an acceptance of contradiction and paradox; and 4) awareness that hope and faith are impossible to separate. These elements are also key concepts in eroding paranoid defenses, promoting patience, and the active exploration of new and different explanations for conflict along with courses of action. However, Buechler warns of possible dangers when the analysand hopes for idealistic or unrealistic outcomes. This is especially important for the narcissistic or borderline patient who experiences difficulty with the acceptance of limitations and unpleasant affects. Buechler further examines how reality is co-constructed by analyst and analysand in the course of therapy and how uncertainties and paradox must be embraced realistically.

From a cultural perspective, Buechler indicates that emotional triggers may vary from culture to culture. However, surprise and uncertainty can be emotional motivators for change and self-extension. This highlights a shift for the analyst from processing the countertransference to self-disclosure and weathering the surprises and uncertainties arising during the course of treatment.

These discussions conclude with an emphasis on hope for the therapist to avoid burnout and discontent. Buechler lists three considerations for instilling hope in the analyst: 1) Hope has an interpersonal aspect, in that it can partially be a gift one person gives another, who may exist in reality, fantasy, or memory; 2) Hope is stronger when it is realistic, not based on an illusory sense of control over life; 3) Hope requires self-knowledge about the strength of our own determination to accomplish something. If we will do anything a treatment requires, we have a greater basis for hope. She references Mitchell (1993) regarding the necessity of love for the therapeutic work and the passion for promoting life and growth.

Buechler cites inspiration for courage from the writings of Aristotle. His view of courage involved a balance between rashness and timidity and stems more from personal character. For the therapist, Buechler suggests the following paraphrase of Aristotle:

“1)… practice allows us to become braver by enduring fear-provoking situations and 2) If we are aware of our natural inclinations, we can compensate for them. The courage on the part of the therapist involves modeling for the patient what it is to be human and imperfect while also taking responsibility for the consequences of choices. This may include apologizing for mistakes (p. 67).”

She elaborates with anecdotes involving instances of impatience and sarcasm on the part of Fromm and Sullivan with the intentions of prompting the patient to move forward in treatment. With case examples, Buechler identifies instances in which these approaches may hinder progress. On the other hand, timidity on the part of the therapist can result in a stagnant therapeutic relationship.

For this reviewer, these discussions are reminiscent of my experiences with inpatient adolescent group therapy. A female adolescent, with borderline traits, consistently attempted to split and sabotage the group process. During a rather heated session (several weeks following her admission), she became highly agitated and personally attacked a peer who provided her insightful and appropriate feedback. She used projection and displaced anger to avoid confronting her core issues. Caught within the countertransference and unrest of the group, I responded in a terse and sarcastic manner that she was hurting others because she was in pain. She countered by berating me for being sarcastic. I immediately apologized to her and the group for my sarcasm and acknowledged my frustration with the patient’s unwillingness to accept the help of others and the use of anger to avoid treatment. This was a pivotal event for the patient and the group in that, to my amazement, the group members began accepting responsibilities for their emotionally-charged shortcomings and mirroring my words. I later learned that the patient in question’s father never apologized to his daughter for his frequent, angry, and hurtful criticisms. This group experience allowed the patient and I to overcome her impasse to treatment progress in individual therapy and to acknowledge unpleasant affects while managing them adaptively. Therefore, for me, Dr. Buechler’s treatment of these topics resonated my inner chorus.

The text also explores the topic of termination and how our profession is unique in that we must sever ties with patients. This can be difficult for both parties after extensive emotional work is undertaken. Buechler provides helpful discussions relating the termination process to parental encouragement for children to branch out and take independent steps. These discussions are especially beneficial for students and inexperienced therapists.

Establishing a sense of purpose for therapist and patient is another key topic for the text. Buechler distinguishes between therapy with goodness-of-fit to analytic theory (although lacking congruence with the patient’s sense of purpose) versus therapeutic progress not conforming well to theory, yet, meaningful for patient and therapist. Buechler provides rich illustrations of the motivating contributions a sense of purpose provides to therapeutic progress. These discussions also parallel the research findings of Cramer (2000) that analysts often perceive a lack of treatment progress (when failing to neatly conform to theoretical models) while their patients endorse highly positive experiences in treatment. Buechler also warns the therapist to avoid being too much of a new affirmative object at the expense of allowing the patient to exhibit and work through self-destructive urges. Allowing the patient to achieve emotional balance is necessary for meaningful progress. Buechler states, “In how we treat ourselves as ‘objects,’ we live our values in front of the patient. Therapy is shame inducing as it prompts patients to let down their pride and face unpleasant parts of themselves” (p. 92).

The previously addressed chapters and topics in this review only scratch the surface of the wealth of information, clinical thought and literary metaphors available in this text. For the student, this book should be required reading as it provides a fresh and contemporary discussion of clinical considerations from the interpersonal viewpoint. For analysts who are proponents of other schools of analytic thought, the suggestions of increased emotional contributions of the analyst in therapy may not be openly embraced. However, from this reviewer’s perspective, Buechler’s text offers a wonderful array of clinical considerations especially with chronic and inpatient individuals. As in any psychotherapy relationship, individual case considerations, clinical judgment, timing, and professional boundary requirements may vary. Furthermore, the comfort level, experience, and skill of the therapist are germane.

In closing, I found this text to be well written, thought provoking, practical, and genuine as it bridges the gap between academic theory and real-world clinical practice. However, the only observation from this reviewer is that he found himself desiring more case and literary examples at times in which narrative treatment of certain topics became redundant or over-elaborated. Overall, this text is a gem and an excellent resource.

References

Cramer, B. (2000). Can therapists learn from psychotherapy research? In K. von Klitzing, P. Tyson, & D. Bürgin (Eds.), Psychoanalysis in Childhood and Adolescence (pp 12-22). Basel, Switzerland: S. Karger AG.
Mitchell, S. A. (1993). Hope and dread in psychoanalysis. New York: Basic Books

Reviewer Note

Gregg A. Johns is Internship Training Director of the Mississippi State Hospital's APA-Accredited Pre-Doctoral Internship Program in Clinical Psychology. He is an experienced child and adolescent therapist.

Copyright

© APA Div. 39 (Psychoanalysis). All rights reserved. Readers therefore must apply the same principles of fair use to the works in this electronic archive that they would to a published, printed archive. These works may be read online, downloaded for personal or educational use, or the URL of a document (from this server) included in another electronic document. No other distribution or mirroring of the texts is allowed. The texts themselves may not be published commercially (in print or electronic form), edited, or otherwise altered without the permission of the Division of Psychoanalysis. All other interest and rights in the works, including but not limited to the right to grant or deny permission for further reproduction of the works, the right to use material from the works in subsequent works, and the right to redistribute the works by electronic means, are retained by the Division of Psychoanalysis. Direct inquiries to Henry Seiden, Publications Committee chair.