Unusual Interventions

Unusual Interventions
Alterations of the Frame, Method, and Relationship in Psychotherapy and Psychoanalysis

Edited by
Salman Akhtar
First published 2011 by Karnac Books Ltd.

Published 2018 by Routledge

2 Park Square, Milton Park, Abingdon, Oxon OX14 4RN
711 Third Avenue, New York, NY 10017, USA

Routledge is an imprint of the Taylor & Francis Group, an informa business

Copyright © 2011 Taylor & Francis

Copyright © 2011 to Salman Akhtar for the edited collection, and to the individual authors for their contributions.

The rights of the contributors to be identified as the authors of this work have been asserted in accordance with §§ 77 and 78 of the Copyright Design and Patents Act 1988.

All rights reserved. No part of this book may be reprinted or reproduced or utilised in any form or by any electronic, mechanical, or other means, now known or hereafter invented, including photocopying and recording, or in any information storage or retrieval system, without
permission in writing from the publishers.

Notice:
Product or corporate names may be trademarks or registered trademarks, and are used only for identification and explanation without intent to infringe.

British Library Cataloguing in Publication Data

A C.I.P. for this book is available from the British Library

ISBN 9781855758971 (pbk)

Typeset by Vikatan Publishing Solutions (P) Ltd., Chennai, India

To Henri Parens a cherished colleague and an unusually kind man
Contents

ACKNOWLEDGMENTS

ABOUT THE EDITOR AND CONTRIBUTORS

INTRODUCTION

PART I: ALTERATIONS OF THE FRAME

CHAPTER ONE
Making extraordinary monetary arrangements
Ira Brenner
CHAPTER TWO
Conducting the treatment outside the office
Mark Moore
CHAPTER THREE
Changing the frequency, length, and timing of sessions
Frances Salo
PART II: ALTERATIONS OF THE METHOD

CHAPTER FOUR
Refusing to listen to certain kinds of material
Salman Akhtar
CHAPTER FIVE
Giving advice
Anton Kris
CHAPTER SIX
Interpreting in the form of action
Marc Jacobs
PART III: ALTERATIONS OF THE RELATIONSHIP

CHAPTER SEVEN
Talking about oneself
Alan Skolnikoff
CHAPTER EIGHT
Touching the patient
Andrea Celenza
CHAPTER NINE
Giving mementos and gifts to the patient
Andrew Smolar

REFERENCES

INDEX
Acknowledgments

I am grateful to the distinguished colleagues whose contributions appear in the pages of this book. I truly appreciate their sacrifice of time, their effort, and their graceful reception of my editorial
suggestions. Dr. Michael Vergare, Chairman of the Department of Psychiatry and Human Behavior at the Jefferson Medical College (my academic base for over thirty years) consistently supported
my work. My patients mobilized the sort of technical questions that this book attempts to answer. My good friends Zvi Lothane and Joseph Reppen of New York (the former editor of
Psychoanalytic Books) and Ivan Ward of London (Director of Education at the Freud Museum) helped in significant ways. Dr. Newell Fischer and Professor Christfried Togel, Director of des SALUS
Instituts, Magdeburg, Germany, provided information that was useful for this book. My wife and fellow analyst, Dr. Monisha Akhtar, offered me valuable counsel and safeguarded the ambience
necessary for meaningful thought to occur. My assistant, Jan Wright, prepared the manuscript of the book with her characteristic diligence and good humour. To all these individuals, my sincere
thanks indeed.

Philadelphia, PA
March 15, 2011
Salman Akhtar
About the Editor and Contributors

Salman Akhtar, M.D., is Professor of Psychiatry at Jefferson Medical College and a Training and Supervising Analyst at the Psychoanalytic Center of Philadelphia. He has served on the editorial
boards of the International Journal of Psychoanalysis and the Journal of the American Psychoanalytic Association. His more than 300 publications include 12 books—Broken Structures (1992), Quest
for Answers (1995), Inner Torment (1999), Immigration and Identity (1999), New Clinical Realms (2003), Objects of Our Desire (2005), Regarding Others (2007), Turning Points in Dynamic
Psychotherapy (2009), The Damaged Core (2009), Comprehensive Dictionary of Psychoanalysis (2009), Immigration and Acculturation (2011), and Matters of Life and Death (2011)—and 33 edited or
co-edited volumes in psychiatry and psychoanalysis. Dr. Akhtar has delivered many prestigious addresses and lectures including, most recently, the Inaugural Address at the first IPA-Asia Congress
in Beijing, China (2010). Dr. Akhtar is the recipient of the Journal of the American Psychoanalytic Association’s Best Paper of the Year Award (1995), the Margaret Mahler Literature Prize (1996), the
American Society of Psychoanalytic Physicians’ Sigmund Freud Award (2000), the American College of Psychoanalysts’ Laughlin Award (2003), the American Psychoanalytic Association’s Edith
Sabshin Award (2000), Columbia University’s Robert Liebert Award for Distinguished Contributions to Applied Psychoanalysis (2004), the American Psychiatric Association’s Kun Po Soo Award
(2004), and Irma Bland Award for being the Outstanding Teacher of Psychiatric Residents in the country (2005). Dr. Akhtar is an internationally sought speaker and teacher, and his books have been
translated in many languages, including German, Turkish, and Romanian. His interests are wide and he has served as the Film Review Editor for the International Journal of Psychoanalysis, and is
currently serving as the Book Review Editor for the International Journal of Applied Psychoanalytic Studies. He has published seven collections of poetry and serves as a Scholar-in-Residence at the
Inter-Act Theatre Company in Philadelphia.

Ira Brenner, M.D., is a Clinical Professor of Psychiatry at Jefferson Medical College. He is a Training and Supervising Analyst at the Psychoanalytic Center of Philadelphia, where he is the Director
of the Adult Psychotherapy Training Program. With over sixty publications, he has written extensively on the topic of psychic trauma, most notably in his books The Last Witness: The Child Survivor
of the Holocaust (co-authored with Judith Kestenberg, 1986), Dissociation of Trauma: Theory, Phenomenology, and Technique (2001), Psychic Trauma: Dynamics, Symptoms and Treatment (2004),
and the Gradiva Award winning Injured Men: Trauma, Healing, and the Masculine Self (2009). He has also edited special issues of the Journal of Applied Psychoanalytic Studies, on Reverberations
of the Holocaust (2002) and on anti-Semitism in Muslim countries (co-editor: Nadia Ramzy, 2007). He has received a number of awards including the Pierre Janet Writing Award from International
Society for the Study of Dissociation for his abovementioned 2001 book and the Simon Gratz Award in 2000 from Jefferson Medical College as a Distinguished Alumnus, having graduated from
there with membership in the honorary Alpha Omega Society. He is private practice in the greater Philadelphia area and continues to share his knowledge nationally and internationally.

Andrea Celenza, Ph.D., is an Assistant Clinical Professor at Harvard Medical School, Faculty at the Boston Psychoanalytic Society and Institute and Massachusetts Institute for Psychoanalysis. Dr.
Celenza has consulted with, evaluated, supervised or treated over 100 cases of therapist-patient sexual boundary transgressions. She has authored and presented numerous papers on the evaluation
and treatment of therapists who have engaged in sexual misconduct with a focus on training and supervisory issues. Her book, Sexual Boundary Violations: Therapeutic, Supervisory and Academic
Contexts, was published by Jason Aronson in 2007. Dr. Celenza has been the recipient of several awards, including the Karl A. Menninger Memorial Award, the Felix & Helen Deutsch Prize and the
Symonds Prize. She is currently working on a new book, titled Passions and Perversions in the Therapeutic Setting. She is in private practice in Lexington, Massachusetts.

Marc Jacobs, M.D., is a Clinical Professor of Psychiatry in the School of Medicine at the University of California, San Francisco, and a faculty member of the San Francisco Center for
Psychoanalysis. He has been recognized as a leader in psychiatric education and psychotherapy training and supervision at regional, national, and international levels, and has written and lectured
widely in these areas. Dr. Jacobs served as the Director of Psychiatry Residency Training at University of California San Francisco (UCSF) for over twenty-five years, and has been a member of the
Executive Council of the American Association of Directors of Psychiatric Residency Training. Internationally, he has recently lent his expertise to the establishment of new graduate medical
education programs at Duke University Medical School-Singapore branch, and to the implementation of psychotherapy training programs under the auspices of the Singapore Ministry of Health. Dr.
Jacobs has been the recipient of numerous awards recognizing his contributions to psychiatric education and psychotherapy training including: The First Annual George Sarlo Prize for Excellence in
Teaching; The Association for Academic Psychiatry Teacher of the Year Award; the First Annual American Psychiatric Association Irma Bland Award for Excellence in Teaching and the UCSF
Residents Association Award for Outstanding Teacher (thrice). Currently, he teaches medical students at UCSF, and is a psychotherapy supervisor for both UCSF residents and early career
psychiatrists. He also maintains a private practice of psychotherapy and psychoanalysis in San Francisco.

Anton Kris, M.D., is a Training and Supervising Analyst at the Boston Psychoanalytic Society and Institute and a Clinical Professor of Psychiatry at the Harvard Medical School. He has served on
the editorial boards of The Journal of the American Psychoanalytic Association, and the International Journal of Psycho-Analysis. Currently, he is serving on the editorial boards of The
Psychoanalytic Study of the Child, Psychoanalytic Quarterly, and Psychological Issues. The author of Free Association: Method and Process (1982) and of over 50 psychoanalytic and psychiatric
papers, chapters, and reviews, Dr. Kris has lectured throughout the United States and internationally, most recently as the Karl Abraham Lecturer of the Berlin Psychoanalytic Institute. He taught as
the Visiting Professor of Psychoanalysis at the Michigan Psychoanalytic Institute in 1997. He maintains a private psychoanalytic practice in Cambridge, Massachusetts.

Mark Moore, Ph.D., is the Director of Psychological Services at the Joan Karnell Cancer Center at Pennsylvania Hospital in Philadelphia, and a recent graduate of the Psychoanalytic Center of
Philadelphia. In his clinical work over the past ten years he has developed expertise in the psychodynamic treatment of cancer patients and in the use of hypnosis for palliative care. He teaches and
supervises clinical psychology interns and post-doctoral students on issues relating to working with cancer patients. Dr. Moore is frequently invited to lecture to health professionals on the topic of
psycho-oncology. His contributions to psychoanalytic literature include many book chapters, including those on the concept of harmony in Japanese culture and sociocultural aspects of dishonesty.
He has also published papers on the topics of domestic violence in cancer populations, outcome research and times-series statistics, preparing patients for therapy, and the empirical status of clinical
hypnosis.

Frances Thomson Salo, M.D., is Associate Professor of Psychiatry at the University of Melbourne School Dentistry and Health Sciences, Melbourne, Australia. Dr. Salo is the author of You and
Your Baby (2005), a member of the British Psychoanalytic Society and a Training Analyst and past President of the Australian Psychoanalytical Society. She is currently serving as the Chair of the
IPA Committee of Women in Psychoanalysis and also as a member of the London Editorial Board of the International Journal of Psychoanalysis. She is an Associate researcher for the Murdoch
Children’s Research Institute and an Honorary Principal Fellow, Department of Psychiatry of the Faculty of Medicine at the University of Melbourne.

Alan Skolnikoff, M.D., is a Training and Supervising Analyst at the San Francisco Center for Psychoanalysis, and Associate Clinical Professor of Psychiatry at the University of California San
Francisco School of Medicine. He has served on the Editorial Boards of the Journal of the American Psychoanalytic Association and Psychoanalytic Inquiry. In a clinical research project with
Emanuel Windholz, he studied the week-to-week reactions of the analyst to his analysand. Both were surprised that the analyst’s activity did not conform to clinical theory. This led Dr. Skolnikoff to
study the moment to moment unfolding of the psychoanalytic process and how and why it conformed and/or deviated from clinical theory. Through his work with the Committee on Scientific
Activities at the American Psychoanalytic Association, he and three colleagues, Robert Galatzer-Levy, Henry Bachrach and Sherwood Waldron, researched the work of analytic practitioners. The
goal was to identify which factors were crucial in determining psychoanalytic outcome. The resulting book, Does Psychoanalysis Work (2000), depicted the myriad methods and clinical theories that
describe psychoanalytic activity. Dr. Skolnikoff has continued his interest in the gulf between theory and practice in other papers.

Andrew Smolar, M.D., is Clinical Assistant Professor of Psychiatry at Temple University School of Medicine, and a Supervising and Training Analyst at the Psychoanalytic Center of Philadelphia.
He is also a member of the adjunct psychiatry teaching staff to Albert Einstein Medical Center and the University of Pennsylvania School of Medicine. He has lectured and written on subjects such as
the negotiation of gifts in the clinical setting, questions of therapeutic action, technique in working with survivors of incest, cross-cultural issues during the psychoanalytic process, and on the process
of change in supportive group therapy. His current interests include the integration of psychoanalytic and group psychotherapeutic techniques in the clinical setting, and the adaptation of
psychoanalytic principles to wider patient populations. A psychiatric consultant to many area colleges, including Haverford College in Haverford, Pennsylvania, Dr. Smolar maintains a private
practice of adult and adolescent psychiatry in Wynnewood, Pennsylvania.
Introduction

Meaningful psychotherapy, especially psychoanalysis, is an enterprise built on the premise of confidentiality, nonjudgmental attitude, the duo of the patient’s honest self-revelation and the analyst’s
evenly hovering attention—all in the service of deepening the patients’ grasp of their minds and, in turn, of their lives. Somber and, to a certain extent, solemn, the work is a blend of theoretically
derived technical maneuvers and spontaneously felt human responsiveness. Nonetheless, surprise is also integral to this drama. Such surprise can come from the patient’s side or from the “doctor’s”
side. From the former, it comes in the form of recovered memories, uncanny experiences, stunning dreams, new insights, and reversals of long held emotional stances. From the analyst’s side, it
comes in the form of unexpected countertransference experiences and spontaneous technical innovations or what Wilfred Bion (1970) has termed “acts of faith”.
This book, titled Unusual Interventions, is about the latter type of clinical surprises. It deals with instances when the analyst makes a radical departure from the set and familiar rules of technique.
This might involve physically touching the patient, conducting a session outside the office, talking about oneself, giving the patient a gift, refusing to listen what the patient has to say, and so on.
Never before brought together in a book, hush-hush tales of analysts making such exceptional interventions circulate in cocktail parties, are passed on from chest to chest in local psychoanalytic
societies, and are imbued with mystery. Awe also enters the picture, especially when posthumous (and most likely apocryphal) vignettes involve a revered analyst’s making a highly unusual
intervention during clinical work. Allow yourself, even if momentarily, to emotionally resonate with the following and you will see what I mean:

Sigmund Freud gave a herring sandwich to the Ratman, books to Smiley Blanton, and his photograph to Roy Grinker and money to Bruno Goetz.
Sandor Ferenczi conducted some analytic sessions while horse-riding with his patient and Spurgeon English while driving his patient around in a car.
Donald Winnicott held Margaret Little’s head when she regressed deeply during her treatment with him.
Michael Balint offered his finger for a patient to hold.
Kurt Eissler suggested that one ought to surprise a delinquent patient in treatment by giving him money.
Ralph Greenson visited his famous patient, Marilyn Monroe, in the hospital.
David Rosenfeld accompanied an adolescent patient to a video arcade.
Calvin Settlage held a follow-up visit with a patient in a hotel room.

More examples can be given but the point, I think, has been made. Interventions of the sort mentioned above have a way of swaying us. They leave us fascinated but somehow unable to turn the
theoretical heat up. We do not consider these “deviations” from technique to be unethical. In fact, we acknowledge (even if begrudgingly) that they have done the trick. In other words, these
interventions ended up facilitating (rather than impeding) the work of intensive psychotherapy and psychoanalysis. They work!
It is for this reason—as well to repeal the shroud of mystery and secrecy around such measures—that I conceived of the book in your hands. It considers nine “unusual” interventions in detail.
These include: (i) making extraordinary monetary arrangements, (ii) conducting the treatment outside the office, (iii) changing the frequency, length, and timing of sessions, (iv) refusing to listen to
certain kinds of material, (v) giving advice, (vi) interpreting in the form of action, (vii) talking about oneself, (viii) touching the patient, and (ix) giving mementos and gifts to the patient. Separate
chapters on each of these interventions provide clinical vignettes that highlight the indications for its use, its potential risks and benefits, and the way our current theory can either offer a rationale
for it or be challenged, stretched, or enriched by their deployment. The book is a hybrid tract that is part anecdotal history of our field, part a reader-friendly treatment manual, and part a conceptual
gauntlet to encourage candid clinical reporting and “out of the box” theorizing. My hope is that the reader will find it enjoyable, thought provoking, and useful.
Part I
Alterations of the Frame
Chapter One
Making extraordinary monetary arrangements

Ira Brenner

The analyst is determined from the first …. to treat money matters with the same matter-of-course frankness to which he wishes to educate [his patients] in things relating to sexual life. He shows them that he himself has cast off false shame on these topics, by voluntarily
telling them the price at which he values his time.
—Sigmund Freud (1913a, p. 131)

One afternoon, I was enjoying lunch at my favourite Chinese restaurant and reviewing some notes for this chapter. I had a neat, orderly outline in mind where I would begin with a review of the
classical description of fee arrangements in psychoanalysis starting with Freud’s (1913) conceptualization of leasing time.1 I was then going to discuss permutations of this arrangement including the
controversy over charging for missed appointments, paying in advance, deferred payments, pro bono treatment, treating the very wealthy and bartering. I was even going to mention an innovative
program in China. While finishing up my tea and opening up my fortune cookie, I became rather startled and amused by what I read. In a moment of synchronicity, my fortune punctuated both my
meal and my contemplation: It said: “Time is money”.
Is time money?

The well-known axiom though admittedly a bit coarse expression is, however, seldom applied to psychoanalysis. Furthermore, our field is not a lucrative profession and there are much better ways
of making more money, especially, if as Fenichel (1938) has described, one is motivated by a wish to amass wealth. From a standpoint of medical specialties, psychiatry and psychoanalysis typically
rank near or at the bottom of income compared to other medical specialists. Freud (1913) himself noted that the income derived from practicing this art would have to be quite limited. No doubt, the
nature of it being based on an hourly wage and it being such arduous work are crucial factors. The distinguished North American psychoanalyst, Warren Poland, summed it up succinctly when,
during his introductory comments to a paper he presented years ago in Philadelphia, he declared that of all of his psychoanalytic achievements, the thing he was most proud of was that he was able
to make a living from his practice. In a more recent discussion with him, Poland added that at this point in his career, that is not the issue. He now is content with whatever fee he and his patient
agree upon. It is only when he thinks of it as a “reduced fee” that he may experience countertransference problems (personal communication, January, 2011). One might assume that a prominent and
successful practitioner, after decades of work, will have derived enough financial security such that monetary pressures are lessened and more sublime issues prevail. That does not seem to be the
case.
Other analysts may view this necessary tension from different perspectives. Akhtar, for example, feels that being solely financially dependent upon people’s mental suffering is problematic and
lends itself to the analyst becoming needy upon them and potentially exploiting them (personal communication, February, 2011). He favours having collateral sources of income to mitigate against
such a countertransference pitfall. For those analysts like himself in institutional settings who earn a guaranteed salary upon which other activities contribute, such a risk is minimized. Also, those
who are financially independent due to inherited wealth, other businesses, wealthy spouses, entrepreneurial success, winning the lottery, etc. are freed up from the pressure of having to live off one’s
practice. This freedom, paradoxically, can have its own risks as counter-resistances in the analyst may build up over time precisely because this work is so challenging.
The expression, “time is money” is more commonly applied to the world of business where, for example, the energetic entrepreneur has created so many time sensitive opportunities that the
failure to act decisively will “cost money”, or, there may be situations where delays in production or sales result in additional expense. Although the analytic patient who is in a “good enough”
treatment much longer than expected may also register the same complaint that his “time is money”, he may not fully realize that his unconscious is contributing to the longer duration and will
blame the analyst for not moving more quickly. For example, a patient complaining about the uncertainty of her progress and seeming endlessness of the process recently acknowledged her own
ambivalence over termination “because then I will have to grow up”.
Part of the challenge in addressing this topic is the recognition that analysts do not agree on what exactly the analysand is paying for and the analyst’s own views over what he is charging for
may vary. Furthermore, there may be uncertainty in the patient’s mind about the exact purpose of the fee so while there may be certain policies put in place at the appropriate time early on, the
nature of the analytic process and the exigencies of life may require additional and specifically tailored arrangements.
In this era of “evidence based medicine” where scientifically based outcome studies are becoming the state of the art and insurance companies are offering “incentives” in the form of increased
reimbursements to practitioners whose patients get “better” faster for less money, analytic treatment has become even more of an anomaly. Indeed, the implications of the recently passed health
care reform bill, which seems more like insurance industry reform, remain to be seen. Clearly, the analyst’s charges are not based on results that are accrued in treatment nor are they based on the
degree of difficulty of the treatment of a given patient’s problems. Mitchell (1993), however, candidly notes that his fees may vary. He says:
Should we regard the analyst wanting to be paid his full fee as a need or a wish? Speaking for myself, sometimes it feels more like one than the other. There are times when I feel I could offer a patient an hour for less and times I do not feel I can. One factor is my own
financial situation and stress at the time; another factor is a potential analysand (1993, pp. 196–197).

Hoffman (1998) states: “There is a fixed routine in the psychoanalytic process, a routine with a kind of symbolic, evocative and transforming potential that gives it the aura of a ritual. There are fixed
times, a fixed place and a fixed fee” (p. 219). Furthermore, the analyst typically does not have different fees for psychotherapy or psychoanalysis nor for treatment offered during different times of
the day although one patient tried to negotiate for lower fees during what he thought were “off-peak hours”. So, if the analyst does not typically charge based on results nor charge different fees for
different therapies nor for different times of day or seasons like telephone companies and airlines do, what indeed is he charging for? Is he charging for the delivery of his “services”, thereby
adhering to a fee-for-service model? And, if so, what exactly is his service? And if analysts with more formal education, more extensive experience, prominence and/or greater narcissism charge
more than their more modest counterparts, there is an assumption that what they are offering is worth more. But, still, the question remains: What are we charging for? Clearly, we analysts are
charging for something related to the promise to spend time with the patient and analyse them which brings us back to the message in the fortune cookie: “time is money”.

Clinical Vignette: 1
One particular patient, referred to above, whose mind functioned like a calculator, bemoaned the fact that he was paying me $4.11 per minute regardless of whether I spoke or didn’t speak, regardless of how many words were emitted. As minutes ticked by, he would make the
“ka-ching, ka-ching” cash register sound denoting the charges per minute. He further expressed his ambivalence by often quoting the words of the mother of television’s famous Mafioso leader, Tony Soprano. She was skeptical of her son’s treatment with the beleaguered Dr.
Melfi. Olivia Soprano nastily remarked about psychotherapy: “It’s a racket for the Jews!” In a nasal, high-pitched falsetto, the patient would recite these lines imitating the voice of the character. The patient conveyed such a mistrust of authority and an expectation of being
cheated that he had to anticipate all contingencies and take preemptive measures. For example, he asked how could he really know that he was getting his full allotment of time? After all, if our appointment was to be at 1:00 p.m., the clock might say 1:00 p.m. but in fact it
could be one second away from 1:01 and he would be cheated. Furthermore, if I ended the session at 1:45 and had someone scheduled immediately afterward, who would pay for the seconds needed for him to exit and for the next person to enter? Or, did the session actually
begin when I greeted him in the waiting room, when he entered the office or when he actually sat down? All these seconds add up in a year. And, for god’s sake, if I had the audacity to charge for missed appointments, shouldn’t I pay him if I had to cancel? Or, if he were
responsible for missed appointments based on the Freudian model of leasing time, if I could fill the hour and charge more for it, shouldn’t he be entitled to part of the difference? Or, suppose he couldn’t make an appointment; couldn’t he send anyone he wanted to in his
place to keep an eye on me and make sure that I didn’t profit from his absence? And on and on …. Though he delighted in demonstrating his cleverness and trying to out-think me, there was a deadly seriousness with which he fought for every penny in every transaction in
his life. He would sit in sessions watching the digital clock on his cell phone, often taking calls and welcoming the disruption, but exploding with rage at the stupidity of his employees who would bother him during the sessions. After several weeks of this behavior, I began
to have the distinct impression that he was actually cheating me on the time as there were occasional disparities between my timekeeping and his; he refused to leave until he was ready. During this early time when we were meeting only three times a week and, despite his
downright provocations, he could be quite engaging with his humor, clever wit and great range of knowledge.

In this case, the patient’s obsession with money lent itself quite easily to it becoming embroiled in the transference. Every aspect of our financial dealings took on such exquisite meaning that at
times his analysis had an absurdist quality to it. Yet beneath the humour and one-upmanship, he was enacting a deadly serious game of trying to outwit the perpetrators of his childhood. Money was
both an aspect of the frame and the central part of the treatment. Dimen (1994), in her work related to fee, notes that:
Money, along with its coordinates, space and time, belongs conventionally to what has been labeled the analytic “frame”. I would like … to argue that the frame which Langer (1973) calls “ground rules” ought to be treated as part of the picture too. To put it more concretely,
unless money may leave the frame and enter the picture, psychoanalysis might renege on its promise (1994, p. 97).

Milner (1952), in her original conceptualization of the analytic frame notes: “The frame marks off the different kind of reality that is within it from that which is outside it; but a temporal spatial
frame also marks off the special kind of reality of a psychoanalytic session … it is the existence of this frame that makes possible the full development of that creative illusion that analysts call the
transference” (p. 182). She then observes that as the patient becomes more tolerant of the difference between the symbolic reality of the analytic relationship and the literal reality of libidinal
satisfaction outside the frame of the session, his condition improves. Clearly, the payment and all of its associated details have enormous psychodynamic significance and the failure to recognize and
analyse these aspects of the relationship will overlook unprecedented opportunities for understanding the patient’s mind.
Bartering

I have a colleague who practices in a small coastal town where families have made their living for many generations by harvesting the sea. The fishing industry has been a central part of the local
economy which until recently was a thriving, seemingly never ending bounty for all concerned. A casualty of its own success and the well-known factors plaguing the world’s oceans, such as
pollution, climate change and human greed taking precedence over long-term conservation measures, this area had fallen on hard times in recent years. Uncertainty over the future and rising
unemployment cast a pall over this once thriving area resulting in a westward migration of some of the more ambitious, hopeful and talented young people. Those left behind continued in their old
ways hoping and praying for things to improve. An air of quiet desperation and great uncertainty pervaded this area whose populace struggled with an epidemic of depression and anxiety. My
colleague would regularly be paid for his long hours of dedicated service to his patients in fish. Haddock, scallops, salmon, halibut, lobster, and cod filled his freezer constantly. He never complained.
He saw this as a sign of whatever was available for appreciative patients and family members to repay in a way that was feasible for them and meant something to them. He always accepted it
even if there was no room in his freezer. While patients’ health insurance may have paid for some of his services, he was never fully compensated. Bartering was acceptable, would have been an
insult if refused and was a way of life. To feel that one was at least offering something in exchange for desperately needed psychiatric care helped maintained a sense of pride and avoided any
further narcissistic injury.
As Canter, Bennett, Jones, and Nagy (1996) summarize it:
Pro bono services, although certainly at times an option, may not always be possible either because of the therapeutic issues, the discomfort or unwillingness of the client or patient to accept free service, or financial pressure on the part of the psychologist particularly in
economically depressed areas where many indigent clients may need psychological services (pp. 51–52).

In the socioeconomic climate of the fishing village, bartering with seafood was congruent with cultural mores. It was used as currency not only for psychological services but for other goods and
services as well. It was not seen as out of the ordinary and was perhaps as normative as bartering with produce would be in a farming community. For example, Russian colleagues who studied with
us in the United States shortly after glasnost and perestroika nonchalantly told us of being paid with sacks of potatoes and chickens for their work in rural areas. The situation becomes more
complex in a heterogeneous urban culture when, for example, a starving, young artist trades his paintings for treatment. In this case, the value of the work may be very difficult to appraise given the
subjectivity and the uncertainty of his ultimate fame. In one such instance, a patient paying a substantially reduced fee was on the cusp of “making it big”. The therapist rightly felt that his efforts
figured prominently in the young man’s mental stabilization so his unique talent could be harnessed and he felt most appreciative. The two were in the midst of negotiating over a fair value for a
given work that especially caught the therapist’s eye a month before that particular piece happened to win a prestigious art competition. Then, almost overnight it became “worth” many thousands
of dollars and, depending upon if and when the barter had taken place, either the patient may have felt cheated for accepting too little or guilty over taking so much. Conversely, the therapist may
have felt guilty over having acquired such a great work in return for offering a few sessions or indebted to the patient for an extended period of time were he to pay the new value of the work.
Wisely, the therapist continued to analyse the complexities of such a barter and stayed with the original financial arrangement until the patient could actually pay more money. Seeking consultation
with a knowledgeable colleague at such times might be helpful in sorting out the nuances and complications that might arise.
Treating wealthy patients

The dual challenges of working with “phenomenally wealthy patients” (Olsson, 1986) relate to their entitlement and the therapist’s counter-transference. Such patients are used to having their
desires quickly gratified and often find psychotherapy tedious. They want immediate satisfaction, exclusive attention, and are often intolerant of being questioned. As a result, they stir up powerful
countertransference reactions in the therapist; these include envy, defensive contempt, undue deference, and excessive accommodation of schedule changes. Further complications arise if the
therapist begins to feel proud at having a rich individual in treatment and gives in to gossiping about the patient’s wealthy lifestyle (Akhtar, 2009a, 2009b, 2009c; Olsson, 1986; Stone, 1972). The
following clinical vignette illustrates the conundrum that can occur in the treatment of such patients.

Clinical Vignette: 2
Ms. X, a prominent and somewhat mysterious woman purporting to possess enormous wealth, consulted me many years ago as one of several analysts she was interviewing to continue her treatment following the death of her analyst. She told of a long and convoluted family
history replete with intrigue, great fortunes amassed and lost and regained, violence, perversion, incest, alcoholism and suicide. Currently embroiled in a legal battle with other heirs of the remains of the estate, she worried that the loss of her beloved analyst, a man who had
seen her through many years of great success and suicidal despair, was more than she could tolerate. In the midst of this personal turmoil and grief, she exuded a seductive, childish helplessness and a deep sense of entitlement. Having had a prior experience with another
deeply troubled woman whose very wealthy husband compensated for her ego weakness and lack of frustration tolerance through instant gratification of her material wants, I knew that the pleasure principle can often predominate over the reality principle in such
individuals. I therefore expected that certain demands and expectations would accompany the therapeutic situation with this patient also.
Indeed, it emerged over the extended consultation lasting weeks that Ms. X wanted to have her personal psychoanalyst to have no other patients than herself. She was offering an exorbitant annual retainer, almost the three times the total amount of my total income from
my practice, to her new analyst. She was utterly serious and conveyed an air that anyone who would be privileged enough to be chosen to work with her should be prepared to terminate all of his patients and devote himself exclusively to her. I began to wonder about her
former analyst, an individual who had lived quite well and was somewhat peripheral in the professional community. Had indeed such an arrangement had been made with him? I would never know. What I did know was that in my work with Ms. Y, a former patient who had
bouts of suicidal despair and multiple hospitalizations, she would frequently call in crisis and would insist upon extended conversations on the telephone. Even though we were meeting five times a week, her sense of urgency and inability to wait were such that I came to
expect regular telephone contact. While I did charge her for the telephone calls as they became part of the treatment itself, I began to feel that I had to be on call 24 hours a day, 7 days a week. Moreover, I began to feel like hired help despite being adequately compensated
and realizing that her voracious oral needs and object hunger were intensified by severe early trauma. I was, therefore, not totally unfamiliar with this character type but, nevertheless, felt somewhat amazed at Ms. X’s demand for exclusivity. I had worked in a private hospital
which routinely accommodated the demands of many very wealthy and disturbed individuals so this patient’s demands were an extreme example of such a pattern. Having observed well-respected senior colleagues tending to these special inpatients in that climate seemed
normative and part of the culture at that time. I consulted a colleague about the nature of this spectacular offer and, assuming that it was bona fide, explored my countertransference reaction to this “opportunity”. I wanted to better understand the mind of someone who could
actually enter into such an arrangement with a therapist. I let myself imagine the possibility of maintaining all of my analytic patients and working towards ending my less intensive psychotherapy patients over time. Having had a half-time inpatient job for many years and
not having a full-time private practice at that time in my career, I had such a template in my mind and it was not out of the realm of possibility to imagine taking on another half-time job.
Would such a grandiose and privileged individual even entertain such a “counteroffer”, having just half of me instead of all of me? What would it feel like to have such a fabulously wealthy and important patient as my half-time job? How special would I feel? A
celebrity’s analyst … After much reflection and a growing certainty that there was much more to this offer than I knew, I did end up hinting at the possibility that I might consider a partial arrangement with her. Perhaps it was my way of testing her since I felt I had been
feeling so tested myself. Not surprisingly, she flatly refused. It was all or nothing. An imperious display of splitting. Shortly after this interaction, the evaluation started to wind down and came to a rapid close. I could not be bought at her price under her conditions and she
went into a quiet, but seething, narcissistic rage. Subtle evidence of a deep vindictive spirit surfaced and I felt a great relief to have ended this most unusual exercise. While it was too soon to know for sure if this dynamic informed some of Ms. X’s motivation also, it was
clear that she came across as someone who was quite used to getting her way and was quite willing to pay exorbitant amounts of money to have people under her control.

Aside from the obvious humane and ethical issues associated with precipitously terminating one’s patient’s in order to take a “better offer” financially, it would be completely untenable to be
“owned” in such a way and still think that one could maintain any sort of an analytic stance. Yet, I was intrigued by the outrageous nature of her sense of entitlement and was quite curious about
where all this would lead. As the evaluation continued, I found myself having fantasies about wanting to negotiate with her. Imagine cutting back my practice to about half-time over many months
and accepting half of the retainer. I then realized that her offer was unconsciously determined to test one’s greed and corruptibility especially when she said she would be prepared to wire the sum in
advance directly to my bank account as soon as I were to agree to her terms. So, the issue of payment in advance also entered into the clinical picture.
Payment in advance

My experience with several analytic patients who had wanted to pay in advance also came to mind. In each of these situations, while the requests were consciously based and well rationalized (e.g.,
for tax purposes to prepay a number of months at the end of a calendar year), they invariably betrayed an underlying fantasy relating to holding onto the object. Whether it was due to fear of object
loss due to illness, death or outright rejection, or an omnipotent fantasy that the patient would stay alive and healthy indefinitely, the common denominator was guaranteeing a continued union with
the analyst. On a deeper level, there was a desire for a reunion with the pre-Oedipal, idealized mother symbiosis and to maintain the idyllic dyad.
In one case, the patient was a woman who was adopted at birth into a family who subtly reminded her of how “lucky” she was for having been taken in by them. Her status as an adoptee was
invoked to induce guilt and obedience in her as she feared being sent away if she did not live up to whatever demands her loving and generous family would make of her. Her deep insecurities over
truly belonging and being acceptable continued into her adult life despite all the trappings of a successful life. In the transference, she insured her place on my schedule through periodic advance
payments. Rationalized and heavily defended, this enactment was not amenable to interpretation until she ran into financial difficulties at which time her deep fear of being summarily dismissed
came to the fore.
In another case, a man in analysis with severe heart disease was undergoing tests and procedures to determine if he were a candidate for an operation. In his situation, the operation would have
been extremely risky in that he might not have survived it so it had to be carefully considered. Were he not to have this operation, however, then it was quite likely that his life would have been
quite foreshortened. During this very tense and uncertain time, he received a bonus check from work. Consciously concerned that he might squander the money, he wanted to apply these funds to
future analytic sessions. His underlying fantasy was deeply repressed, the handling of which required great delicacy and tact given the life-and-death situation he was contending with.
Deferred payment

A senior colleague who was well known in his earlier days for having the highest fees around taught his students that psychoanalysts should not have to apologize for charging money for their
services. It was an important and healthy message for those who might be feeling guilt or a sense of inadequacy early on in their careers. He even had a credo which was a parody of the sacred
Latin expression in the finest Hippocratic tradition “Primum non nocere” (First, do no harm). His motto was “primum, suscipio tributim” (first, get paid). In other words, before undertaking a course
of analysis which could reasonably extend over a number of years, it was important to carefully evaluate the prospective patient’s capacity to pay for the services and determine what kind of
resources might be there in case of an emergency.
Although this esteemed analyst had good reason to have a high opinion of himself, some thought his attitudes were a bit mercenary when, during an economic downturn when analytic patients
became even more scarce than usual, he began advocating a deferred payment model. After a careful assessment of the patient’s analysability, he suggested an equally careful financial analysis
including their monthly budget, a review of their annual income tax forms. Then, based upon these figures, he would then offer them a payment plan which included an affordable amount of his
standard fee per session up-front and the balance to be paid at a later date, possibly near or after termination. This deferred balance would then accrue an interest charge consistent with the bank’s
fluctuating rates for comparable loans. The patients would then be required to sign a legal contract before analysis could begin. In this way, he argued, analysis could be offered to many more
patients even during difficult times and he felt certain that all the issues associated with such an arrangement were analysable.
It was never clear how many people he attempted to analyse were agreeable to such an arrangement. Moreover, I am not aware of his ever having written about this experience or shared his
feelings in any methodical fashion. What was clear was that as he got older and near the end of his career he became very outspoken about the need for young training analysts to be willing to
sacrifice in the name of furthering the cause of psychoanalysis and accept drastically reduced fees for candidates. It appeared that this analyst, once having achieved financial security in the autumn
of his career, adopted a rather different attitude for analytic fees for others. Whether the new attitude reflected hypocrisy or an enlightenment based on his failed experiment functioning as both an
analyst and a loan officer simultaneously was not clear. To his credit, however, I believe a number of analysts became more willing to consider accepting some deferred payments from their
analysands but did not levy interest charges on the agreed-upon unpaid balances. These analysts did, however, make it clear to their analysands that all aspects of such arrangements were subject to
analysis.
Leaving aside the “outlying” stance (and its later transformations) of the senior colleague mentioned above, one has to address the clinical situations where the policy of deferred payment might
serve as a stop-gap measure. Individuals who have started new employment, out-of-town college students, and workers who have been temporarily laid off fall into this category. Their inability to
pay as originally agreed upon is generally transient and poses few problems for their ongoing treatment process. This is not to say that the therapist’s willingness to defer payments under these
circumstances can never get caught in transference distortions. It certainly can but, by and large, such problems are resolvable by ordinary analytic means and do not become entrenched. All in all,
when it comes to deferred payment, Freud’s (1913a) guideline remains valid till today. He said that “ordinary good sense cautions him [the analyst] not to allow large sums of money to accumulate,
but to ask for payment at fairly short regular intervals—monthly, perhaps” (p. 131).
Gratis treatment

As is so often the case in Freud’s writings, one might come across conflicts or contradictions in his thinking. This is the case in his attitudes about offering gratis treatment. He notes that the analyst
“… should also refrain from giving treatment free and make no exceptions to this in favour of his colleagues or their families” (Freud, 1913, p. 132). Having set aside an hour or two a day for ten
years for such treatment in the hopes of learning more about how to reduce patients’ resistances to analysis, he concluded with a fair amount of certainty: “Free treatment enormously increases
some of the neurotic’s resistances—in young women, for instance, the temptation which is inherent in their transference-relations and in young men, the opposition to an obligation to feel grateful,
an opposition which arises from their father-complex … The absence of the regulating effect offered by the payment of a fee to the doctor makes itself painfully felt; the whole relationship is
removed from the real world, and the patient is deprived of a strong motive for endeavouring to bring the treatment to an end” (Freud, 1913, p. 132).
Freud (1913) also recognized the special problems associated with poverty and observed that in trying “to deal with the neurosis of a poor person by psychotherapy [one] usually discovers that
what is here required of him is a practical therapy of a very different kind” (p. 133). Then he makes a tantalizing remark: “Naturally, one does occasionally come across deserving people who are
helpless from no fault of their own, in whom unpaid treatment does not meet with any of the obstacles that I have mentioned and in whom it leads to excellent results” (p. 133). Unfortunately, he
does not offer any criteria for these “deserving people” and leaves it open to our imagination and subjectivity. Perhaps this statement foreshadows his vision of establishing psychoanalytic clinics
which he outlined in 1918:
The conscience of the community will awake and admonish it that the poor man has just as much right to help for his mind as he now has to the surgeon’s means of saving life; and that the neuroses menace the health of the people no less than tuberculosis, and can be left as
little as the latter to the feeble handling of individuals. Then clinics and consultation-departments will be built to which analytically trained physicians will be appointed, so that the men who would otherwise give way to drink, the women who have nearly succumbed under
their burden of privations, the children for whom there is no choice but running wild or neurosis, may be made by analysis able to resist and able to do something in the world. This treatment will be free (Freud, 1918, quoted in Lorand and Console, 1958, p. 59).

In an attempt to operationalize the parameters of free treatment, Akhtar suggests the following preconditions
(i) The financial situation of the patient must be explicitly and “shamelessly” evaluated before the decision for gratis work is taken; (ii) Gratis work should not be undertaken by therapists who are themselves struggling with finances; (iii) Even those who have financial
security should not take more than one or two patients on a pro bono basis; (iv) An attitude of flexibility must be maintained and fees should be introduced if the patient’s reality changes (p. 92).

Yet, after all these deliberations, he suggests that an ultra-low token fee is usually possible and preferable to gratis treatment. I agree with his position as it maintains the analytic frame and is more
amenable to analytic exploration than an absent fee.
The CAPA experience

The Chinese American Psychoanalytic Alliance (CAPA), has been making history in its efforts to bring psychoanalysis to China.2 The American Psychoanalytic Association’s recent outreach to
interested and qualified mental health professionals in China has resulted in a number of analyses being conducted using the latest technology available via the Internet. American psychoanalysts
who may have never met their Chinese analysands in person have evaluated and been conducting psychoanalytic treatment via Skype, a videoconferencing program which allows for face-to-face
telecommunication in real time. While the efficacy of the treatment itself utilizing such innovations is a crucial topic, it is too soon to know for sure and being such a complex subject that
undoubtedly much will be written about it in future publications elsewhere. For the moment, however, the aspect of payment for the analytic sessions is more relevant to our discussion here.
Payment is arranged through the Internet via PayPal which is a financial intermediary where those who have accounts set up online have their credit cards linked to these services. Access is
gained through entering an ID name and secret password. In this way, those who use PayPal may, for example, buy items from others whom they have never met who are advertising them online
and know that there will be a safe, reliable exchange of money for that given piece of furniture, jewellery or automobile. While there may not be a guarantee about the quality of the item itself,
unless yet another agency get involved to appraise and authenticate it, the passing of funds from one to another is assured. Therefore, the use of PayPal to collect analytic fees from the Chinese
being analysed over Skype was a logical plan under the circumstances. Of course, the yen would have to be converted into dollars as part of their transaction and, given the fluctuation of currency
on the world market, the cost of the session could vary considerably from day to day. And, given the economic disparity between the two cultures, greatly reduced fees or even pro bono fees have
been necessary for many. Furthermore, some analysts have reported that there have been delays in receiving payments for their services and it has not always been clear whether or not the problem
has been due to resistance and acting out on the part of the Chinese analysand or a technological problem in the transfer of funds (Fishkin, L. & Fishkin, R., 2011). It is, therefore, quite evident that
those extremely dedicated and daring analysts who are participating in this remarkable project have much to analyse about money issues with their analysands. The extent to which it is possible and
what will be learned that may further our understanding about this aspect of payment will become more evident over time.
The missed appointment dilemma

There is perhaps no other issue pertaining to the ground rules in treatment is as contentious and central to the process as the handling of missed appointments. I entered analytic training at a time
when the classical approach was the preeminent model and many still thought it was the pinnacle of ideal technique to say as little as possible for as long as possible and wait for the right moment
to deliver the perfect interpretation which would result in the necessary structural change in the psyche. That was all that was needed. If this sequence did not occur, then either the analyst was
practicing poor technique or the patient was not suitable. In either case it simply was “not psychoanalysis”. In this climate, charging for all missed appointments was axiomatic and failure to do so
was seen as a reflection of the fledging analyst’s inability to maintain the proper analytic posture and/or the inability to tolerate the patient’s aggression. After all, how could the analyst render a
judgment over which absences were “legitimate”? Moreover, how might a liberal policy on cancellations undermine the analytic process through an unconscious collusion with the analysand’s
resistance to addressing painful and conflictual material? In addition, how could the analyst rely on a steady and predictable source of income if he, unlike medical professionals, did not double-,
triple- or quadruple-book patients at the same time, have them set up in different examining rooms and circulate between them at a time vaguely corresponding to their given appointment time? In
that model, a patient who cancels or does not show up is hardly even missed. Needless to remind the reader that this position represents Freud’s (1913a) stance; the rationale for this “classical”
perspective is best explicated by Ursano, Sonnenberg, and Lazar (1998), who assert it to be:
the most neutral and fundamentally respectful stance for the therapist to take. Otherwise, the therapist takes the position of making a moral judgment about whether the absence was justified. In such a case, the therapist, in effect, volunteers to make a personal financial
sacrifice if an absence is deemed worthy of being excused. If the patient is angered by paying for a missed hour, there is then an opportunity to explore the dynamics of the anger and why the patient feels that the therapist should absorb the exigencies of the patient’s life.
Similarly, the therapist operating on these guidelines can more appropriately set fees reflecting a known stability of chargeable hours and therefore potentially lower per-session fee (p. 174).

An opposite point of view is expressed by Schlesinger (2003) who never charges for missed appointments. Akhtar (2009a, 2009b, 2009c), while also leaning in this direction, attempts to strike a sort
of compromise between the “conservative” position of Ursano, Sonnenberg, and Lazar (1998) and the more “liberal”, if not radical, position of Schlesinger. He suggests that the analyst should
consider not charging for missed sessions due to:
(i) developmentally appropriate out-of-town interludes (for visiting parents, studying abroad) of college students; (ii) serious medical illness of the patient, and, according to Pasternak (1986) of the patient’s immediate family members; (iii) family vacations which the patient,
despite earnest effort, could not manage to match with the therapist’s time away; and (iv) natural disasters (pp. 81–82).

My own position has evolved over time. Having experimented at both ends of the spectrum with short- and long-term psychotherapy and psychoanalytic patients, it is clear that, as the saying goes,
“One size does not fit all”. Having said that, however, not having a consistent policy would make it difficult to recognize certain enactments as they emerge in the relational matrix. As a result, my
current policy is to charge for missed appointments unless they can be rescheduled that week or unless I can fill the hour. Since other patients are often waiting for additional hours, it is frequently
not a financial issue but remains an essential topic for psychoanalytic exploration, as other issues emerge, such as the fantasy of being easily replaced.
Coming back to Schlesinger (2003), I cannot fail to note his claim that none of his patients have ever abused this policy on his part. This is remarkable, in my experience. In another context, I had
heard that Harold Searles once confronted a presenter making a claim about treatment of psychotic patients and asked, “Why is it that I never see such patients like that?” The following vignette
describes charging for a missed appointment and the implications it had for the analytic process.

Clinical Vignette: 3
Simon was a young, single man who entered analysis with a history of depression, homosexual anxiety, low self-esteem, difficulty in intimate relationships and chronic rage against his very successful but aloof and caustic father. He was very engaging and likeable, but did
not realize his own assets. He carried an enormous burden of unconscious, predominantly neurotic guilt which was periodically expiated through enactments of victimization which alternated with a wish to be treated specially. He had only an inkling of awareness that this
pattern had psychological significance which related to perceived danger of his Oedipal strivings for his overstimulating and unavailable mother. Early in the second year of treatment when derivatives of this material were becoming manifest in the transference, he was
rushing for an appointment in his habitual way of “cutting it close” which often resulted in several minutes of lateness. This time, however, he never made it to his appointment and I waited for him past his usual time of arrival.
It was uncharacteristic of him to miss an appointment as he was quite involved in the process and in general a responsible individual. I turned the ringer on to my telephone, sat back down and started to read a journal. A few minutes later, the phone rang and it was Simon
calling in a very excited state. He was speeding to his appointment and was hit by another motorist. Physically he was okay but had to wait for the police. He would not make it to the appointment. Oh, and by the way, he mentioned, he was just around the corner … It was
clear to me by the tone of his voice and the way he spoke that he was quite shaken up and as he lingered on the phone an unspoken question was being asked of me in the maternal transference: “Will you walk over and see how I am doing?” At that moment, my own
parental protective feeling welled up as I heard his scared, little boy voice break through his brave, self-sufficient veneer. I immediately sensed that this event and all of its ramifications could have enormous significance for Simon’s analysis. What was enacted in both of us
during this unexpected moment of an averted tragedy would take years to analyse but for the present there were immediate technical considerations. The end of the month was approaching and I needed to consider the implications of how to handle his “missed session”.
At this point in my career many years ago, as noted above, the culture of having been trained in a rather classical institute was such that charging for missed appointments was quite normative. Despite whatever theoretical or humane rationale to behave to the contrary
under extenuating circumstances, such as bad weather, illness or attending funerals, those who publicly espoused making “exceptions” would risk furtive glancing among certain colleagues who were concerned about such exceptions. Making such exceptions might be an
enactment of childhood special treatment and serve to reinforce the patient’s pathological narcissism, rendering it less analyzable. Moreover, the analyst’s anxiety over tolerating the patient’s aggression has been seen as an important factor in why such exceptions would be
made. Indeed, such a difficulty in tolerating aggression in the patient is for psychoanalytic candidates, perhaps one of the most frequently discussed topics in progression committee deliberations over whether the analyst-in-training is ready to take on another case, graduate
or “need more analysis”. With this traditional foundation imbued in my analytic “superego”, I had maintained a consistent policy of charging for missed appointments unless I were able to fill the hour. At that time it was rare to be able to fill the open hours so, as a result,
Simon was often charged if he were on vacation. He understandably thought it rather unfair. Given his characterological difficulty in expressing anger towards authority, his protests were meek, tentative and oblique complaints about the rigidity of my rules. He would then
berate himself for having such a weak-minded confrontation with me, rationalizing and at times defensively empathizing with the plight of the analyst. He also felt a debt of gratitude for my having negotiated a lower fee with him so he could proceed with analysis in the
first place. This kindness on my part intensified his conflict over being angry lest he feel ungrateful and more guilt-ridden. At the time of the automobile accident he was on the threshold of an appreciation of the phenomenon of transference, i.e., he was still in the phase of
resistance to the awareness of transference (Gill, 1983).
It was striking that during his next analytic hour the day after the accident, of all things that might have come up in his associations, it was his question over whether he would be charged for the appointment! Still very unsettled over what could have been a catastrophic
accident, he quietly waited for my response as though my verdict of his financial responsibility would have either exonerated him from his guilt over the accident itself or condemn him to be indicted for some unconscious crime. At the same time it felt a bit cold on my part
to hold him to “the rules”, given the terrifying nature of the accident and the impossibility of his being able to keep the appointment. I was also aware of perhaps wanting to let him know that even though I did not walk over and see him I still did care about him, i.e., that I
was a good and attentive parent unlike his own. However, I was concerned at the time about losing an important analytic opportunity if I did not remain consistent. On the other hand, I was also concerned that he might become so hurt by my seeming callousness that he
might drop out. I was not sure that our therapeutic alliance was strong enough that he could appreciate the ambiguity of the analytic situation enough to experience me as anything other than being truly indifferent to his suffering. Yet, I was also aware of his tendency
towards an idealized homoerotic transference and his wish that I would relieve him of his suffering. He no doubt wished that if I had not stepped out of my office literally and walked over to comfort him, the least I could do would be to waive the fee for the session. I was
not sure what to do.
After an extended silence when the patient was waiting for my response, I made an empathic remark about recognizing how frightened he had been, how well-intentioned he had been to make the appointment and how apparently unavoidable the collision had been. I
made no mention of his confession that he had exceeded the speed limit at the time. I also told him that I thought the whole incident had psychological ramifications that when he felt better we would explore. Simon listened carefully and was not satisfied with what he
experienced as my evasive answer. He seemed to need more in order to contain his mounting anxiety and I felt a bit pressured to give him something, mindful of the regressed state that he was in following the collision. I then told him I would think a lot about this dilemma
as I wanted to make a decision that would be best for his analysis. While it was not entirely clear to me that there was indeed one decision that was better than the other, the worst case scenario of either decision, i.e., an unanalyzable, gratifying enactment or hurt and enraged
patient who dropped out of treatment, loomed in my mind.
The patient was mollified in the short term and more associative material began to follow which pertained to fantasies about the other motorist and how many close calls and fender-benders he had had in the past. Medical concerns over musculoskeletal strain as well as
police reports, insurance claims, his family’s reaction and childhood reminiscences came to the fore. Then, on the last day of the month he apprehensively and excitedly awaited my handing him the statement. This ritual was well-known to us by now, but this time it had
assumed the import of opening “the envelope” at an Academy Awards ceremony where the winner of an Oscar would be announced to a tense and eager crowd. Having tolerated the suspense for several days as the shock of the collision began to wane, the patient was
certainly hoping to find the good news in his envelope.
With tentative optimism he tore open the bill and was confused by what he saw. In my own deliberations, I concluded that the best way to handle it was to actually postpone making the decision until the decision itself could be analysed. I therefore communicated that
stance by including the charge for the session in question and then literally writing in a question mark next to it. The question mark was intended to say that I was open to questioning to charge also and would be willing to take as much time as necessary to anal it with him.
While I myself felt mildly pleased with this intervention, Simon was dismayed. Like a disgruntled crowd at a boxing match which sits through many rounds of a fight only to have the referees not declare a winner and call it a draw, he was disappointed and puzzled. Why
didn’t I take a stand? Did I really want him to pay and was too polite to tell him right away? Did I hope to wear him down so that he would ultimately submit to my demand? Or if I didn’t want him to pay why was I being so cagey? Or were there other nuances that he was
not yet able to see? Why couldn’t I just be clear with him? Why did we have to drag it out? Wasn’t I being cruel and unjust making her languish in his uncertainty? Why couldn’t I just decide and let it be over? These and other questions enraged him over subsequent
months as our analytic exploration of the missed appointment became a central issue around which virtually all of his transferential issues crystallized. From capricious parental authority and domination/submission issues associated with sadomasochistic enmeshment with
the object, to compliance/defiance and issues associated with autonomy, Simon struggled with this challenge. Over time he began to see that the significance of our plight went way beyond the actual dollar amount of the appointment itself. Indeed, he bemoaned how many
more dollars he was spending “just talking” about that “damn session” but refused to come to his own conclusions about how best to handle it. Paying the fee at times felt like humiliating and passive surrender to his father’s imperious demands which then merged with
frightening, early sexual experiences in adolescence where he found himself in vulnerable situations with older boys who forced him to perform fellatio, but in so doing exonerated him of any guilt over his own homosexual wishes.
The disowning of his instinctual strivings, both sexual and aggressive, then emerged as an important dynamic incorporated into his character structure. It became evident over time that through projective identification he could subtly induce others to make decisions for
him on his behalf which freed him up from taking any responsibility. Through a passive pseudo-helplessness, others would do for him or to him. As Simon railed on and on about my unfairness about the missed appointment, his analysis unfolded and actually blossomed. In
time, he could begin to appreciate the nature of transference and how it was colouring his perceptions of me. Yet, it continued to offend his sensibilities that he might have to pay for the hour. He tried hard to empathize with the analyst’s point of view over paying for missed
appointments but still insisted that it would be unjust to pay for the session in question. But, maybe he should and maybe he wasn’t because he was being obstinate. He wondered whether or not I had gotten enough out of this exercise with him.
Couldn’t I just tell him it was okay? How much sadistic enjoyment might I be deriving from watching him squirm over all of this? On the other hand, maybe he could end some of his own anguish if he resolved some of his own guilt. After all, he was speeding. He did
have destructive, aggressive thoughts and he did become more conscious of feeling guilt. Psychological guilt, however, could not be easily distinguished from culpability and guilt in a legalistic sense so why didn’t I just put him out of his misery?3 Yet, we persisted and
material continued to flow. In each subsequent month’s bills, the questionable charge was carried over and he paid for everything except for that fee. It remained a major annoyance for him and, like the proverbial irritating grain of sand in the shell of the oyster which over
time is worked over and over until it becomes a smooth pearl, so, too, did Simon work and rework the issue in the transference. In time and begrudgingly so, it, too, became very valuable for him.
I made no attempt to push him to get closure on the issue. Eventually he reached a point of mental exhaustion over it and decided he should just pay the fee and be done with it once and for all. Since, however, the magnitude of the issue was such that it could not simply
go away, his deciding that he wanted to pay needed to be anald also. This experience was not an exercise in behavior modification masquerading as psychoanalysis whereby I covertly wanted him to pay me and eventually come to that conclusion “on his own”. Each of us
had a conflict over whether he should indeed be charged. Therefore, whatever he decided was less important than the process of deciding and understanding the meaning that it had to him. Feeling that he had gone as far as he could go, he then included the payment in his
next monthly check to me about a year after the accident.
Not surprisingly, the issue never really left the analysis and coloured all future absences on his part. As the treatment progressed and he neared termination, the issue resurfaced during times of reminiscing over the high and low points of the treatment. I sensed a continued
grievance on his part about how it was handled. Expressing himself in a much more enlightened way as his observing ego and insight into his psyche had grown, he maintained that I had erred in levying a charge under such circumstances. And, what do you think, he
insisted? Inviting me to confess to having made a mistake, I empathized with his continued hurt and wanted to point out to him how much “grist for the mill” we had been able to derive from this incident but I doubt he would have felt that the end justified the means.
Frustrated with me that I either could not see the error of my ways or refuse to acknowledge it, I interpreted the continued grievance he had towards his parents also. Perhaps if I could acknowledge my error then it might compensate a bit for all the unacknowledged errors
his parents had committed. Without protesting, he accepted my interpretation but felt I was avoiding the immediacy of our situation, nonetheless.
As a testament to his persistence, up to the last hour of his analysis, which occurred on a date which had been set many months in advance and had been carefully considered after years of productive analytic work, Simon gave me one last chance: “So, tell me,” he asked
with a wry sense of humor, “if you had it to do over again, what would you do? Would you have charged me? Would you?”

Simon’s analysis continued up to the last minute of the last hour (Lipton, 1961). Just as a patient may try to engage the analyst in a different kind of conversation “before the session starts” or after
getting up from the couch on the way out the door, so, too, did Simon want his answer before he left for the last time. Regardless of whether I answered him or not, the profound meaning of the
question for him is the important issue here. It took on such significance in his mind that much of his analysis crystallized around it. While it certainly may be that we might have gotten to the same
dynamics of his character had I handled things differently, we cannot know for sure. Conversely, what might have been missed, overlooked or simply not having entered into the transference
because of how I handled it needs to be considered also.
Conclusion

In this report on variations of payment, I have tried to illustrate some of the modifications of the “usual” model. It was not intended to cover all possibilities but, rather, to extend the discussion and
to invite others to describe their experiences also. For example, I did not discuss extending professional courtesy in an initial consultation. This practice is not uncommon when dealing with
colleagues and their families and acquaintances. Nor did I address issues of payment associated with child analysis, a topic worthy of extensive study. One aspect of this area would be the transition
of payments by the parents for the treatment to payments by the patient himself in late adolescence or early adulthood.
I also did not elaborate upon the myriad details that characterize our “usual” practice, those subtle nuances that may fluctuate which communicate so much consciously and unconsciously to our
analytic patients about our attitudes about money, our sense of self-worth, our professional work and our feelings about the patient. These tiny vibrations in the analytic field may send huge ripples
which have important repercussions in the analytic dyad. For example, how timely are bills given to the patient each month? How accurate are they? Who prepares them? How aware is the analyst
of the patient’s current payment status in the treatment? Are the bills hand-delivered or mailed? With or without an envelope? Typed up or handwritten? How legible are they? Do they include
diagnoses and treatment codes for insurance companies? If so, how are these issues decided and analysed? When in the session are the bills given? How long does the analyst usually wait to be paid
after the bill is given before it becomes an issue for the analyst? Does that period of time vary from patient to patient? And why? How actively does the analyst then “listen” for material referable to
the nonpayment and actively make interventions? Are these interventions more active than other interventions? And why? How does the analyst handle fee increases? Does the fee stayed fixed
throughout the duration of the treatment? If so, then why? If not, then how much and how often are such increases levied? How are these changes decided and how they are analysed in the
treatment? And, finally, how is the last bill of the analysis handled? What effect, if any, does when and how it is presented have on the termination process if that payment occurs weeks after the last
session and is not analysed with the analyst? Clearly, there are many more questions than have been generated here which highlight the multitude of details that may take on “undreamed of”
significance.
The analysis of the payment arrangement is an essential aspect of the treatment situation. Whatever is negotiated—be it a reduced fee, standard fee, deferred fee, advance payment, credit card
payment, Pay-Pal payment via the Internet, barter, daily payment, weekly payment, monthly payment, or annual payment—it all has meaning. Moreover, the handling of missed appointments, I
would contend, is at the heart of the analysis of money and whatever financial arrangements are made for the patient. The psychology of the analyst, and where he or she is on the professional life
cycle, are crucial considerations in understanding the complex communication that occurs intersubjectively over the exchanges of money in the treatment.
Notes
1. In his paper, “On beginning the treatment”, Freud (1913) elucidated his stance in the following manner. “In regard to time, I adhere strictly to the principle of leasing a definite hour. Each patient is allotted a particular hour of my available working day; it belongs to him and
he is liable for it, even if he does not make use of it” (p. 126).

2. This is by no means to diminish the outstanding contributions of the IPA China Committee and the associated work of such distinguished colleagues as Peter Loewenberg (USA), Sverre Varvin (Norway), Alf Gerlach (Germany), and Maria Teresa Hooke (Australia). My focus
on CAPA is solely due to my greater familiarity with its work; many of my Philadelphia colleagues are involved in it.

3. There is a curious aspect of this situation about which a thoughtful consideration is warranted but is beyond the scope of this paper. That is the fact that this patient did not develop any posttraumatic symptomatology following the collision. In the past he had suffered from
recurrent nightmares and traumatic reliving associated with other terrifying and possibly life-threatening incidents. So, it was known that he was susceptible to have such a psychological reaction. In this situation the patient realized that there was going to be a collision,
could not have avoided it and had a fleeting awareness that he might be killed, yet he did not suffer from any of these phenomena. In analysis he had a daily opportunity to associate to it and analyse any and all aspects of it. It may be that his suffering in the transference and
the issue of paying for the missed appointment served as an externalization of his conflict, which perhaps prevented the crystallization of PTSD symptoms.
Chapter Two
Conducting the treatment outside the office

Mark Moore

I am now learning … how to ride, and, in fact, quite seriously: in the morning I ride for one—sometimes three, even four hours with the company … Since today I have been having an analytic hour on horseback: I am analyzing my commandant, who has been neurotic since
suffering a head wound in Galicia, but who in reality suffers from libido difficulties. So the first hippic analysis in the history of the world!
—Sandor Ferenczi (letter to Sigmund Freud, February 22, 1915)

Conducting aspects of treatment outside the office is unlikely to be considered unorthodox by nonpsychoanalytic therapists. For example, exposure therapy for phobic patients may involve in vivo
exercises during which the patient is accompanied by the therapist (e.g., Craske & Barlow, 1993, p. 7). However, for psychoanalytic therapists, treatment outside the bounds of the office can seem
unsettling, counter-therapeutic, and ill-advised. Indeed Ferenczi’s “hippic” analysis may resonate with our deepest fears of the risks of unstructured treatment and typify our worst fantasies of how
wild and risky a venture it is to conduct treatment outside one’s office. Who among us today would attempt treatment on horseback or during military exercises or with one’s commanding officer?
Nonetheless I believe that many psychoanalytic practitioners make reasonable compromises about where their work takes place as the needs of specific patient populations may require flexibility
about what constitutes a therapeutic physical space. For example, my own work with cancer patients often requires sessions to be held in a hospital room or in the home of a dying patient. Other
practitioners are expanding their work into the consulting rooms of primary care physicians where they see a patient for evaluation before referring him or her for ongoing treatment. And while
such settings are not conducive to psychoanalysis proper, valuable work can still be done in the form of supportive interventions, engaging new patients in a therapeutic process, and even offering
insights into the workings of their unconscious. This chapter will attempt to consider how this may be so and to elucidate the fundamental prerequisites and optimal conditions for effective
psychoanalytic therapy outside the office. Before doing so, however, it is necessary to consider the typical role of the office setting in treatment.
In distinguishing two aspects of Freud’s work, Winnicott (1954) divided it into technique, related to how the patient’s material is to be understood and interpreted; and the setting in which the
work is conducted. Of the twelve points that Winnicott (1954) enumerates about the description of the setting, one speaks directly to the physical surroundings:
This work was to be done in a room, not a passage, a room that was quiet and not liable to sudden unpredictable sounds. Yet not dead quiet and not free from ordinary house noises. This room would be properly lit, not by a light staring in the face and not by a variable light.
The room would certainly not be dark and it would be comfortably warm. The patient would be lying on a couch, that is to say, comfortable, and probably a rug and some water would be available (p. 285).

The reality of our work often corresponds to this idea of the office—a quiet and comfortable room where both the therapist and patient can feel safe and free of distraction to conduct their work.
However, the setting is neither composed by nor limited to the mere physicality of a closed entryway, four walls, a couch and chairs, and unobtrusive lighting. Winnicott also emphasized the
importance of reliability with regard to the setting: the analyst “would be reliably there, on time, alive, and breathing … would keep awake and become preoccupied with the patient … on the whole
punctual, free from temper tantrums, free from compulsive falling in love, etc” (1954, p. 285). In considering alternative settings for therapy, when the familiarity, privacy and comfort of one’s office
space is left behind, one must heed how such elements can be created anew. The possibility of doing so, rather than the physical variables of relocation and spatial change, determines the viability of
helpful treatment occurring.
In writing about the analyst’s office, Akhtar (2009) notes that Winnicott’s description of the office has a “home-like soothing stability” characterized by “comfort, reliability, the warmth of
authenticity, and the availability of minor provisions as well as protection from extreme changes” (p. 114). Akhtar uses these attributes of comfort, authenticity and constancy in framing his own
discussion of the analyst’s office and I will likewise use them as guideposts in structuring this discussion of therapy that occurs outside the office.
Comfort serves to create a safe environment that gives confidence to the patient to engage in the inevitably regressive work of analytic therapy and “facilitates ego-relaxation necessary for
candid self-revelation” (Akhtar, 2010, p. 116). Authenticity as it relates to the physical setting of therapy addresses the degree to which the therapist’s office reflects his or her own character and
values. “The interior of the consulting room mirrors the analyst’s general attitude towards his patients … In unconscious phantasy, all the concrete objects to be seen form parts of the analyst”
(Carpelan, 1981, p. 152) and that “it is sufficient if the analyst feels at ease with it, without eliciting excessive envy” (p. 153). Constancy or reliability strengthens trust and the therapeutic alliance, and
frequent alterations in office décor can have a destabilizing impact upon patients.
One may therefore surmise how the physical parameters of the setting in and of themselves offer leverage to the therapeutic process. What we choose to place in our offices, how we decorate,
our choice of furniture and our mindfulness in making alterations in the physical space all impact the patient’s experience of the setting. Yet what of the location itself? When the fundamental
physical space of the treatment is altered, how does the experience of the setting change? And how will it impact the process of therapy? How must the therapist compensate for the loss of spatial
constancy? Can it be offset by an increased emphasis on reliability within the context of the therapeutic holding environment, or might the disruption of physical constancy overwhelm the patient’s
basic confidence and trust? Can the therapist continue to guarantee an adequate sense of comfort? Of basic safety? And to where does the patients look for signs of authenticity?
In trying to answer these questions, it is surprising to find that while the analytic literature provides a small number of interesting examples of treatment conducted outside the office, nothing is
written on its meaning and presumed impact on the treatment. Yet, it is difficult to imagine that all settings are equally suitable to facilitating the necessary sense of comfort, safety and confidence
for a patient to engage in self-examination in the presence of a therapist.
Freud’s clinical work in unorthodox places

The most striking aspect about examples in the psychoanalytic literature on treatment outside the office is a paradoxical absence of commentary about how the setting might have altered the
experience of the treatment for either the therapist or the patient. It would seem that the physical setting had no relation to treatment process or outcome. However, just as psychoanalytic treatment
proceeds by heeding to the unspoken, so too must this consideration of unorthodox spaces proceed by considering what has not been written of it. I am thus forced to speculate as to what elements
may have contributed to or detracted from the patient’s and therapist’s ability to engage in a therapeutic process. I will not focus on what I consider extra-therapeutic interventions such as Freud’s
feeding the Ratman (Freud, 1909). Such interventions, while no doubt affecting the course of the therapy and being arguably therapeutic, fall outside the scope of this contribution. Instead, I am
concerned with elucidating the practice of typical psychoanalytic therapy (with a focus on clarification and interpretation) in unusual spaces.
1893: Treatment of Katharina in a mountain inn

Freud’s treatment of Katharina occurred during his vacation in the Alps, when “one day I turned aside from the main road to climb a mountain … renowned for its views and for its well-run refuge
hut” (1893, p. 125).1 He was sitting lost in thought when his waitress, a “rather sulky-looking girl of perhaps eighteen … no doubt a daughter or relative of the landlady’s” asked if he was a doctor.
She had noticed his name in the visitor’s book and asked if he had a few moments to spare as her “nerves were bad”. A prior doctor had given her something for them but she was still not well.
Freud provides no insight as to how or why he made the decision to listen to her story. In the case history, he simply remarks that “I was interested to find that neuroses could flourish in this way at
a height of over 6,000 feet; I questioned her further therefore.” His memory of their conversation was that he simply asked her what it was she suffered from and she informed him that she got so
out of breath sometimes that she thought she would suffocate. Freud took this to be a symptom of an anxiety attack and he asked her to “sit down here” and to tell him what it was like when she
got out of breath.
We are likely correct in assuming that the beginning of their conversation began with the girl standing by his table—it is only when he asks her to sit down, thus allowing her to be more
comfortable, that he asks her to elaborate on the details of her symptoms. One might also assume that the invitation to sit down also conveyed to her that he was genuinely interested in hearing
what she had to say, and thus encouraged her to earnestly engage in trying to understand her problem. It is possible that the inn was relatively empty that day; after all Katharina had the time to
take off from her waitressing duties to sit down and talk with Freud. Perhaps sitting down enhanced her sense of protection from curious bystanders—it is easier to have a more discrete conversation
when sitting opposite each other. She apparently felt comfortable and secure enough to tell Freud that her experience of the anxiety was characterized by the feeling of something pressing on her
eyes, her head becoming heavy, dreadful buzzing, giddiness, a feeling that her throat was “squeezed together as though I were going to choke”, and that she was going to die. Despite being generally
independent and “brave”, on the days of her anxiety attacks she thought “all the time that someone’s standing behind me and going to hold of me all at once”. Freud diagnosed her experience as a
hysterical attack and pressed her to consider what thoughts or images came to mind as she had the attack. She responded that it was “an awful face that looks at me in a dreadful way” but not one
that she recognized, and she explained that the attacks had started two years prior when she was living on another mountain with her aunt.
At this point, Freud asked himself if he should “make an attempt at an analysis” as he could not “venture to transplant hypnosis to these altitudes, but perhaps [he] might succeed with a simple
talk … to try a lucky guess”. The guess was based on his experience that girls’ anxiety was often the consequence of the “horror by which a virginal mind is overcome when it is faced for the first
time with the world of sexuality”. His intervention at this point was to simply tell Katharina how he thought she had developed her attacks of anxiety—that two years ago she had seen or heard
something that embarrassed her and that she had rather not seen. Her immediate response was that at that time she had caught her “uncle with … [her] cousin”. In fact, in a latter note to the case
Freud clarifies that it had been her father but that he had changed the relationship for the purposes of disguise. Freud encouraged Katharina to say more: “What’s this story about a girl? Won’t you
tell me all about it?” This is a question that one might ask in the confines of our office, trusting that the unforeseen contents of Pandora’s box might be safely contained. However, what enabled both
Freud and Katharina to trust that they were in a setting in which this question might be safely and profitably answered? Perhaps Freud wagered on Katharina being astute enough to decide how
much she was willing to say in the confines of the inn.
This also raises the question of how much we are responsible for determining the comfort and safety of a setting, and under what circumstances a patient may comply out of desperation and
distress or may be so regressed or impaired as to be unable to consent to engaging in a therapeutic intervention. It is unlikely, even in those early days of psychoanalysis, that Freud was oblivious to
the need to respect and protect privacy; after all he made efforts to disguise the identity of the patients he wrote about. Yet what is unclear is whether he understood privacy as more than a matter
of common decency but also a necessary factor in successful therapy, and was he sensitive to the role of the setting in promoting that necessary sense of privacy and safety? In this case, we must
allow the patient to be our guide. Katharina’s response was that she supposed one could say anything to a doctor and she proceeded to explain how she had looked into her father’s room to find him
lying on her cousin and when she came away from the window she could not get her breath, everything went blank, her eyelids were forced together and there was a hammering and buzzing in her
head. Katharina’s revelatory answer encouraged Freud to continue his line of questioning as he pursued the question of whose head she saw when suffering anxiety. She was initially unable to
provide an answer as the room had been too dark to accurately see her father’s face. She mentioned that she had been sick in bed for three days following the incident and Freud interpreted her
sickness as an expression of her disgust over what she had seen.
Katharina acknowledged that she had indeed been disgusted but she was initially unsure why. Her immediate response was to detail how she had told her mother, who then left her husband.
Katharina’s father stayed with her cousin who had since become pregnant. As Freud pressed his inquiries these associations would later turn out to have a connection to the head she saw when
anxious—it was the face of her enraged father who blamed her for all that had occurred. Katharina’s associations then shifted to a time four years prior, when she was fourteen, when her father had
made sexual advances towards her. She had travelled to an inn with him and he became drunk. Later she woke up “feeling his body” in the bed with him telling her to keep still as she did not know
“how nice it is”. She refused to stay in bed and remained by the door until he gave up and went to sleep. Other similar situations continued to occur later during which she had “every time felt the
pressure on her eyes and chest”. She relayed a memory of another night in an inn and waking to seeing her father leaving to enter the adjoining room where her cousin was; he claimed he had
made a mistake when she pointed out he was using the wrong door to leave. At this point Freud noted how “at the end of these two sets of memories she came to a stop … like someone
transformed … the sulky, unhappy face had grown lively, her eyes were bright, she was lightened and exalted”. Freud’s understanding of what had occurred was that she had not been primarily
disgusted by the sight of her father with her cousin but by the memory the incident had stirred up for her of the time when she felt her father’s body in bed with her.
Freud pressed her, as she was “a grown-up girl now and knew all sorts of things”, to tell him what part of her father’s body she felt that night. She gave no definite answer, offering instead an
embarrassed smile “as though she had been found out”. Freud conceded that he could not penetrate further yet he felt grateful to her for “having made it so much easier … to talk to her than the
prudish ladies of my city practice, who regard whatever is natural as shameful”. He ended his description of the case by stating his hope that Katharina, “whose sexual sensibility had been injured at
such an early age, derived some benefit from our conversation”. The outcome was left uncertain, however, as he admitted that he had “not seen her since”.
1910: Encounter with Gustav Mahler in Leiden

This consultation occurred while Freud was on vacation in Leiden, Holland, in 1910. He had plans to leave by ship from Rotterdam to Naples on August 29th, but before his departure he was
contacted by the composer, Gustav Mahler (1860–1910), who wished to consult with Freud about his marriage. Dr. Nepallek, a relative of Mahler’s wife and also an early psycho-analyst, had
recommended it. Jones’ (1955) biography of Freud tells the rest.
[Mahler] telegraphed from the Tyrol to Freud asking for an appointment. Freud was always very loath to interrupt his holidays for any professional work, but he could not refuse a man of Mahler’s worth. His telegram, making an appointment, however, was followed by
another one from Mahler countermanding it. Soon there came another request with the same result. Mahler suffered from the folie de doute of his obsessional neurosis and repeated this performance three times. Finally, Freud had to tell him that his last chance of seeing him
was before the end of August, since he was planning to leave then for Sicily. So they met in a hotel in Leiden and then spent four hours strolling through the town and conducting a sort of psychoanalysis.2
Although Mahler had had no previous contact with psychoanalysis, Freud said he had never met anyone who seemed to understand it so swiftly. Mahler was greatly impressed by a remark of Freud’s: “I take it that your mother was called Marie. I should surmise it from
various hints in your conversation. How comes it that you married someone with another name, Alma, since your mother evidently played a dominating part in your life?” Mahler then told him that his wife’s name was Alma Maria, but that he called her Marie! She was the
daughter of the famous painter Schindler, whose statue stands in the Stadt Park in Vienna; so presumably a name played a part in her life also. This analytic talk evidently produced an effect, since Mahler recovered his potency and the marriage was a happy one until his
death, which unfortunately took place only a year later.
In the course of the talk Mahler suddenly said that now he understood why his music had always been prevented from achieving the highest rank through the noblest passages, those inspired by the most profound emotions, being spoilt by the intrusion of some
commonplace melody. His father, apparently a brutal person, treated his wife very badly, and when Mahler was a young boy there was a specially painful scene between them. It became quite unbearable to the boy, who rushed away from the house. At that moment, however,
a hurdy-gurdy in the street was grinding out the popular Viennese air “Ach, du lieber Augustin”. In Mahler’s opinion the conjunction of high tragedy and light amusement was from then on inextricably fixed in his mind, and the one mood inevitably brought the other with it
(pp. 88–89).

Kuehn (1965–1966) in his paper “Encounter at Leiden” provides additional details about their meeting and its outcome. It occurred nine months before Mahler’s death from complications of
streptococcal heart disease. He had met his wife Alma in 1901 when he was forty-one and she in her early 1920s. Kuehn (1965–1966, p. 11) notes that Mahler’s home-life was “marked by a
tremendous need for reassurance, childlike dependence, and a desire for inappropriate attentions from his wife”. In her memoirs written some thirty years after the encounter, Alma wrote of
Mahler’s concerns about his ability to adequately engage in sex and the lack of physical intimacy in the marriage. Alma succinctly put their problem as one in which they tormented themselves “not
so much from love as from fear of love” (Mahler, 1946, p. 28).
During a visit to a sanitarium, Alma had drawn the attention of a young artist who later misaddressed a letter to Gustav rather than Alma expressing his love for her. When Gustav confronted
her, Alma expressed her frustrated longing for Gustav’s love throughout their marriage and she explained how she had felt overlooked in favour of his work. Mahler demanded that Alma choose
between them. She felt she had no choice: “I could never have imagined life without him, even though the feeling that my life was running to waste had often filled me with despair … the whole
truth could not be spoken … I knew my marriage was no marriage and that my own life was utterly unfulfilled. I concealed all this from him … we played out the comedy to the end to spare his
feelings” (Mahler, 1946, p. 160). It was at this point in the marriage that Mahler sought out Freud for a consultation.
As mentioned in the earlier description of this encounter in Jones’ biography, an important remark by Freud about Mahler’s mother’s name—Marie—and the connection with Alma whom he also
referred to as Marie seemed to enable Mahler to more openly express his fears about his marriage and to acknowledge his recent irrational jealousy and neurotic behaviour. According to Alma’s
later memoir (Mahler, 1946, p. 173) Freud confronted Mahler quite strongly about his attitude and behaviour: “How dared a man in your state ask a young woman to be tied to him? I know your
wife. She loved her father and she can only choose and love a man of his sort. Your age, of which you are so much afraid, is exactly what attracts her”. Freud also explained to Mahler that he was
looking for his mother in every woman and thus wished his wife to be careworn and ailing. In her memoirs, Mahler (1959). lends support to Freud’s interpretation about the difficulties in their
marriage, noting how Gustav had called her Marie early in their relationship and he had told her how he wished her to look more stricken. She also acknowledged that she too sought a man like her
father: “a small slight man who had wisdom and spiritual superiority” (Mahler, 1946, p. 179). Furthermore, in the remaining eight months of his life, Gustav Mahler’s letters indicate a warmer re-
engagement in his relationship with his wife thus suggesting that he had found some relief from his distress. Of course, a single session, regardless of the setting, is unlikely to have resolved all
concerns for this couple. Did Alma chose to placate her ailing husband, accepting his warmth and endearments as a kindness and perhaps out of a sense of resignation that fulfilment was not to be
her lot with Gustav? And did Gustav truly recover his potency and his marriage remain a happy one until his death, as Jones (1955, p. 89) claimed? Regardless of his new found tenderness and
appreciation of Alma, potency in the face of physical decline would be likely difficult to maintain.
We shall never know with any certainty but for our purposes the significance of this encounter is what Freud was able to achieve outside the bounds of his office, in fact without spatial bounds at
all, as practically the entire encounter occurred outdoors in the course of a stroll around Leiden. Without the customary privacy of an office, and surrounded by the distractions of a bustling tourist
destination in the height of summer, Freud was capable of focusing his attention sufficiently to clarify key dynamics that were intensifying the current difficulties in the marriage.
Indeed, far from complaining of the unusual circumstances and apparent limitations of both time and setting, in a letter to Reik (Reik, 1953, p. 344) Freud described the discussion as a “highly
interesting” expedition through Mahler’s life history that provided “plenty of opportunities” to admire Mahler’s capacity for psychological understanding. Freud claimed that “he had achieved much
with Mahler and that they had discovered his personal conditions for love, especially his Holy Mary complex (mother fixation)” (Reik, 1953, p. 344). He also noted that he had “plenty of opportunity
to admire the capability for psychological understanding of this man of genius” although “no light fell at the time on the symptomatic façade of his obsessional neurosis—it was as if you would dig a
single shaft through a mysterious building” (Reik, 1953, p. 344).
These comments suggest that Mahler was also not disconcerted by the circumstances of the meeting. Indeed, he appears to have been impressed by the insight Freud could offer about his mother
fixation and its impact on his relationship with Alma. Mahler’s response to Freud’s comments and his confrontation regarding how Mahler treated Alma gave rise to an unexpected insight about his
craft as a musician. In a moment of new understanding, Mahler recognized that his experience of hearing comedic street music after witnessing his father attack his mother had left a deep impact
upon his work. He replicated the jarring combination of the tragic with the comedic throughout his career by inserting unexpected commonplace melodies in his most sublime musical pieces. The
emergence of such an emotionally powerful memory and the surprising insight Mahler had about his work demonstrates that their encounter entailed an analytic process that was not lessened by
the setting.
I suspect that choosing to walk outside felt more comfortable for Freud, or else he could simply have suggested meeting in his hotel room when they first met in the hotel lobby. Perhaps his
family was up in the room and so his choice to talk while strolling may have provided a greater opportunity for privacy, and freedom from distraction and intrusion. Or perhaps the room was too
warm and stuffy on an August day. It is also possible that Freud’s decision represented the most authentic choice for him—after all, he was on vacation and however much he may have felt that he
“could not refuse a man of Mahler’s worth” ( Jones, 1955, p. 88), remaining cooped up in his room on a summer day may have felt intolerable, and resentment may have interfered with his ability to
freely offer his time and attention. Thus, we can surmise that Freud’s unorthodox decision may have been made with the aim of maximally providing comfort, ensuring the analyst was reliably
available in terms of attention and interest and facilitating an authentic experience. Mahler’s positive response to the meeting also suggests that he experienced the setting as comfortable and Freud
as reliably and authentically engaged.
Subsequent reports of clinical work in unusual places

While Freud certainly opened up interesting possibilities regarding where treatment may occur, few since have opted to do so, or at least to openly write about it. From an admittedly less than
exhaustive search of literature, I was able locate the following specific illustrations.
1960: Greenson’s treatment of Marilyn Monroe in his home

Ralph Greenson is known for his classic text on the technique and practice of psychoanalysis (Greenson, 1967) but he is also known for his work with rich and famous patients, including his
treatment of Marilyn Monroe in the last two years of her life (Turner, 2010). Kirsner (2007, p. 478) quotes from Spotto’s biography of Monroe that she “came to consult Greenson seven times a week
at his home, later twice daily at his or her home, even living in Greenson’s home for a time” (Spotto, 1993, p. 553). Greenson presented a paper in 1978 entitled “Special problems with the rich and
famous” that may have provided information on his decision to see her in his home but Kirsner (2007) notes that this paper is in the closed section of the Greenson papers at UCLA and will not be
available for reading until 2039. Thus currently we have little insight into Greenson’s thinking about the special conditions of that treatment.
Fortunately Turner (2010) described some of the conditions of the treatment as recalled by Greenson’s family members. Turner notes that Greenson had begun seeing his afternoon patients in his
home after suffering a heart attack in 1955 and that reportedly many of his famous clients preferred this arrangement as they did not want to be seen entering a medical facility. In 1960 Marilyn
Monroe had returned to Los Angeles from New York and she was referred to Greenson by her New York analyst, Marianne Kris. At the time her marriage to Arthur Miller was failing and she was
suffering from depression and using drugs to manage her chronic insomnia.
According to Turner’s article, Greenson diagnosed Monroe as a “borderline paranoid addictive personality” and that he was of the opinion that conventional psychoanalysis was not effective for
her. He decided to utilize an unorthodox approach by inviting her to spend time with his family for dinner and champagne after his final analytic session of the day. He also encouraged his children
to befriend her. In the summer of 1960 Monroe suffered a nervous breakdown that involved auditory hallucinations. Then in January 1961 her marriage to Miller ended and in February she was
admitted to Payne Whitney psychiatric clinic for threats of suicide, where she was subjected to the star-struck curiosity of the staff, until Joe DiMaggio arranged for a transfer to a private room in a
nearby hospital.
Turner (2010) quotes Greenson’s son explaining how his father became desperate in response to her situation, and that he felt that hospitalization was not a viable option and that neither
medication nor conventional therapy were sufficient treatments. A colleague, Milton Wexler, who shared office space with Greenson and who had sat in on some sessions with Greenson and
Monroe suggested that she spend as much time as possible at Greenson’s home so as to create the environment she had lacked in childhood with the assumption that “it would alleviate her
separation if she knew she had a place to return to” (Turner, 2010).
Turner (2010) goes on to describe how Greenson “hoped to teach Marilyn what a good family looked like, to create a cocoon-like environment that would compensate for her troubled upbringing
in orphanages and foster homes and help her to make a new start … to treat her as an adolescent girl who needs guidance, friendliness and firmness … and by taking on the role of good father he
adopted … a foster-home fantasy of a haven where all hurts are mended”. Turner (2010) also quotes Greenson’s daughter reporting how he asked her to accompany Marilyn on strolls around a
nearby reservoir while waiting for her appointment and that they became friends. Greenson’s son, Daniel, is also quoted by Turner (2010) as stating that Marilyn was “the only person I ever met
who was in treatment with him at the same time. It was very much a thought-out process—to have her hang out with us—and we’d do things together and go places”.
Of course, the treatment ended in the tragedy of Monroe’s death by suicide. According to Turner (2010), Greenson maintained that she would have killed herself earlier if he had institutionalized
her. However, I present this case of an example of the use of unorthodox space gone awry. Langs (1989, p. 44) notes that the “selection of one’s home for the office must be accompanied by a special
alertness to the realities of the situation … and must include an understanding by the therapist of the real and fantasied meanings of his particular location for himself, as well as for his patients”.
While Greenson may have thought he had Monroe’s best interests at heart and that he was using the space of his family home as a therapeutic agent, it is not clear that he was specially alert to the
problematic realities of the situation.
For example, how genuinely comfortable could this arrangement have been for either party? Upon finishing a day’s work, Greenson would invite Monroe to spend time with his family for the
purposes of providing a therapeutic environment and it is difficult to imagine that it did not create some form of resentment both for him and for his family. How could he be authentically himself if
at the end of an exhausting day when he had decided to share family time with his patient? And as for Monroe, did she feel she could ever refuse his offer? How indebted she did feel to him for this
special treatment? Turner (2010) reported that she would “bring over Dom Perignon 1952 by the case—and for dinner, after which she’s always help wash up”.
Furthermore, given his initial diagnosis of Monroe as a borderline paranoid addictive personality, careful consideration should have been made of the consistency and reliability of the frame—how
did Monroe experience of sense of consistency as she shifted from a therapy session to a family meal with her therapist? And what of her response to seeing his living space? Did it arouse envy to
see a warm home space, perhaps standing in stark contrast to the institutional spaces of childhood orphanages? It would seem that the use of unorthodox space in this treatment left open too many
unexamined questions and stands as an example of a failure to ensure authenticity and reliability. Even the issue of comfort is uncertain for both the therapist and the patient, as it is unclear how free
they felt to negotiate the parameters of the space.
1963: Norton’s treatment of a dying patient in the hospital

Another, and more detailed, example of an intervention outside the office is Norton’s (1963) work with a terminally ill breast cancer patient whom she saw for the final three months of the patient’s
life. The patient she treated was a thirty-two-year-old mother of two who presented reluctantly on the urging of her sister, with symptoms of severe pain, anaemia and fatigue due to metastatic
breast cancer as well as associated weight loss, decreased appetite, low energy, and impaired sleep. She was depressed and suicidal but she felt that this was appropriate given her deteriorating
medical condition. However, Norton quickly determined that the patient was struggling with coming to terms with a premature death and yet was prevented from talking to loved ones about this
because of the intense feelings it provoked in them. A recent Protestant minister to whom she had grown deeply attached became unnerved by her expression of love and withdrew from her; her
husband threw himself into work and her parents could not bear crying in her presence. These withdrawals were linked to her increasing thoughts of suicide.
Realizing that the patient’s family had decathected their relationship too much to be re-engaged, Norton decided to make her treatment goal that of making the patient’s death less lonely and
frightening. Norton reports that: “To that end, I saw her daily in my office, the hospital, or at her home, depending on her physical condition, for the last three and a half months of her life” (p. 546).
In the early phase of their work, the patient shared her grief over dying and leaving loved ones, while also allowing herself to daydream about their possible futures, which Norton understood as a
form of working through in mourning. After six weeks, the patient was hospitalized and became comatose for three days. This brought about a change in the therapeutic relationship marked by a
regression that was characterized by an increasing maternal transference that provoked the patient’s concern that she was “being such a baby”. She was becoming physically sicker and Norton noted
that “she frequently needed physical care during the time I spent with her, and I made her bed comfortable, fed her at times, and at other times sat quietly with her … I responded to her regression
by assuming certain … ego functions for her” (p. 551). Clearly, this phase of the therapy was not occurring in the therapist’s office but rather by the patient’s bedside where the therapist was best
able to provide care and comfort.
Perhaps in reading this, some will wonder if Norton was providing more nursing care than therapy and question if this is truly an example of psychoanalytic treatment occurring outside the office.
However, it was during this phase that Norton made her only transference interpretation in response to the patient’s angry demand that she stop seeing her because the therapist’s relative health
and attractiveness was too much of an affront to her. She told the patient that “what troubled her was that because she was sick, she was re-feeling with me some of the feelings she had had as a
child about being a child and not able to do what her mother did” (p. 552). The patient was relieved and changed her mind about ending the therapy.
The patient returned home for a brief period and was able to resume care of her two sons and to prepare for her older son starting school. However, she was soon hospitalized again and she
became intermittently blind. Norton continued to visit her in the hospital and “at her request visually described and identified for her hospital personnel and the details of her room … “loaning” her
my sight as well as reassuring her that her loss of sight did not mean a disruption of our relationship” (p. 553). Here the physical surroundings became an important aspect of how the therapist
engaged with the patient as she lost her sight. Norton makes no comment on how this act of description may have impacted her own awareness of the space in which treatment was occurring, but it
is clear that space was an unavoidable element of her work. It is also clear that the patient was ultimately helped by this experience of therapy in a variety of locations and it had a positive impact
on her experience of dying.
In the final days of her life, the patient asked to die at home and Norton began to visit her twice daily. In her absence, the patient had begun to hallucinate her presence and this regression seemed
to have the protective benefit of reducing psychological and physical suffering while preventing the “narcissistic, hypochondriacal preoccupation that is so frequently a part of serious illness” (p. 555).
A few hours before entering a terminal coma, the two had a long conversation about her dying. The patient expressed her gratitude, especially for Norton’s helping her to not commit suicide, and
also asked her to take and wear a red dress she had recently bought in the hope that the dress could have some fun; this Norton understood as a creative solution whereby the patient extended her
life through the dress, knowing that something of her would go on in life.
2001: Settlage’s follow-up of a child patient in a hotel room

Settlage, a well-respected child analyst practicing in San Francisco, retired and moved to his original home in rural Arkansas. He remained concerned with the welfare of his patients, however. He
writes that on return trips to California, he met one of his patients, Ira, a twelve-year-old boy, in his hotel room during which time they discussed Ira’s anger at his therapist for leaving (Settlage,
2001). No mention is made of the impact of the physical setting—how the space was arranged, its suitability for therapy, the patient’s reaction to meeting in a space other than the office—other than
noting that Ira expressed aggression in “who is going to kill whom games on the hotel television set” and that Ira complained of the [hotel] phone pad being too small for drawing on (pp. 70–71).
Settlage interpreted the complaint about the pad as an “unconscious expression of how he felt about talking to me by long-distance telephone” (p. 71). There is a notable lack of reference to the
possibility that Ira’s complaint was a comment on the hotel room itself: its size, its quality, or its status as a compromise space—neither the old familiar office nor the new and dissatisfying virtual
space of the phone. This pattern of omitting any comment on the impact that an unfamiliar space may have on the process is remarkable, especially when one considers that as psychoanalysts we
are generally mindful of changes in the frame and their potential impact on the patient’s experience. I do not wish to subject Settlage to marked criticism, for I think it is laudable that he had the
flexibility to meet in a hotel, and in so doing try to process an important aspect of termination and to prepare his patient for work with a new therapist.
However, as with Freud, we can imagine that Settlage was aware that his patients would have some reaction to meeting in a hotel room and yet it does not seem to warrant even a brief
comment. Is it that we take our surroundings for granted, and that once basic privacy and comfort can be provided for, we give no more thought to the impact of our physical surroundings? It could
also be that our profession’s unique preoccupation with the internal world blinds us to our surroundings. Or perhaps because the outcome of treatment in unorthodox places is often positive, we
forgo consideration of how the physical space itself may have been a factor in the outcome. As Settlage notes in this particular case, he was hopeful that those few sessions would “help resolve his
underlying separation anxiety and facilitate the work with his therapist” (p. 72). Why therefore be concerned about the space if all ended well, just as it did for Freud with both Katharina and
Mahler, and Norton with her patient? This question is answered in part by the author of the next case example.
2006: Rosenfeld’s taking an adolescent patient to a video arcade

Rosenfeld (2006) describes his work with a seventeen-year-old male patient, Lorenzo, who was referred soon after his hospitalization for a violent episode which had occurred in response to
attempts to make him stop playing a video game in a video arcade. His mother explained in the first family meeting that he had had communication problems since age 12, few friends and
difficulties with his school studies due to the amount of time he spent playing violent video games. When the therapist asked him what went on in the video games, what he felt and whether they
aroused him, Lorenzo became enraged and accused the therapist of being crazy for talking about sex (Rosenfeld, 2006, pp. 118–119). Lorenzo then reported on how the treatment team in the
psychiatric unit had decided to confiscate all his video games at home and to ban him from arcade.
Rosenfeld notes that in the first session he realized that the characters in Lorenzo’s video games were all projections of characters from his inner world and so he told Lorenzo that “we would be
talking together, that I would gradually explain to him what was the matter with him, and then when he got a little better, we would go together to a video-game arcade” (Rosenfeld, 2006, p. 119).
Lorenzo responded by claiming the therapist was still mad but that he would accept his treatment because he was willing to “go to the video games”. Note how the patient phrased his acceptance—
it was predicated on Rosenfeld’s willingness to go to the game arcade.
Over time, Rosenfeld discovered “how in his quest for physical feelings and bodily sensations, Lorenzo was ensnared in the lights, the colours, and the sounds of video games” (Rosenfeld, 2006, p.
120) and he decided that “it was clinically vital that I learned what happened to the patient while he played, so I decided to go with him to a video-game arcade and to get to know the characters he
played with, and those he identified with me and with the psychiatrist on my team” (Rosenfeld, 2006, p. 122). Lorenzo played violent games exclusively and he frequently won the games played
with Rosenfeld. Yet he would then return to sessions terrified because he had won and he felt as if he had killed his therapist.
He developed terrifying delusional fantasies about how his therapist would mistreat him for winning and Rosenfeld focused on relating the delusional fears to the fact that Lorenzo thought he had
in fact killed him when he was represented by the characters in the game (Rosenfeld, 2006, p. 122). Rosenfeld noted how it was “an enormous exercise in containment and holding” but that the
important therapeutic task was to “bring what had formerly projected into the inanimate object, the screen of the video game … into the transferential relation with the therapist, and to play it out”
(Rosenfeld, 2006, pp. 122–123).
After a “particularly vicious video game” (Rosenfeld, 2006, p. 120) that involved fighting with laser beams, Lorenzo developed a persecu-tory delusion that his schoolmates would attack him with
lasers and he refused to go out without a protective suit. When he came in for his next session, he expressed his wish to play the game again and after their second session that day, they did so.
Lorenzo won the first game and Rosenfeld the second, at which point Lorenzo explained that when Dr. Rosenfeld won he could be “transformed and become other characters, so even if I kill you
now, you are still alive and have turned into another character” (Rosenfeld, 2006, p. 123). Rosenfeld felt that this description was the key which allowed him access “to the delusion in which the
different and multiple characters of real bad life become fragmented aspects of Rosenfeld, Lorenzo’s analyst. We departed from the screen and entered real life” (Rosenfeld, 2006, p. 122). By
interpreting the origin of the delusion in the transference, Rosenfeld was able to resolve the delusional psychosis.
A month later, Lorenzo asked to play a 3-D videogame but while playing it he suffered a panic attack related to fear of persecution. Immediately afterwards, Rosenfeld took him with a colleague
to a nearby coffee shop to have tea and help him calm down. Once he had calmed down they asked him to explain his experience and they were able to clarify how he had discovered that a 2-D
plane differed from the depth of a 3-D space. This coincided with “his discovery that Rosenfeld’s live image is not the same as the image of the characters … on a flat television screen” (Rosenfeld,
2006, pp. 124–125). Over time, Lorenzo began to be able to express hatred and anger directly rather than in videogames, to express a sense of humour and to begin to enjoy cooperative games and
show many signs of significant improvement.
For the purposes of this chapter, I believe that Rosenfeld’s comments on the setting of this complicated treatment are especially instructive. He notes that “the setting is a dialectic creation that
takes place over a period of time” and it consists of what is “fixed or formal—the hours, the place or space, the fees—and in what is mobile, which is the dynamic aspect, the process which occurs
within the setting” (Rosenfeld, 2006, p. 137). He further notes that while the order, time and place are important, at other moments “the dynamic part of the process is more important” and “the
frame or setting is the creation of holding and of mental space in the psychoanalytic field” (Rosenfeld, 2006, p. 137).
He notes that “no one can prevent me from thinking like a psychoanalyst, even when I am walking through the hospital with a patient, or going to a shopping mall and playing video games.
Here, what is important is to create a mental space in common that is appropriate for holding and psychoanalytic work” (Rosenfeld, 2006, p. 137). Thus for Rosenfeld, a viable therapeutic space is not
defined solely by physical parameters but also by the state of mind of the analyst. The success of his work with Lorenzo offers hope and encouragement that we can work effectively beyond the
confines of our office when necessary, and that such work can often be enhanced by the change in location provided the analyst can continue to think like an analyst.
Some vignettes from my own practice

The following three case vignettes describe examples from my own experience of psychotherapeutic interventions that took place outside the office. I have chosen to illustrate difficulties in such
work as well as to offer some concrete suggestions of how one can adapt to a new environment and attempt to maintain privacy, comfort and a sense of safety and authenticity for both the therapist
and the patient, thus fostering a continuing analytic process.
Escorting a patient to the emergency room

Ms. A was a thirty-year-old graduate student whom I had been seeing for less than six months in four-times-a-week psychoanalysis. She had presented for help understanding her recent loss of
motivation in scholastic work, a change that was immediately predated by the death of her estranged alcoholic father. Her history revealed a traumatic past involving emotional abuse by the father
and the suicide of her mother during her late latency years. She had felt abandoned by extended family and for many years had denied to herself that her mother’s death was not accidental. Her
adult years were marked by relationships of saving others from themselves or the hope of being saved from herself. Despite resilience, self-sufficiency and intelligence, Ms. A had recently become
stuck in a destructive relationship with a depressive alcoholic man.
Over time, I would come to understand that Ms. A had a depressive core centred on an empty sense of lifelessness and an unspeakable identification with her dead mother. She also had deep rage
turned against herself and a sense of envy over the emotional deprivation and abandonment she had experienced. Over time this would come to be expressed in a series of self-destructive
enactments designed to elicit a rescue response from me, while also taunting me with the impossibility of helping her.
The first of these blindsided me but also served as a forewarning of what was to come. I received a call at 3 a.m. on a Sunday morning from Ms. A’s distraught sister who informed me that Ms. A
was having an adverse reaction to pain medication that had been prescribed to help her recover from a recent dental procedure. Ms. A’s sister explained to me that their father had similar—possibly
allergic—reactions to the same type of medication but Ms. A was unwilling to take herself to the ER because hospitals made her anxious. I was concerned and worried that Ms. A was experiencing a
change in mental status due to the medication that was impairing her judgment and exacerbating her anxiety about going to the ER. I called her immediately and she was clearly distressed. She
agreed with my assessment that she was in danger, given her father’s history, but she felt too overwhelmed to go to the ER. I asked if she would be willing to meet me at my office—which was one
block from the ER—with the goal of helping her overcome her anxiety and seek appropriate medical care. She agreed and when she came in she was agitated, rocking back and forth in her chair,
and unable to be comfortable or calm. We spoke about her past negative experiences with hospitals and she was able to agree that her negative expectations were likely exaggerated. However, she
simply felt too physically distraught and overwhelmed to be able to imagine taking herself to the ER. I felt that given time this might change but I was concerned that time might not be a luxury as
her symptoms of rapid breathing and increased heart-rate were not abating. Thus, I asked if it would make a difference if I escorted her to the ER and stayed until she felt more settled. Rationally, I
felt this was a sensible offer to make, yet I had a sense of misgiving which I dismissed as an expected response to venturing outside the comfort zone of my typical working space. In retrospect, I
realize that I was minimizing my discomfort with how I imagined the ER would be—the potential awkwardness due to lack of privacy and the dramatic shift in the frame of the analysis. I ignored
basic tenets of seeing patients outside the office—the capacity to act in a manner that feels authentic and the need for a comfortable setting that affords a reasonable amount of privacy.
Ms. A agreed to go with me. While I attempted to sustain a reassuring conversation on the way over, the short walk felt awkward and unnatural. Once we arrived there, it was evident that Ms. A
hoped I would take charge of the situation and facilitate her being seen quickly. Of course, I had no such influence over the ER staff, and Ms. A took their seeming indifference as further
confirmation of how terrible ER personnel were. When she was finally taken back, she became quite angry about being asked to take a urine screen, even when the nurse patiently explained its
necessity before she could be treated. While this should have served as a warning to me, I was still surprised to be informed by Ms. A that the urine screen tested positive for cocaine. She sheepishly
admitted that she had snorted a significant amount of cocaine earlier that night and that her agitation was an adverse reaction to too much cocaine. I was presented with a dilemma—I had been lied
to and I felt manipulated and disoriented. I was also angry—angry that I had been pulled out of bed at 3 a.m., angry that I would be facing a full schedule of patients with only a few hours of sleep,
angry that the trust between us had been broken. Yet there we were in an ER setting, in a cubicle that afforded little true privacy due to the constant comings and goings of the staff. It was not the
place to begin processing what had occurred. I decided to tell Ms. A that while we would need to talk about what prevented her from being more honest with me in the beginning, I stressed that she
had made the right decision to go to the ER. She seemed embarrassed and was apologetic for disrupting my night, but she also assured me that she was feeling much less anxious. Her attending
physician assured us that there was no physical danger and that she would be discharged after receiving Ativan to help reduce her state of overstimulation. I took my leave and arranged to see her
later that day for our usual session. Trying to engage in any form of therapeutic process at that point would have been futile, not only due to my state of mind but also because the space itself could
not provide the necessary sense of comfort, privacy and authenticity to promote a reflective dialogue about what had occurred. Needless to say that the repercussions of this night lasted long into
the analysis in both negative and positive ways.
A brief hypnotic intervention in an oncology setting

Mr. B was a patient who had been referred to me by his oncologist for symptoms of depression that seemed to be both a sign of his sense of helplessness in the face of a recent diagnosis of
lymphoma and also the consequence of a series of narcissistic blows in his life that included the loss of his job, relationships problems, aging and now cancer—the body’s ultimate insult to a man who
had always thought of himself as unstoppable and in control of his destiny. Sporting a brittle grandiosity, Mr. B struck me as a likeable rogue, who used his considerable charm and affable manner to
induce those around him to support his exaggerated view of himself. We worked together for two months, meeting once weekly, and I was able to help Mr. B consider the various contributing
factors to his depression. I clarified how his recent life story was a series of losses and disappointment that together could break anyone’s spirit but that would be particularly difficult to someone
who placed such value on self-sufficiency and being strong. I emphasized how coming to terms with these changes would entail developing new strengths, an idea which Mr. B took hold of and used
to turn around his growing despair and sense of futility. I should note that we had a particularly warm and strong alliance that likely contributed to the development of a twinning transference
whereby Mr. B felt we were jointly facing and fighting his cancer and depression.
On a day when I was scheduled to see him in my office I received a message from one of the blood lab technicians to let me know that Mr. B would be running late due to difficulties with his
recently placed port (a device that is surgically implanted in the chest that allows for easy access to a vein thus simplifying the use of IV’s for chemotherapy). The staff were already aware of his
treatment with me as he had made it a point of pride to let them all know about his “personal shrink,” and so the technician felt comfortable informing me that Mr. B was becoming anxious about
his port not working and that he was worried that he would have to return for a second surgical procedure to fix it. Knowing that setbacks were particularly difficult for Mr. B and that he was
invested in putting on a brave face for the staff and being perceived as indefatigable, I asked the technician to check with Mr. B to see if he thought I could be of help in reducing his distress. Mr. B
asked to see me and as I made my way up to see him, I thought about his often overly familiar style and outspokenness and I wondered if he would say something in front of the technician that
would later feel embarrassing or too revealing. With that in mind I resolved to take charge of the situation as quickly as possible by focusing his attention on the problem at hand and to propose
teaching him self-hypnosis to help himself relax and to increase blood flow. My strategy worked, in part because Mr. B was already feeling deflated and not his usual ebullient self and also because
his attention was fixated on his port. He offered me a weak, defeated smile when I saw him and I asked him to tell me his assessment of the problem, with the hope of rekindling in him some sense
of control and agency. The nurse concurred with his description of how they were inexplicably having difficulty accessing the port, and she also agreed with him that a return to the surgeon might
be necessary.
I informed him that I suspected he could be quickly helped with the application of self-hypnosis that I could teach him to do that moment. I noted to him that there were a lot of potential
distractions as we were seated in an open cubicle with a steady stream of staff passing by. I would need his utmost attention so that he could focus on my voice as I helped him enter a hypnotic state
and he would need to remain focused throughout so that he could later use hypnosis for himself. Here I was mindfully using the surrounding environment as a rationale for requesting his focused
attention on me, all the while intending to distract him from his anxiety about what the technician was doing. This worked well as he readily closed his eyes upon my suggestion that they were
growing heavy and he became visibly relaxed. I continued in a soothing tone to describe how he might imagine his entire body relaxing, his heart beating calmly and steadily just as his breathing
felt calm and steady and feeling an opening up inside himself as he became more hypnotized. My calm tone and occasional reassuring comment on what the technician was doing while his eyes
were closed also acted as an indirect suggestion to the technician to feel less tense and anxious. I suspected that part of the difficulty was that she was also becoming flustered, but as I continued to
speak I also noticed that her actions seemed more smooth and decisive. Within three minutes she had accessed his vein and his blood began to flow. The relief and delight that Mr. B felt was
palpable and I ended the intervention by asking how it had felt and by offering him positive feedback on how responsive he had been. In our follow-up session, I addressed how it had felt to work
with me in that situation and the key point he emphasized was how everything around him seemed to fade—through focusing on my voice he had been able to set aside any sense of distraction and
sense of dislocation. One question that this example raises is whether the use of hypnosis, with its effect of intensifying transference, helps patients become more comfortable in an unorthodox
setting. What is clear, however, is that it is possible to take steps to ensure that the patient feels comfortable and safe enough to accept a therapeutic intervention and to benefit from it. Whether
exploratory work involving interpretation of transference and resistance is possible outside the office, however, will be considered in the next vignette.
Treating a dying patient in the home

Mr. C had been diagnosed with metastatic lung cancer four months prior to seeing me; his prognosis was poor but he felt compelled to seek me out as he had recently begun to experience panic
attacks that were triggered by taking showers. We were able to clarify that his anxiety was in part due to the fear that he might have to renounce his independence and in so doing also begin to
accept that his disease was progressing. Mr. C was a deeply intelligent and sensitive man who could accept the possibility of death, and felt little fear about dying, yet who also refused to
prematurely surrender his joyous engagement with the world around him. He feared that continuing anxiety would taint his enjoyment of the remaining months of his life but over the course of
two months of once-weekly therapy I helped him to talk about his underlying fear of the unknown and his symptoms of anxiety receded. Over time, his anxiety occasionally re-emerged but only in
response to increased pain or physical concerns such as nausea and vomiting, and this seemed an appropriate reaction and quickly disappeared once the physical concern was managed.
His mood steadily improved as he focused on being active with family and friends, and pushing himself to counter feeling trapped and passive. However, within two months, his tumours
increased in size by twenty percent and by the third month of our treatment he was admitted to a hospice. Knowing that he had a private room and aware that he had been upset by the sudden
disruption in our work, I visited him there. We discussed his changing goals and he explained to me that he wished that he could continue to see me as he felt that he was “getting into deeper
things” in therapy and he wanted closure on our work. He explained how cancer had become an opportunity to understand himself and his life in a more reflective and satisfying manner. I felt no
misgiving continuing our therapy despite the necessity of now seeing him in his home; we had developed a warm and close relationship and I felt that his request was appropriate and that it also
reflected our shared sense that there was more we could do together to help him as he faced death. Thus the decision to see him in his home felt like an authentic response to his approaching death
that reflected our deep investment in the therapeutic relationship.
I spoke to him about the practicalities of continuing therapy in his home and I explained the need for a comfortable, private space where we could meet uninterrupted. I suspected that his comfort
would be the most important accommodation due to growing weakness and pain. He thoughtfully considered how we could achieve this and he explained that he would be spending most of his
time in a hospital bed in his living room—this was a large comfortable space that could be closed off from the rest of the home. He conferred with his wife and she agreed this was a good idea, and
indeed she was relieved to hear that I could continue to see him as she had seen how our sessions lifted his spirits. A week later I began weekly visits to see Mr. C in his home which was a warm and
welcoming space; his living room contained several small modelling projects that he was working on. These were a source of great pride and we frequently talked about them and his investment in
them as parts of himself that he would leave behind. He had also been correct in describing the space in which we met as both comfortable and private. Of course, meeting his wife beforehand and
knowing that she was strongly supportive of continued therapy as well as respectful of boundaries helped me feel more at ease in visiting him. Like many terminal patients, he vacillated between
his acceptance of death and his hope that perhaps he could rebound and eke out a few more months on chemotherapy.
The early home sessions focused on his concern about being a burden to others, especially his wife; I used this as an opportunity to address his concerns that it was a burden for me to visit him. He
also had a scary experience of his blood pressure dropping to 80/40 and he was critical of himself for being distressed; as a deeply religious man he felt he should be more accepting of death. I
suggested that perhaps acceptance of death would mean allowing himself to feel human fear and uncertainty rather than striving for some detached and idealistic response. Mr. C pondered this and
agreed that he had work to do on accepting his human limits; subsequently he experienced physical setbacks with much less agitation and distress. He continued to decline physically although he
remained alert and sharp-minded. He became frustrated with himself whenever he struggled to remain awake and focused for visitors and I encouraged him to explore his sense of obligation to me
and his fear of “wasting my time”. He was able to express his concern that he ought to always be productive with me because I was making so much effort to go out of my way to see him. We
discussed this as a general transference concern he had about people in his life but also as an expression of his concern over abandonment as he prepared to take leave of those he loved. However,
given the usual circumstances of our work at this point, and the risk of an intensified regression in the face of declining health, I also felt it was important to clarify that the time burden was
relatively minor as his house was on my way home and I left work earlier in order to see him. This seemed to produce a greater sense of ease for him in our work and he noted how he felt more
able to be open with me about how his physical suffering. He also took comfort from the idea that loss of physical control could be offset by a sense of increased psychological control he
experienced by talking honestly with me.
Three weeks before his death, as he struggled with increasing weakness and chest pain, he again began to discuss his concern about how my visits must be an inconvenience because of the time it
took and he worried about me coming during winter. As I encouraged him to say more he had the impressive insight that my decision to see him in his home placed me in a position whereby I was
out of my own comfort zone and forced to adapt to his environment, and that in fact I had to surrender a certain amount of control. This marked a point of lived understanding for both of us of
what he was suffering through and while I would go on living, he had experienced a sense of connection with me in the face of final separation. When he died soon after, I felt a deep sadness yet
also a profound gratitude that I had had the opportunity to continue our relationship beyond the office. In many ways, it was the dislocation itself that finally helped us bridge the unspeakable
unshared.
Theoretical and technical reflections

As psychoanalysts, it behooves us to be curious about the feelings and fantasies stirred up in our patients and ourselves by meeting in a new space.3 For the patient, a significant change in the frame
of therapy often gives rise to an intensification of transference wishes, such as the desire to be a part of the therapist’s life outside the office. The patient can also experience a shift in their experience
of the therapist’s omnipotence and perceived power as the “home advantage” of the office is lost. The patient may also feel more intruded upon as the change in location, e.g., a home visit or a
hospital setting, may involve the therapist visiting them rather than vice versa, thus depriving the patient of a necessary sense of choice about engaging in therapy. It has been my experience that
patients’ primary conscious concern is that the therapist is not feeling discomfited or inconvenienced, although this is often expressed as concern about having to travel to a new location rather than
the physical space itself. Rarely will a patient spontaneously comment on how the space may require readjustment on both their own and the therapist’s behalf. Further inquiry can often reveal a
sense of gratitude mixed with guilty pleasure that the therapist thinks enough of the patient to make such an accommodation. Patients may wonder if the therapist makes such exceptions for other
patients and the therapist must be sensitive to the potential costs of imagined victory over “sibling” rivals.
It is also easy for both the therapist and the patient to defensively overlook what feels unalterable, namely the physical setting and to focus instead on everything but the setting. Yet, if one pays
attention to one’s own thoughts as a therapist in an unfamiliar setting it is readily apparent that one is working to orient oneself not only to the patient but to the space itself. Questions such as
where to sit, awareness of sounds and distractions, distance from the patient, presence or absence of a clock, lighting, heat, or cold—all are being assessed and adjusted to, often with little discussion. I
would suggest that if the patient does not mention the change or if there is not a clear reference to it in their initial associations, then the therapist should acknowledge it and inquire about the
patient’s reaction. While it is not common analytic practice to lead patients with direct questions, I believe that unusual circumstances require unusual accommodations and asking how it feels for
patients to be in a new setting can encourage them to pay attention to their inner response to the change. Equally important is that it may also enable them to overcome any guilty inhibitions about
discussing the change—they may feel that they have asked too much of the therapist by having them meet outside their office and so defensively avoid the topic. And, of course, if the patient has
much to say about the change, it is also reasonable to ask if they would have mentioned their thoughts if the therapist had not asked. This line of inquiry can be of benefit in a variety of ways: not
only might it help the patient feel more comfortable about the change, it conveys the importance of speaking about associations to the setting and it can also lead to a clarification of resistances to
the transference as patients struggle to articulate their fantasies about what the change means to the therapist and what it says of the nature of their relationship.
All locations are not created equal. Specific locations “pull” for particular responses and create unique challenges. Due to my clinical involvement with oncology patients, my most frequent
“unorthodox” location for therapy is in the hospital or a chemotherapy treatment room. With the recent increased interest in health psychology and the continuing development of the field of
consultation liaison psychiatry within hospitals, I suspect that the hospital will remain the most common alternative therapy space to the office. Within the hospital setting, I would further
differentiate treatments that occur in the emergency room from those occurring in hospital rooms. Home visits are also becoming relatively more common as psychotherapists begin to work with
dying patients and hospice organizations (Connor, 2010). Some therapists are opting to become “embedded” in primary care offices and may often be expected to initially meet patients in a
consulting room before agreeing to meet regularly in their private office which may be located off-site. Finally, there may be more unusual circumstances that dictate meeting, for example in a hotel
room, a coffee shop or outdoors. While some may be aghast to think that any circumstance would require meeting in such unusual and open places, recall that Freud met Katharina in an inn where
she was serving him, and treated Mahler while out walking. Before discussing the potential pros and cons of such locations, let me state what I believe is of paramount importance in deciding if any
space is suitable for a psychoanalytically therapeutic encounter.
First and foremost is the provision of privacy, which must be respected if the patient and therapist are to feel at ease engaging in a psychoanalytic process. This is not only a professional mandate,
but a therapeutic one, too. However, certain settings inherently limit the degree of privacy and often lack of privacy may dictate the form of intervention. For example, a lack of privacy may require
that the therapist works on a supportive level to avoid exploration of deeply defended material, both in order to respect the patient’s dignity but also out of necessity, as there will be a stronger
resistance to the emergence of unconscious material in the presence of a larger public audience.
Secondly, both parties must feel adequately comfortable—physically, that would mean a comfortable place to sit that is neither so far apart that hearing each other is difficult or so close that it
feels cramped. The surrounding environment should also be comfortable—a reasonable temperature so that neither individual feels too cold or hot and comfortable lightning that is neither too
bright and harsh nor oppressively dark. Sufficient freedom from distraction and interruption is also a form of necessary comfort, and prerequisites for the patient and analyst to be able to turn their
attention to internal process. Both the therapist and the patient should feel relatively at ease in the space. The psychological state of the patient should also be considered when assessing comfort.
The significant change in the frame occasioned by meeting outside the office can be destabilizing for patients who are already regressed or in the throes of an intense transference. Furthermore,
patients who struggle with maintaining boundaries or who have trauma histories that involved boundary transgressions should generally not be seen outside the office.
Hospital rooms can create particular difficulties with regard to the need for privacy, as patients may have a roommate in an adjoining bed or there may be multiple intrusions from hospital staff.
If a roommate is present, it may be possible to move the patient to a separate meeting room or lounge area. If this is not possible the roommate may be willing to leave, or sessions may be
scheduled when the roommate is expected to be out receiving treatment, e.g., physical therapy or scans. Failing these possibilities, pulling over the adjoining curtain and speaking in a lowered voice
while keeping the TV on may improve the situation and the patient could be informed that it is understandable that discussion of deeply personal concerns has to be postponed. However, it is my
experience that hospital patients can often become quite regressed or overwhelmed by their situation and often undervalue their privacy for the sake of being able to express their distress. The
therapist is then left to decide if the patient’s distress is sufficient to warrant the chance that a roommate would hear what is being said. Intrusions can often be more easily managed by the therapist
introducing himself to the charge nurse on the unit and explaining the need for uninterrupted time with the patient. If the therapist regularly sees patients in a particular unit then cultivating a good
relationship with the nursing staff is essential.
Emergency rooms can present similar spatial problems in terms of trying to maintain some reasonable level of privacy—in some emergency rooms patients are only divided by a curtain, and
obviously one cannot ask a neighbouring patient to get up and leave. The therapist can model speaking in a low voice in order to not only increase privacy but to also induce greater calm in the
patient. Interactions with the staff who are often working under pressure and accustomed to the intensity of the ER can feel strained—the slower, calmer work of a psychotherapist can feel jarringly
out of place and may be met with skepticism. However, asking for their assessment of the patient’s situation and then explaining how one’s interaction with the patient may help calm the patient
and make their work easier often leads to greater cooperation. The patient is also likely in physical discomfort due to whatever presenting issue brought them to the ER and an assessment must be
made if the patient is indeed capable of benefiting from any form of psychotherapeutic intervention. Noises from adjoining cubicles can be distracting or even unsettling and I believe it is often
helpful for the therapist to comment if the patient has an obvious reaction and to acknowledge how difficult it can be to be a patient in an ER setting.
Consult rooms in medical settings, such a primary care practice, often afford much greater privacy and typically the therapist working in such settings already has a strong, positive relationship
with the staff. However, the patient may be habituated by the cues of the consult room to treat the session as a medical encounter and adapt a relatively passive role, providing factual answers only
when asked. Manipulation of the space, such as moving the chairs, insisting that the patient does not sit on the examination table and changing the distance between each other can help signal that
this a different type of interaction.
Seeing patients in their homes for therapy will almost invariably require the cooperation of their family (or housemates) if privacy and minimal distraction is to be ensured. The therapist is not
simply entering the patient’s home, but a home they share with others and that is a reality that must be respected. Often, one will need to request that a room is set aside for the session that might
otherwise be used by others; doors that are typically left open may now be closed, and furniture may need to be rearranged. It is advisable to ask the patient beforehand about the feasibility of
arranging a private and comfortable space for therapy in their home before agreeing to see them there. And just as a medical consulting room may pull for certain habitual responses form a patient,
be prepared that seeing a patient in their own home setting may present you with a new side of their character—greater ease or confidence, increased familiarity, or a harsher side that is evident in
interactions with their family. Also, in contrast to the professional setting of the office, the patient’s home is a uniquely intimate space that can give rise to a range of transference and
countertransference experiences. A common positive transference response is the patient’s experience of the therapist’s visit as a sign of their special commitment to the patient. Such feelings can be
deeply comforting to dying patients as they face pending separation from loved ones. On the other hand, home sessions should be avoided with patients who are in the throes of an erotic
transference as the location will likely prove to be too stimulating and invite attempts at boundary transgressions.
Finally, I would like to mention a particular example of therapy in a seemingly orthodox yet effectively novel setting and that is the occasion when one must use a colleague’s office rather than
one’s own. Such instances may occur for example if one’s office is temporarily unusable due to construction, or due to environmental problems such as flooding or strong odours, electrical problems,
faulty air conditioning, a fire drill, or fire damage. Many of the basic concerns that I mentioned above are a moot point—one would hope that colleagues also value privacy, comfort, and freedom
from distraction. However, the novelty and nature of the space itself will impact both the therapist and the patient. The patient will likely be very curious as to how the new office compares to yours
both in terms of size, comfort, and design; if they are not, then it is you who should be curious about their seeming indifference! The therapist may also feel acutely aware how their own office
compares—is it more thoughtfully designed, does it have more space, a better view or is the furniture more comfortable or newer looking? Also, the possible introduction of new art or curios invites
comparison and comment from patients—while also reminding both parties of the absent third—the owner of the office whose personal choices and preferences now come to define the space in
which the therapy occurs.
Conclusion

As psychoanalytic practitioners, we strive to create optimal conditions for patients to engage in the often difficult process of self-reflection and exploration of their unconscious. At their most basic,
these conditions necessitate the patients’ feeling comfortable and safe from intrusion and distraction. Patients must also feel free to express whatever may come to mind, even if doing so often meets
with internal resistances, and thus, privacy is also a necessary condition for our work to occur. Our offices are typically designed or arranged with these conditions in mind; indeed, we so naturally
rely on the physical setting to provide these conditions of the therapeutic experience that, like a “good-enough mother” (Winnicott, 1960), the importance of the physical environment can often be
taken for granted. However, recent changes in both the scope of psychoanalytic treatment and also in the range of practice settings in which therapists work can occasionally necessitate radical
changes in the therapeutic setting. This chapter has described examples of possible alternative locations in which therapy can occur, such as hospital rooms, emergency rooms, and the homes of
patients. In such settings, special provisions must be made to ensure an adequate provision of comfort, safety, and privacy. The therapist needs to be aware of the changes wrought by a new
environment and actively seek to compensate for these changes. The therapist must also attend to associations in the patient’s material about the setting, and remain mindful of their own response
to the change. Such changes can result in both the patient and the therapist feeling uncomfortable and, quite literally, unsettled but effective treatment can occur outside the office.
Notes
1. Instead of inserting page numbers for each quotation throughout this section on the case of Katharina, I will simply note that all quotations come from pages 125 to 133 of the referenced article.

2. On May 6, 2006, the 150th anniversary of Freud’s birth was celebrated in Leiden. The event, sponsored by the Dutch Psychoanalytic Society and the Embassy of Austria in Holland, included a replication of this walk.

3. While important, accidental encounters between the patient and the analyst outside their regular meeting place (Strean, 1981; Tarnower, 1966; Zuckerman & Horlick, 2006) are not what I have in mind here. My focus is upon the analyst’s deliberate choice of seeing the patient
in a place other than his or her office.
Chapter Three
Changing the frequency, length, and timing of sessions

Frances Salo

This chapter selectively reviews and considers some of the potentially profound aspects of a change in the temporal framework of sessions in analysis and psychotherapy. It aims to explore
interventions that many analysts make, sometimes feel that they are “forced” to make, and assess any risks and potential benefits. The dialogue in the analytic space has special features stemming
from the special device of analytic time (Puget, 2009), “a time out of time” (Kurtz, 1988, p. 990). When the analyst alters the temporal framework, with its fixed times, length and number of sessions,
it affects the patient’s sense of self as a continuity in lived experience through time, through its reverberations of the patient’s history. While a number of analysts have generously shared details of
such interventions, for reasons of confidentiality many have not been named.
The analytic session offers the patient the possibility of becoming conscious of his or her unresolved relationship with time (with their history and experience, unresolved pre-Oedipal, Oedipal,
and transgenerational conflicts) (Milmaniene, 2009). The set time and length is an essential part of the frame, and the temporal structure of the setting allows the different temporalities of the
patient’s internal world to become conscious to the patient and the analyst. Containing and challenging the patient is what underlies the high frequency of analysis (Rose, 1997). The importance of
the temporal framework is far removed from any implications about the use of time as trivial, as often explored in literary works. There is extensive literature on psychoanalytic perspectives on the
sense of time and of timelessness in the unconscious—the only temporal dimension the unconscious takes is that time does not pass (Pontalis, 1997). There is similar literature on the part that time
plays in analysis (e.g., Arlow, 1986; Green, 2002; Hartocollis, 1983), and on the meaning of time within the culture (Akhtar, 1999a, 1999b). In comparison, detailed literature as relevant to the focus of
this chapter is relatively less; while references to it permeate the clinical literature it may not have been examined as fully as it might have been.
The mother’s care, Winnicott (1961) wrote, enabled the infant to “catch hold of time” and research suggests that infants are aware from birth of rhythm and time. Stern (1985) suggested that the
infant’s sense of self is constructed out of memories of their affects and histories. The analyst’s intervention meets a layering cascade of fantasies and life experienced. A four-year-old boy patient
who was terminating in analysis told me, “Don’t think that this place is an airport”, meaning that children are not like aeroplanes running according to a schedule; a six-year-old girl who had been
adopted at two years of age told me, “You have to remember so much harder when you are adopted” and an eleven-year-old boy who had been placed in a children’s home told me, “time
disappeared” when he could no longer remember his sister’s face from a few months previous. For each of these children, time had a highly personal significance with which they would respond to
any interventions.
I propose to consider in this chapter the topics of changing the time, length, frequency and timing of sessions and conclude with termination of analysis. Consequences of interventions to a
previously agreed-on frequency will be covered but not the arguments underlying the number of sessions offered per week. When the analyst changes times, how does the patient hear it—is the
analyst changing the contract, saying that time and his/her mind is not available? The frequency and duration of sessions may be more context-dependent then than analysts often acknowledge. The
number of sessions per week, for example, whether it is four or five sessions, may vary according to country, local culture, and the personal circumstances of the analyst. In considering any changes
to the usual temporal frame, it is important to consider the context of the analysis—the strengths and vulnerabilities of the patient and the history of their analysis or therapy.
Varying session time

Sometimes sessions are varied for ostensibly practical reasons such as when an analyst shortens a child’s session time by five minutes in response to a parent’s request because of a change in the
school timetable. Requests to change times of session, however, whether on the part of the analyst or patient and whether on a one-off basis or permanent, inherently face many transference-
countertransference difficulties. Many analysts, if the patient requests a change in the times of sessions for external reasons that seem reasonable, usually offer such changes if they can be
accommodated within their schedule. Some, however, do not for various reasons: Laufer (1991, personal communication) described not always offering a patient a makeup session as this offer could
unhelpfully increase the envy of the analyst perceived as having an endless cornucopia.
Langs (1989) in his study of patients’ responses to frame breaks, stated that every accommodation to a requested frame break was always followed by associations which suggested that patients
viewed it as measure of the analyst’s insecurity in the role, an inability to hold the patient, and perhaps as exploitation, seduction or use of power. Further study of the patients’ associations indicated
that the analyst should have refused and kept the frame intact. Langs gave an example of a patient whose analyst inadvertently kept the patient ten minutes over the agreed-upon time limit and
while subsequent associations could suggest symbolic material around fear of the father’s castration Langs, preferring to work in the here-and-now of a “communicative analysis”, related it back to
the frame break as he felt most patients wish to revert to the original frame. One question is whether there are developmental considerations to take into account, for example, when an adolescent
patient is rebellious about an early morning time as he wants to sleep in. Does occasionally offering a later time when possible safeguard the analysis in recognition that sometimes the patient needs
to feel that their difficulties have been heard and responded to courteously or is this an enactment? This question will be returned to in the discussion.
Some analysts have described initiating the offer of another time when the patient indicates that they are unable to come to a session. Jacobs (2001) described his taking a corrective initiative on
an occasion when he interpreted that a patient had not asked for a change of time out of her anxiety about him. Once she had accepted his offer of a time she could then bring her feeling that he
covered up his irritation with her and he came to agree with her and to feel his offer was an enactment. Similarly, Meissner (2007) described the offer of a substitute time to a patient had the effect
of putting pressure on the patient who had wanted to skip the hour, but he accepted the time. Meissner thought that he himself had unconsciously created an authoritarian impasse that violated the
patient’s autonomy. He considered it was an enactment and changed his practice to not offer a change of time unless requested by the patient.
Slightly differently, an analyst’s offer to let a patient make up the sessions she would otherwise lose if she went on vacation allowed an analytic dyad a way out of a technical difficulty. Geerkin
(2010) described how her young adult patient, Beatrice, had wanted to take a holiday and accused the analyst of taking her parents’ money for sessions that she did not attend. The offer to make up
missed sessions was regarded as “a creative solution”, in which the patient’s parents did not “waste their money”, the analyst did not lose her fees, and the young woman could set off on holiday.
This “exchange of gifts” freed up the situation by partly satisfyingly the patient’s demands and it was felt that it allowed the analysis to continue. Barredo (2010) commented that Geerken had
showed “a willingness to give up her need to control the situation and let herself be surprised by the suggested solution” and this allowed her “to find the ‘rhythm’” and take up her role as analyst
again, which enabled forward movement and new topics to emerge.
An analyst’s change of times or cancellations are likely to be met by the patient with feelings of being slighted and hurt, and of feeling special, grateful, and envious. Schwaber (1996) gave an
example of when she made a couple of changes to her schedule that she thought would be acceptable to her patient; in the next session the patient was in a confused state, immersed in implicit
memories from a time when she was four years old and her mother had temporarily lost her. This helpfully brought into the transference the fear of the anger of the mother/analyst and the sense
that her time and her possessions were given to other people.
In another case, a series of cancelled sessions by the analyst led the patient to feel abandoned by the analyst, and he became covertly vengeful towards him, paying his account late and missing
sessions (Beattie, 2005). He also developed what appeared to be a near-psychotic thought disorder. This, however, enabled the idealizing transference and his guilt to be analysed. Ferro (2005)
describes a perhaps relatively inexperienced analyst cancelling an appointment and offering to replace it with a session later in the evening. The patient accepted but felt that she had to submit,
recovered her wish to be more relaxed like her analyst and then was able to bring in her feared violent and mad split-off aspects, with material suggestive that she felt her analyst stole from her and
should be tried in court. While on the one hand, Ferro describes the offer of time as a kind of abuse on the analyst’s part, it however initiated material that could be productively used. To sum up,
Meissner (2007) stated that the analyst coming late or interrupting the schedule can be taken by the patient as their not being invested enough to be keep their side of the contract and is never
positive to or contributory to the effective work of the analysis. He pointed out that when patients speak out of a transference context about the analyst neglecting them with his or her time away
from the practice, they may have a point that the analyst needs to consider. However, it seems that in many of the examples given the analytic process had continued and perhaps even been freed
up with the changed session time, and this point will be returned to in the Discussion.
Varying session length

Varying the length of sessions needs first to be set against the cultural context in which the analyst works. For example, in some countries, e.g., the United Kingdom, the fifty-minute session is
standard, whereas in others it may customarily be less. It may be forty-five-minutes to fit in with the analyst’s timetable or when that is the length of time for which an insurance company or other
agency pays a rebate. The practice of having no break between sessions produces resentment in patients who feel that the analyst is preoccupied with managing the transition and has hostilely
deprived them of time (Greenson, 1974). Here I shall mainly explore the analyst increasing or decreasing the frequency of sessions. Lacan thought that the session should not end routinely but as a
significant act when important material emerged. “The interruption would then acquire the value of an interpretation” (Aisenstein, 2010, p. 463). This technique has been critiqued by many analysts
including Etchegoyen (1991) as carrying a “heavy burden of a training through rewards and punishments” (p. 513). The shortened or less frequent sessions of the Lacanian approach will not be
discussed in detail here as it does not seem appropriate to extract this from a whole body of theory, explicated for example, by Etchegoyen (1991) and Green (2002).
Developmentally, it would be expectable that therapists engaging in parent-infant or child therapy would work with sessions of variable length in order to fit in with the needs of the infant or
child. With some child patients, many therapists recognize that at certain times it may be more therapeutic to finish the session earlier than the standard length. With a six-year-old boy in analysis,
who was referred for a “fetish” for stroking women’s long hair and dressing up in their clothes, I came to recognize that a fifty-minute session felt persecuting and I adjusted session times closer to a
thirty-minute one. Sometimes, with a child who has become out-of-control in a session, rather than battle on, an analyst might stop a session early and explain why. At a particular point in the
analysis of a six-year-old patient, he kicked me hard and with the pain I felt hurt and angry. I decided to stop the session early explaining that I needed to be able to think and we would meet again
the following day but not go on seeing each other that day. As Winnicott (1947) wrote, the analyst needs to be able to hate the patient yet temper his or her hate.
Some analysts have described that their intervention consists of a more or less implicit agreement with the patient not to intervene if the patient needs to end the session say a couple of minutes
early out of extreme anxiety or their need to control. What is critical is that in time this can be interpreted or the patient comes to understand for themselves the need to control. In one case, a
patient had needed to change analyst for training purposes and had not fully made the analysis his own. His leaving analytic sessions a couple of minutes early for a number of years was
multidetermined; it functioned as a pocket of resistance as well as giving the analyst the experience of helplessness. The analyst interpreted if it seemed appropriate, but chose mainly to bear in the
countertransference the experience that the patient needed to communicate. Freud’s (1913) technique included “occasionally” prolonging a session to longer than one hour with less communicative
patients, “because the best part of an hour is gone before they begin to open up” (pp. 127–128). Winnicott thought that sessions with very regressed patients with borderline personality difficulties
needed to be longer than an hour and variations should tend towards lengthening the session with perhaps a longer space between sessions (Green, 2002). A number of analysts have acknowledged
briefly extending the session to give the patient an extra two to five minutes at a time of particular stress or vulnerability, if the material was important and until a reasonable point of closure was
reached. These occasions are mostly not reported as having negative effects but positive ones. If a patient tries actively to extend the length of the session, the analyst can either keep to the frame or
extend the time. Extending the time may acknowledge in a helpful way the patient’s needs and wishes but also contribute to countertransference difficulties: analyst and patient may engage in a
transference-countertransference enactment which the patient experiences for example as a seduction.
Kurtz (1988) gives a vignette in which both the time of the session and its length were altered. He recounted how he went over the end of the session without realizing it, which resulted in his
male patient bringing material about a car crash he had witnessed as a child. In the next session, Kurtz suggested they move the patient’s session to the end of the day to keep this flexibility possible,
for a patient who struggled against feeling inhibited. The patient was at times able to experience feelings more fully and gradually this tended to happen more often and in shorter time spans. In
parallel, the handling of the end changed. “I allowed myself to be guided either by my feeling that the natural end had come or that it would not be reached in the length of time I was willing to
continue. (‘Natural,’ here, indicates the achievement of a state of mutual satisfaction such as that of a symbiotically attuned mother and infant.)” (p. 994). The patient had experienced endings as
painful and asked the analyst to prepare him for them shortly beforehand and was gradually able to do this himself. Increasingly, sessions ended within the standard time and he asked for an earlier,
more convenient time. Kurtz, while suggesting that this might be viewed as a special case, nevertheless, saw this as embodying a universal principle that if the analyst provides a framework with a
beginning and end, the patient will structure the session in ways that reveal his feelings. Using a flexible hour may or may not be needed “but, provided the analyst’s own time sense is open, the
patient will eventually be able to take clock time into account without losing its affective measure” (pp. 994–995).
If patients are caught up in intense affect at the end of the session, they may need a few minutes to compose themselves. This is different from the experience of a number of patients who, in the
midst of intense transference feelings, particularly in a regressed state, were unable to leave the consulting room. While extending the time tends to lead to countertransference problems, it is
sometimes inevitable and has to be managed. Coltart (1989, personal communication) reported a dramatic example when a patient refused to leave her analyst’s living quarters (above her office) for
the best part of a day. Rather than calling the police, which Coltart knew from the patient’s part history would have a negative effect, she chose to allow her to say until her mental state had
improved.
If an analyst runs over time this will also produce reactions to what may seem a trivial, inadvertent break of routine. Lichtenberg and Slap (1977) report an occasion when an analyst, who was
engrossed in his efforts to understand a dream related by a young woman late in the hour, allowed the session to run over by five minutes. This patient, relying on the analyst’s integrity, had
previously suggested that they spend an analytic hour in a nearby hotel. That night the patient had a dream that she was being chased through a subway by delinquents whom she associated to
characters in a novel who had been part of her adolescent masturbation fantasies. She then recalled the extra few minutes, and with feeling made the connection between the past sexual fantasies
and her current wishes. Subsequently, she took a more analytically productive attitude towards her erotic feelings for the analyst.
While an analyst’s lateness for a session is not a planned intervention, there are a number of recorded occasions of an analyst being a few minutes late for a session and the patient’s extreme
sensitivity to this—in one case with an analyst who took five seconds longer than usual to answer the doorbell. When an analyst has been say, five minutes late, the analyst’s offer to make it up at
the end may well be heard not only as fair but also as the analyst’s exercise of power in a situation where they are felt to be indifferent to the patient, and as such pulls material into the sessions.
Varying frequency of sessions

From a North American perspective, Meissner (2007) reported that many analysts find reducing slightly in frequency to enable patients to continue in treatment until they could resume a four-
times-a-week schedule does not seem to make much difference. From a similar perspective, Ehrlich (2010) discussed a case when the patient presented with financial difficulties, and the analyst
considering reducing to a lesser frequency could have resulted from the analyst not being able to fully keep the patient’s analysis in mind. The increase from three- or four-times-a-week intensity to
five-times-a-week is usually noted to make a difference, mainly in intensification of the transference. Interruptions in sessions because of the analyst’s pregnancy have been reported as having a
productive effect in enabling the patient to work through related difficulties (Reenkola, 2010). Respecting the patient’s judgment about their needs and requests to vary the frequency of sessions is
sometimes thought to be paramount. Puget (2009) described how some patients request therapy with her after having had analyses with other analysts and feel that they want to concentrate on
what is happening for them in the present rather than on the past; she came to feel that it was appropriate for the analyst to actively accept this.
The analyst’s thoughtful response to the “presence of absence” is called for when the patient does not attend for what may be quite some considerable time but there seems to be an analytic
process underway. Symington (personal communication) described a patient who had previously been in analysis with another colleague and, after starting analysis with Symington, wanted to
reduce the frequency of the sessions. He agreed, feeling that it was important for her to develop a sense of autonomy of her self. The patient continued to reduce the frequency of her sessions to
about once a month and then gradually was able to ask for them to be increased back to the initial frequency. Symington felt that this had had a therapeutic outcome. Similarly, an analytic therapist
described a patient with borderline personality difficulties who, at a time when the patient was extremely fragile, was mildly abusive with her on the phone and then did not attend for three weeks.
The therapist was able to keep sessions available, knowing that this was a pattern in the past and aware that not all therapists are in a position to do this if there are financial constraints or perhaps
are less experienced. Two analysts described patients not attending for several months although in each case the analyst kept their sessions for them and felt that there was an analytic process of
some kind in place. In one case a cheque for payment of sessions was posted to the analyst at the end of each month for three months without the patient having attended sessions. When the
patients returned to analysis, they felt that it was important to have been allowed to complete this experience, and their analyst concurred.
Several analysts have found that for patients in a relatively severe regressed state, for example, a neurotic patient during a period of intense infantile transference neurosis or in patients with
borderline personality difficulties, separation from the analyst can result in disorientation and other difficulties. A psychiatrist described in supervision a very deprived patient with whom she had
been working for a number of years and would increase the number of sessions at times of need. She commented, “We often meet four times a week before a break, up from once or twice a week,
and I don’t know where I stand”. This apparently not-knowing state belied the fact that this seemed appropriate for this patient at this point when she had allowed herself to become more
vulnerable and dependent on her analytic therapist. With the increase of sessions, this patient opened up in following sessions and brought new material from an early level. Greenson (1967) felt that
it may be necessary to see such patients during a weekend or to have telephone contact with them and that sometimes knowing the analyst’s whereabouts made it unnecessary to arrange for a
substitute to replace him. (Greenson also noted the technical aspect of countertransference responses in those analysts who seem compelled to work on Sundays.) He thought that the question of
who is leaving whom can be an important technical point with very sick patients and to spare such a patient the feeling of acute abandonment, he often found it advisable to allow them to leave for
a brief holiday a day or so earlier than he did. Differently, with a patient who in intensive sessions began to decompensate, Spero (1993) suggested that they discontinued the analysis as such but
continued on a session-to-session basis until the patient could follow the schedule. Attempts to acquire more of the analyst’s time through extra-analytic contacts have changed with increased
technological developments, with requests for telephone calls, emails, or getting the analyst to respond to a text message via mobile phone (an SMS) that the patient has sent, particularly outside the
time of their session if they have not attended or to prompt them in advance to come to a session (Stone, 2009).
Sometimes an analytic therapist feels that it is necessary to make an extra-analytic contact to keep the patient alive. Nathan (2010) described a dramatic intervention in a psychotherapy case. “I
made a sudden and unannounced emergency intervention into the life of the suicidal patient …. At the time I felt I had contravened the psychoanalytic canons of practice. However, I could no longer
bear the anxiety, the fear that my patient could kill herself and place her children at risk. The intensity of the anxiety, amongst other analytic considerations, I believed was diagnostic of an imminent
suicide …. The work demands at times that one must be prepared to be able not to bear uncertainty in the face of imminent death or injury or abuse” (p. 12). She therefore arranged extra contact
with the patient and her family. Akhtar (1999a, 1999b), in support of a flexible approach wrote that, “If the analyst can manage to have both flexibility of perspective and a tempered yet deep regard
for the spirit over the letter of the analytic rules and guidelines, he will be able to come up with what is technically needed” (p. 147).
Varying session timing

This section, which awaits fuller discussion, refers only to how therapists might cluster sessions in unusual ways, or with long and/or irregular gaps between consultations or moving sessions to a
particular time of the day. While most analysts might prefer to give each patient the same time every day or to have psychotherapy sessions on consecutive days rather than spread out throughout
the week, to maximize their effect, other analysts actively consider that in varying the times, different aspects of the personality can be seen as people do not function the same way at different
times of the day (Etchegoyen, 1991). Winnicott is well known for seeing patients with long and/or irregular gaps between consultations when patients had to travel long distances to see him or
during World War II when the regularity of consultations was interrupted. As noted before, he thought that with some patients, sessions should tend towards being longer with perhaps a longer
space between them. Currently, when a patient has to travel long distances for their analysis, sometimes between countries, the practice of shuttle analysis and concentrated analysis has developed
to assist in such cases. Here the temporal framework has changed massively. Qualitative research with such analysands suggests, nevertheless, that the motivation on their part is so strong that it can
compensate for the disadvantages of this arrangement (Etchegoyen, 1991; Szonyi & Stajner-Popovic, 2008).
Termination varied or decided by the analyst

Here those terminations which are either varied or imposed by the analyst are referred to, rather than mutually agreed upon terminations. In analytic training, it used to be taught that the prospect
of termination would ideally arise about the same time in the mind of the patient and in the analyst, or at least would be initiated by the patient and that the analyst does not usually set a
termination date alone. Green (2002) thought, however, that it is more likely to be the analyst who, several years after the start of the analysis, feels like raising the question of termination with the
patient who is by then well into the timelessness of the analysis. One analyst described how after eight years of analysis, when the patient did not consciously have the idea of terminating in her
mind, he was prompted in response to an intuition about the material to suggest a termination date two years ahead, which seemed beneficial in the analytic process. Some patients need at times to
increase the frequency, while others need to reduce the frequency to face the reality of the separation (Firestein, 1969); other analysts describe sitting the patient up, before reducing frequency and
duration of sessions analysis.
Much recent literature on termination has focused on interruptions, “impasses” and re-analyses (Kogan, 2010). When the analyst responds to an analytic impasse with an ultimatum about the need
to either work analytically or to terminate, this may propel the patient to be able to move through a potentially destructive phase and resume analytic work. Initiating termination is “a parameter of
treatment, which analysts may resort to, in order to counteract the effects of timelessness when those effects have become undesirable, counterproductive, or self-defeating” (Hartocollis, 2003, p.
949). But Freud’s (1918) setting a time limit in the Wolf man’s analysis can be viewed as a “forced termination” and considerable negative potential traced (Novick, 1997).
Analytic interventions that attempt to move the process of termination out of an impasse may be further tailored for the individual patient. Meissner (2007) describes how with a patient whose
analysis he had assessed as stalling, he suggested reducing the frequency from five to four hours a week to lessen the attachment to him (although he did not initiate setting a termination date). The
patient, after expressing his hurt and anger, quickly came to a resigned acceptance and continued the four-hours-a-week schedule for the remaining four years of analysis but with continued
reverberations about missing the closer contact of the five-hour schedule. One analyst described an inhibited patient in analysis for many years who was reluctant to terminate. In an attempt to get
beyond a strong resistance and drawing on Ferenczi’s idea of raising the clinical temperature in the analysis of the regressed patient to come closer to the resisted affect, the analyst suggested that
she might scream. While the patient was cross at the ending, she knew that even if another year was offered, she would still have to face at some point how impossible she found it to end. Initiating
the termination process may convey to the patient that the analyst has processed guilt about the analysis ending and is relatively satisfied with what has been achieved. To scream meant the patient
could experience her emotional pain about loss rather than defending herself from it and could end the analysis with sadness. In a continual dialectic between a more classical technique and the view
that it is important for the analyst to retain their flexibility, views about practice proliferate. While some patients have difficulty committing to the undefined period required for analysis, two
analysts recently acknowledged as though their stance was unusual and not quite correct, their active acceptance of a time limit imposed at the outset by the patient who said that because of a pre-
arranged work posting they would only reside for two years in the town where the analyst practiced. In both cases the analysts felt that an analysis under those conditions worked well.
Most analysts tell their patients that they will see them after termination if they need further help. One analytic therapist described a situation where her ex-patient requested a further two
sessions because her mother had died; the therapist agreed and offered twelve sessions. The therapist then described feeling in a panic that this would not be enough time to process the mother’s
death and discussed in supervision whether she should continue to work with her ex-patient or refer on to another therapist. It seemed important in this case to do the latter, as the patient knew that
the therapist had partially retired. As clinical observations of analyst-initiated post-termination contacts suggest that these are not damaging but usually consolidate gains, facilitate self-analytic
function and posttermination mourning (Schachter & Johan, 1989), recommended that in the termination phase, the analyst offers a single face-to-face extra-termination contact within the year to
assess gains (and help the patient achieve further help if needed), and only at the patient’s request. Women analysts were more likely to have post-termination contact with their analysands than
men analysts, and this gender difference needs further elucidation.
Finally, some patients may need intermittent analysis. Green (2002) suggests that although there are analyses that seem to end well, often additional analyses are necessary before it is possible to
finish definitively. He thought that when there are resistances which may prove insurmountable and play a useful role in the subject’s equilibrium, it is probably wiser to “free” the patient and to
suspend the analytic process, while waiting until circumstances create the need to take it up again. This is only appropriate with patients when the analyst does not feel that terminating is likely to
have damaging effects, seriously compromising future prospects or health. In such cases the analyst would show, but without applying pressure, that s/he disagrees with the patient’s wish to end the
analysis. Green thought that an analysis extending over different time periods is more likely to bring about structural changes than a single analysis in an intense rhythm of five times a week. He
therefore thought that the analyst, while remaining open to the possibility of psychic movement at a later stage, needs to be able to accede if the patient wants to terminate (or interrupt), and if this
is achieved in a good-enough way it may facilitate the patient having more analysis.
Discussion

As Meissner (2007) put it succinctly, manipulations of the analytic schedule, even for the best of reasons, cannot be done without cost: requests on the part of either analyst or patient to change times
of session, whether on a one-off basis or permanently, inherently face potential transference-countertransference difficulties. A temporal variation alters the framework of treatment and therefore
changes the analytic situation. A number of the instances may be viewed as amounting to enactments along a spectrum. They raise questions about why analysts vary their technique. What is the
extent of analytic disclosure about this and has it been relatively guarded?
Handling patient requests for modification of the frame has been taken as evidence at least in part of the patient’s anxiety and conflicts, and correspondingly the analyst’s inclination to initiate
changes to the external frame should at least be considered a signal of the analyst’s fears and a possible enactment of conflict or trauma (Ehrlich, 2010). Ehrlich found, however, that when making
the offer to increase sessions patients became more engaged and hopeful, and the work deepened. A main point discussed here is whether temporal variations are to be viewed as a breach of the
setting or are rather to be regarded as analyst and analytic situation having a flexible frame (or both)? Do changes in the setting imply, as many analysts suggest, a moving away from rigorous
psychoanalytic practice, defined as aiming to elicit transference (Aisenstein & Smadja, 2010)? Or, as Ferenczi argued, is it a move away from rigidity to an independent stance of occasionally
encouraging the patient to do certain things, i.e., as an analyst who takes an active stance but without actually making suggestions to the patient. Kurtz (1988) discussed two views of time
exemplified particularly by two major schools, the classic analytic, in which the patient’s behaviour is understood as resistance to be interpreted, whereas in the self psychology approach the infantile
developmental needs are viewed as having been revived and therefore need appropriate handling to be met sufficiently for growth to proceed. Making exceptions to the temporal framework of
sessions would then follow from the second approach. Thus Kurtz’s offering a patient a flexible session at a time of need constitutes a parameter only if the fixed time session is taken as a rule, in
which case the outcome is the only test for the validity of altering it.
Let us turn now to whether the outcome if known seems to be a therapeutic one. The fantasized meaning of temporal change for both analyst and patient—whether the analyst initiates the
interventions (or co-creates them)—affects the patient with ongoing reverberating resonances in the transference-countertransference and intersubjectively. Currently, there is considerable support
for the view that this co-creation may be the only way that the patient can bring material that is “beyond words”. Many analysts have the experience that some temporal enactments when they, for
example, misread the clock and finish the session a few minutes early or late or make a mistake about session times, have the effect of helpfully bringing into the session material about a parent
who was felt not to be caring enough to be in touch with the child’s needs. This seems more to do with enactment rather than acting out (Etchegoyen, 1991). What appears to be a transference-
countertransference stalemate is often the heart of the analytic work and if this is what precipitates the intervention may be very informative. Many transference-countertransference difficulties
prove fruitful for the work proceeding. The patient’s response is the key factor and if there is a therapeutic outcome this suggests that the patient’s fantasies have a more benign outcome. One may
think here of Winnicott’s (1971) concept of the necessity for the infant to feel that the object, the mother, survives the infant’s aggression and the corresponding importance for the patient to feel, if
the frame is changed, that the analyst’s mind survives. An intervention by the analyst to the temporal framework as an object in the transference relationship may feel to the patient to be an
individually tailored intervention and therefore to have some similarities with Green’s (2002) objectalizing function—the key issue in development of the transforming drive activity by the
intervention of the object in its relation to time. That is, similar to the Independents’ concept of becoming the analyst that the patient needs.
If we study closely what happens following an intervention to the temporal frame, the affect storm often quickly releases useful material to work with. What emerges as a theme is how often an
intervention is reported as helping the material move along, as grist to the mill. Viewing an enactment as communicative information allows the possibility for a more nuanced view of a temporal
intervention. An intervention in the temporal framework may help a patient who feels that there was a failure of the environment in infancy, to feel that he or she has been heard (Green, 2002).
Conclusion

Psychoanalysis is a deepening of a relationship between two people to explore the meaning of the patient’s concerns. Interventions and alterations to the temporal framework have the potential to
have considerable transference-countertransference effects on the relationship, clearly facing the patient with “the time of the Other” (Green, 2002). To summarize the chapter: the different
interventions to the temporal framework have been considered in the light of the literature and what analysts share privately, and in particular the fantasized meaning to analyst and patient, the
layers of resonances in the transference-countertransference and intersubjectively to begin to assess how often they were judged to be therapeutic.
Part II
Alterations of the Method
Chapter Four
Refusing to listen to certain kinds of material

Salman Akhtar

The discharge of feeling tension, when this is no longer relieved by physical discharge, can take place through speech. The activity of speaking is substituted for the physical activity now restricted at other openings of the body, while words themselves become the very
substitutes for the bodily substances.
—Ella Freeman Sharpe (1940, p. 157).

Spring 1978. I am a junior faculty member in the Department of Psychiatry of University of Virginia’s School of Medicine. I am considering psychoanalytic training and want to apply to an analytic
institute. But I am hesitant. Real and imagined burdens of time and money are not what bother me. I am fearful of rejection, entertain all sorts of scenarios in which the institute will refuse me entry.
Feeling stuck, I seek the counsel of Dan Josephthal, who is a supervisor of mine. He is a warm man with a radiant smile and a twinkle in his eyes. He is solidly grounded in reality and unpretentious.
There is also a matter-of-fact sort of tenderness about him. In short, he is a mensch.
We arrive at an Italian restaurant near his office the next day. After we have placed our orders and exchanged a few pleasantries, he looks at me keenly and says, “Tell me why would you not
apply for analytic training?” I mumble something to the effect that I fear I might be rejected. He seems puzzled and asks me, “Why?” As I open my mouth to reply, he raises his hand indicating me
to stop and says, “I am not interested in listening to those kinds of reasons.” His warmth and friendliness tell me that his shutting me up is not from rudeness. It is actually an act of fatherly
tenderness, a nudge to momentarily pull me out of my silly neurotic inhibitions. I get the point he is making. By refusing to listen to (what he rightly anticipated to be) my misplaced self-castigation,
he cleaves my ego into an experiencing and an observing sector. In effect, he makes an interpretation, telling me that I should not allow my neurotic anxieties to come in the way of my academic
growth. Two days later, I mail my application to the psychoanalytic institute.
The memory of this encounter remains with me. I return to think about it off and on. Such self-analytic work leads to a far deeper understanding of what actually took place then, what I had
wanted from my supervisor, and how many meanings were embedded in his deft gesture. Gradually, the whole episode changes its status from a zen koan to a cherished poem. I think I am more or
less done with it. Little do I know that the topic of refusing to listen to certain kinds of material would pop up in my clinical writings thirty-four years later.
First, about listening

Any consideration of “analytic listening” must begin with the injunctions made by Freud (1912b) that the analyst should maintain an attitude of “not directing one’s notice to anything in particular”
(p. 111) and “adjust himself to the patient as a telephone receiver is adjusted to the transmitting microphone” (p. 116). Together these statements advocate the attitude of “evenly suspended
attention” (p. 112) in listening to the patient’s material. Of note in the second statement is that Freud says one ought to adjust oneself to the “patient” rather than to the patient’s utterances.1 Such
relaxed and lambent cognition helps the analyst capture important links between disparate elements of the patient’s material as well as seemingly unintended upwards cues from the latter’s
unconscious.
While these ideas of Freud remain the cornerstone of “analytic listening”, contemporary psychoanalysts have added significant insights to this realm. Prominent among these are: (i) Brenner’s
(2000) proposal that a selective and shifting focus of attention is more useful than “evenly suspended attention” in listening to analytic material; (ii) Schwaber’s (1983, 1995, 1996, 2005, 2007) emphasis
upon listening from the patient’s perspective and its contrast with Arlow’s (1995) attunement to discerning unconscious fantasies; (iii) The distinction in types of listening, dictated by what Strenger
(1989) has termed “classic” and “romantic” visions of psychoanalysis. The former prompts listening geared to deciphering ways in which the patent’s wishes and fantasies colour his perception of
past and present realities while the latter mobilizes listening geared to healthy strivings for wholeness and authenticity; (iv) Killingmo’s (1989) reminder of the necessity for the analyst to oscillate
between skeptical listening and credulous listening in accordance with shifts in the patient’s level of psychostructural organization; (v) Makari and Shapiro’s (1993) reminder that “analytic listening”
attends to nonlinguistic communications and to the linguistic categories pertaining to narrativity, symbolic reference, form, and interactive conventions; (vi) the role of the analyst’s reverie and
meandering subjectivity (Benjamin, 1995, 2004; Jacobs, 2007; Ogden, 1994) in listening to the patient, either because the material is cocreated or because the patient’s disowned affects and
unthinkable thoughts have been deposited in the analyst by “projective identification” (Klein, 1946); (vii) the trend of “close process monitoring” (Gray, 1982, 1994), which advocates focus on the
minutest shifts in the flow of the patient’s free associations. Interestingly, two seemingly “opposite camps”—contemporary ego psychologists and the neo-Kleinians—are equally interested in such
moment-to-moment changes in the direction of the patient’s thoughts. The difference, however, is that the ego psychologists focus upon what cases the turn in the flow of associations while the
Kleinians seem interested in what is caused by the turn in the flow of associations.
After having described the historical landscape of attitudes about analytic listening, it might not be out of place to return some basic stuff. Rather than taking it for granted, let us go over the kinds
of material that we, as analysts, pay attention to while listening to our patients. A quick enumeration of these includes the following:

Listening to the overt content of the patient’s narrative helps establish a sense of mutuality and of being “on the same page.” It provides a glimpse of the patient’s ego functioning in the
external world and of the issues that preoccupy him, even though they might be chosen due to their significance in terms of unconscious conflict. Such attention to “surface material” also
gives a hint of transferences that are about to unfold or are already going on.
Listening to the omissions in the narrative (e.g., an individual talking in detail about a house he is purchasing but never mentioning its price, a woman talking about her boyfriend but
omitting his name) helps discern pockets of anxiety and transference-based resistances.
Listening to the patient’s dreams is of course well recognized as the “royal road” (Freud, 1900) to the unconscious but listening to daydreams, fantasies, and the description of fleeting visual
images (Kanzer, 1958; Warren, 1961) is also important.
Listening to slips of tongue, mispronunciations that are not based on unfamiliarity with the language being spoken, and other verbal gaffes of the patient also provides access to his
unconscious functioning at that moment.
Listening to the intonations and points of emphasis (e.g., “All I want from my husband is a little attention,” “I really do love my mother”) yields useful information regarding
characterological styles and self-deceptions that individuals are often compelled to deploy.
Listening to pauses can also be informative. Often the clause of the sentence added after a pause turns out to be defensive against the anxiety the first part of the sentence has stirred up (e.g.,
“Sometimes I think of committing suicide” followed by a pause, and then the phrase “well, not really”).
Listening to negations and unsolicited disavowals reveals the distressing deeper content (e.g., “The last person who comes to my mind in this connection is my father,” “Look, I’m not
competing with you”).
Listening to the patient’s sighs and grunts permits access to areas of pain, anxiety, and resistance. Attention to such sonic cues yields even richer data when an eye is also kept on the patient’s
bodily movements during the session (McLaughlin, 1992).
Listening—if such extension of the word is allowed—to one’s own thoughts and feelings is a great source of information about the patient. Vigilance towards countertransference phenomena
often reveals significant dynamic issues operative in the patient (e.g., a sudden feeling of shame about the quality of one’s clothes while encountering a new and strikingly well dressed
patient often results from the projection of dissociated feelings of insecurity in the patient).
Next, about variables that can affect listening

Listening is fundamentally a maternal activity. It requires putting one’s own concerns aside and cultivating at a sense of devotion to the other; Winnicott’s (1966) phrase the “ordinary devoted
mother” readily comes to mind in this context. Listening requires opening one’s heart and mind to someone else and taking in their mental content; the metaphor of a receptive maternal vagina that
grasps father’s penis is hard to overlook here. Listening requires not being in a hurry to interrupt the narrative, to question, to arrive at conclusions, and to give the material being offered a readily
well-polished form. All these qualities, namely, devotion, receptivity, and containing without rushing to “explain”, are characteristically maternal, hence feminine. Well-developed capacity for
listening therefore requires characterological comfort with feminine identifications, regardless of one’s actual gender.
A related facet of listening is the “ingestion” of someone else’s spoken words. Such openness also has the remote echoes of an infant gladly taking in the maternal breast. Good capacity for
listening therefore also emanates form comfort with one’s orally receptive infantile self-representations. Yet another element in listening is a certain amount of slowing down, an unhurried sort of
mentation, or to borrow a phrase from Mahler, Pine, and Bergman (1975), a certain “low keyedness”. Absence of internal noise and tolerance of what noise does exist within oneself therefore
enhance the capacity of listening. In essence, good capacity for listening comes from a character organization that has peacefully assimilated early identifications with a devoted mother, accepted at
an archaic but deep level the imago of a receptive maternal vagina, is unafraid of one’s own baby-on-the-breast self-representation, and does not rely upon “manic defence” (Klein, 1935; Winnicott,
1935) on a habitual basis. Too conflicted (or deficient) maternal identifications, too anxiety-producing infantile self-representations, too intense a denial of maternal sexuality, and too much use of
manic defence lead to a characterological style that is unsuited for the act of listening.
Another variable that can impact upon listening is strict allegiance to one or the other psychoanalytic model. Look at the following examples. an “ego psychologist” sees only drive-defence sort of
compromises in the patient’s material. A “Kernbergian” sees idealization as a defence against regression and a “Kohutian” sees it as a resumption of a thwarted developmental need. A “Mahlerian”
regards patients’ fluctuating levels of intimacy as representing merger-abandonment anxieties while a “relationist” sees a craftily enacted scenario of mutual teasing and seduction in the same
oscillation. A “Kleinian” views patients’ hatred of the analyst’s silence as an envious attack on a withholding breast while a “Winnicottian” views that very outrage as manifestation of hope (that the
analyst can “survive” the patient’s assault) and therefore of love!
Admittedly, these are caricatures. Nonetheless, the point I am trying to make is a serious one: a rigid allegiance to one or the other type of analytic thinking can narrow the way one listens to the
patient. Worse, it can lead to a situation where the analyst does not listen at all because his theory offers him a prepackaged and formulaic understanding. Also of note in this context is Freud’s
(1910b, p. 145) grim warning that “no psychoanalyst goes further than his own complexes and resistances permit” highlights how personal problems on the other side of the couch can impede proper
listening and intervening. Racker (1968) went on to distinguish two types of countertransference blocks to the receptivity of the analyst. “Concordant countertransference” responses are those in
which the analyst identifies with the patient’s own central feeling state. “Complimentary” countertransferences result from the analyst’s identification with a significant object that is projected into
him by the patient. In the former, the analyst identifies with the patient’s self-representation and in the latter with the patient’s object representation. While partial and transient identifications of this
sort can help develop empathy for the patient’s inner experience, unquestioned and total identifications in this regard make listening peacefully to the patient difficult. The reason for mentioning
these well-established observations is to balance the current enthusiasm about the informative potential of countertransference since that seems to have eclipsed the fact that countertransference can
also impede listening.
Listening can also be affected by cultural difference within the clinical dyad. This is most clearly evident in the treatment of bilingual patients (Amati-Mehler, Argentieri & Cansestri, 1993).
Denotations, connotations, aphorisms, colloquialisms, proverbs, curse words, and terms of endearment as well as the mere prosodic qualities of language, all enter into how one speaks and how
ones’ spoken words are received and processed by the listener. Linguistic difference, however, is not the only cultural variable that can alter the analyst’s listening. Matters of nationality, social class,
race, ethnicity, aesthetic preferences, and politics can also have an impact upon the empathy and attunement of the analyst (Abbasi, 2007; Akhtar, 1999a, 1999b; Gorkin, 1996; Roland, 1996). Subtle, or
not too subtle, prejudices on the analyst’s part can get mobilized when differences along these dimensions exist and preclude a stance of neutrality vis-à-vis the patient’s material. Patient’s value
system and ideals may take forms compatible or incompatible with the ideals of individual analysts: propensities towards austerity or luxury, towards the acceptance or nonacceptance of commonly
held standards of choice of work, or even of dress, which may be treated by one psychoanalyst as symptoms and by another with tolerance (Klauber, 1968, p. 131). Religion also plays a role here. If,
for instance, the analyst is indifferent or hostile to religion, he is likely to be highly skeptical towards his analysand’s spiritual yearnings. He may side-step such issues, subtly devalue them, or quickly
reduce them to their alleged instinctual origins. On the other hand, if the analyst is religious, his attitude towards such associations is likely to be more tolerant and permissive. Matters involving
abortion, homosexuality, impending death, and life after death, especially tend to evoke countertransference reactions that are, at least in part governed by the analyst’s religious beliefs.
Finally, about refusing to listen

Having elucidated the types of listening, and the factors that can impede effort to listen, I move on to a provocative but serious and hitherto unexplored technical possibility.2 This pertains to the
analyst’s letting the patient know that he (or she) refuses to listen to the patient’s material. The mere mention of such intervention is sure to horrify most, if not all, psychoanalysts. Therefore, let me
quickly explain what I mean by this innovation, under what circumstances it might be indicated, and what is the theoretical rationale and technical yield of it.
The first indication for refusing to listen is when the patient is repeating something ad nauseum. This might include angry complaints about childhood mistreatment by parents, dissatisfaction in a
marriage, or a sense that one is being dealt unfairly at the place of employment. Regardless of the content, the material is repeated over and over again and on each occasion as if it was being
reported for the first time. At times, there is a quality of feigned disbelief in the patient who begins complaining with a “can-you-believe-it?” intonation. The analyst who has heard the complaint
hundreds of times before feels burdened and impatient. He wishes to put an end to this litany, and refuses to hear the patient tell the all-too-familiar story once again.
Before going any further let me add something important here. I am fully aware that prominent among the constituents of the analytic attitude are not only a nonjudgmental “benevolent
neutrality” (Stone, 1961) and the trio of survival, vision, and faith (Akhtar, 2009a, 2009b, 2009c), but also a resolutely unhurried stance. The analyst must have patience. He listens to the material
offered by the patient again and again, each time with a slightly different vantage point and each time grasping a fresh nuance of what the patient is trying to convey. The process is slow and cannot
be rushed. This is especially true in the case of patients who suffer from a “basic fault” (Balint, 1968), harbour tenacious “someday …” and “if only ….” fantasies (Akhtar, 1996), and have been severely
traumatized during their childhoods. Such patients carry a desperate hope of being understood and helped, though often their expectations are somewhat magical. Nonetheless, before their excessive
hope is frustrated either directly or by way of interpretation,
the patient ought to experience for a sufficient length of time and at different levels the soundness of the therapeutic rapport, the security of being understood, the benefit of a careful and thorough working through of the transference, and a relational structure that enables
him or her to contain the comprehension and the elaboration of the disruption of the transference play (Amati-Mehler & Argentieri, 1999, p. 303).

Considerations of actual time are involved here. For instance, when a patient endlessly laments the loss of a loved one or a bad marriage or a frustrating job situation, it is better, for a long while, to
“agree” with the patient and to demonstrate one’s understanding of the nature and conscious sources of the patient’s agony. Balint (1968) emphasizes that, under such circumstances, the analytic
process
must not be hurried by interpretations, however correct, since they may be felt as undue interference, as an attempt at devaluing the justification of their complaint and thus, instead of speeding up, they will slow down the therapeutic processes (p. 182).

However, sooner or later the time arrives when the analyst is compelled to address the patient’s defensive pattern of repeating a familiar story and the sadomasochistic enactment inherent in such
discourse. Failing to engage the patient in this interpretative undertaking, the analyst must be prepared to limit and even rupture the patient’s manner of relating. Now the analyst explicitly refuses
to listen to surface material and insists upon going deeper. This tactic is neither conventional nor risk-free. It can traumatize the patient and require much “damage control” sort of work. However,
an intervention of this sort can also constitute the turning point in the analytic process and provide access to deeper configurations in the transference-countertransference axis.

Clinical Vignette: 1
Rachel Rosenblatt is a school teacher in her mid-fifties. She has sought analysis with a vague fear of being purposeless, lack of ability to commit herself to any pursuit in a meaningful way, and a sense that her marriage is emotionally over. She is vivacious and talkative. Her
track record reveals a surpassing of the lower middle class and rather provincial family background. She wants to grow, travel, and experience life in broader and deeper ways.
A major and recurrent theme in her analysis is constituted by her attempts to “prove” to me that her husband is intellectually dull and boring. Rachel recounts episode after episode, offers big and little details, to drive this point home. He does not respond to her appeals
for “real” conversation, fails to say more than a word or two after they walk out of a movie theater, and responds in monosyllables when she recounts her day at the school where she teaches. She finds him very boring. He is driving her up the wall. Weeks pass and months
turn into years but Rachel keeps bringing up more and more evidence of how boring her husband is.
My attempts to point out her insistent need to convince me and her implicit disbelief in my essential agreement with her go nowhere. When I link the “boring husband” scene with the unengaged mother of her childhood, she sees it but the material remains superficial. I
feel helpless, annoyed, and, frankly, “bored”!
What is going on, I ask myself and her. This is to little avail. Each day, Rachel has a fresh story with the same end: her husband was totally inept in conversation and was very boring. Time passes.
One day, she begins the session with “You know how F. (her husband) behaved last evening?” Sensing that the Tale of the Boring Husband is about to unfold for the four hundredth time, I respond by saying, “I am afraid that I am not interested in listening to last evening’s
details. But I am very interested in listening to your thoughts about why you want to tell me the same story over and over again. What do you get out of it? What do you think you are doing to me by such repetitions?” Rachel brushes me aside and proceeds to tell me about
how boring her husband was the last evening. I interrupt and say, “No, I do not wish to hear the details of what happened last evening since I know that these would contain nothing new. What I am interested in is the need you feel to tell it to me as if I have not heard this
story before and as if I do not agree with you”. Rachel presses on. I challenge her again, noting silently to myself at this point that the sadomasochistic banter is slowly becoming a bit “delicious”. Further speculations begin to arise in my mind, as a result.3

A second indication for refusing to listen is when the patient seems to be obtaining too much instinctual gratification by talking. That speech can become instinctualized has been noted from the
earliest days of psychoanalysis. Freud (1895, 1900) repeatedly noted the magical quality of words and Ferenczi (1911) underscored the greater emotional power of obscene words in one’s mother
tongue as compared to those in a later-acquired language. Abraham (1924) observed that
… we meet certain traits of character in people which can be traced back to a peculiar displacement within the oral fear. Their longing to experience gratification by way of sucking has changed to a need to give by way of the mouth, so that we find in them, besides the
permanent longing to obtain everything, a constant need to communicate themselves orally to other people. This results in an obstinate urge to talk, connected in most cases with a feeling of overflowing (p. 401).

Later analysts (Fliess, 1949; Sharpe, 1940) have noted the contributions of anal and urethral discharge functions in patterns of speech. In addition, Lowenstein (1956) stated that “a patient’s way of
talking may reveal that at times he uses speech for either seduction or aggression towards the analyst” (p. 462). A case in point is constituted by those borderline patients who frequently get enraged
and scream loudly at their analysts. Getting emotionally flooded at the slightest misattunement on the therapist’s part, they embark upon yelling, shouting obscenities, and at times, emitting blood-
curdling screams. The first manifestation of such emotional flooding is usually a rapid
… accumulation of memories and fantasies that support the same emotion. The patient can refer to these memories or fantasies only in a kind of “shorthand”—fragmentary sentences, or a single word. He may then begin stuttering and lose the power of intelligible speech
altogether. The patient may scream and exhibit diffuse motor activity; he may seem to have lost his human identity (Volkan, 1976, p. 179).

Under such circumstances, the analyst ought to stay still, lay affectively low, say little except naming the affect (Katan, 1965) and, sometimes, address the patient by his or her first name (Volkan,
1976). Naming the emotion provides a cognitive handle for ego dominance and naming the person restores human identity, precluding the diabolical transformation caused by intense rage. These
technical measures work well when screaming is occasional and transient. However, when such rage attacks are a matter of everyday occurrence and especially when the patient seems to be
drawing great sadistic gratification from them, behavioural limits must be set. Kernberg’s (1975, 1984; Kernberg, Selzer, Koenigsberg, Carr & Appelbaum, 1989; Kernberg, Yeomans, Clarkin & Levy,
2008) extensive writings on the treatment of borderline patients discuss such limit-setting in detail. Here it will suffice to say the analyst might refuse to listen to such screaming, firmly explaining to
the patient that such behaviour adds little to the treatment process; in fact, it detracts from deepening their understanding of what is troubling to the patient at his or her core. Such acting out needs
to be “controlled”.4
Other patients can also draw so much instinctual gratification from talking that the communicative function of what they are saying is eclipsed. One category of such patients is formed by sexual
perverts and the other by narcissists. The pervert can resort to talking in a highly sexualized manner, lingering just a bit longer on sexual details, and uttering the name of genitals with ever-so-
slightly wet emphasis. At other times, he does not resort to “dirty talk” and yet seems to be having sex via talking. The narcissist can also utilize speaking for purposes other than communication.
Bach (1977) notes that:
… in the narcissistic state, language is used predominantly in an autocentric manner to regulate well-being or self-esteem, rather than in an allocentric manner for purposes of communicating with or understanding an object. Thus the emphasis is less on the communicative
function and more on the genetically earlier manipulative function of words, which may be used to frighten or to soothe, to distance or to merge, to control or to be controlled …. Because language is used more manipulatively or as a substitute for more primitive, proximal
and autocentric modalities, such as touch, taste, and smell, one has the overall sense that the language is impoverished, although at times, it may be rhetorically brilliant (pp. 218–219).

The analyst must attempt to unmask such perverse and narcissistic uses of language. Confronting the patient—at first, gently, but, if the pattern persists, firmly—with his hidden agenda might draw a
wedge between what the patient says and how he says it. This, in turn, can be used for deepening the awareness of the transference that is operative when such speaking is deployed. However, this
is easier said than done. Instinctualized speech patterns of such sorts are deeply embedded in character; they are ego-syntonic and pleasurable. Therefore, it might become necessary to “block” them
in their earliest and nascent state by calling attention to the “juicy” (in the case of the pervert) and “self-soothing” (in the case of the narcissist) quality of speech and letting the patient know that one
would refuse to listen any further if the patient talks in this manner. Paradoxically, it is such blockade that often brings forth into consciousness the particular self-object relationship that was being
played out by “swearing”, “dirty talk”, or “narcissistic rambling”.5
Finally, there is a third indication for refusing to listen and this is when a thoroughly analysed transference resurfaces a day or two before the mutually agreed-upon date of termination. There is
often an ironic, if not humorous, tenor to such an occurrence. This is evident in the following vignette lent to me by a distinguished colleague.

Clinical Vignette: 2
David Conn, a thirty-six-year-old man, grew up with a sense that his father did not like him. He yearned for paternal love and in the course of his analysis oscillated between defending against imagined criticism from me and desperately seeking my approval and praise.
Years of interpreting the implicit oedipal transference and painstakingly deconstructing the projective distortion of his father’s image led to a real-life rapprochement between him and his father. Within the analysis, too, tension lessened. His hostile competitive impulses
could now come to surface and undergo genetic linking as well as ego-modulation toward healthy work-related ambition. A termination date was mutually agreed upon in the sixth year of his treatment. Matters proceeded more or less according to expectation. Then, in the
very last session, David said, “You know, I find myself wondering all over again if you do secretly hate me. What if …” I interrupted him with an exaggerated and clearly mocking groan, saying, “No, no. Please don’t tell me this now. I don’t want to hear this now!” David
burst out laughing and the session moved toward its last minutes with us saying goodbye to each other from a position of mutual regard and affection (Vamik Volkan, personal communication, February 11, 2011).
Conclusion

In this contribution, I have briefly surveyed the old and new literature on analytic listening. I have underscored Freud’s views on the topic and then highlighted various subsequent developments
including those from Kleinian, self-psychological, and relational vantage points. I have then raised the tricky question of whether listening is always “good” and helpful. I have suggested that the
analyst might actually refuse to listen (i) when the patient is repeating something ad nauseum, (ii) when the patient is using speech predominantly for instinctual discharge or narcissistic stabilization,
and (iii) when the patient is bringing forth a much-analysed transference in an unconsciously playful manner towards the end of the analysis.6 I have emphasized that such “refusal to listen” is a
technical strategy that (i) is reserved for later phases of long analyses, and (ii) should be used after much listening, affirmative interventions, and interpretive work has been done. Even under these
circumstances, the analyst actually does not stop listening. What he does stop is listening to the surface material. The analyst, who has heard five hundred times about a parent’s indifference towards
the patient, might raise his hand and say “you know what, I am not really interested in listening to this tale all over again but I am very interested in why you feel driven to tell it to me again and
again as if I never heard it”. Seeming to not listen (to surface material), the analyst actually shows that he is more attuned (i.e., “listening”) to what might be lurking behind the patient’s need to
repeat something endlessly. In effect, such “refusing to listen” constitutes an “interpretive action” (Ogden, 1994; see also Chapter Six in this book). It is the analyst’s way of saying that “look, let us
not get derailed by derivative phenomena and/or get caught up in an instinctual enactment. Instead, let us focus upon the need you have for such maneuvers and upon the anxieties that propel this
need”.
The theoretical rationale for the intervention I have outlined here rests upon the fact that listening, like all other human functions, can become delinked from ego control and come to lie under the
domination of id or superego. In other words, the function of listening itself can become instinctualized.7 One might go on listening to endless repetitions or instinctualized discourse as a form of
masochistic submission to the patient. One might also keep on listening eternally because one has come to idealize listening; the more one listens the better one is in the eyes of internalized analytic
ideals. This complication can doom the analyst and render his listening to be ultimately superego driven. Needless to stay that this problem is more likely to occur among candidates and those
striving to become training analysts, since both these groups remain dependent upon third-party approval of technique.
To my mind, the patient’s violent screaming and “dirty talk” has to be forcefully stopped, if gentler efforts at confrontation and interpretation do not seem to be going anywhere. I also believe
that endless listening to repetitive material is a perversion of the analytic attitude. This too should not be allowed to develop or continue for long. The pathological optimism underlying the patient’s
repetition needs to be confronted and, in tenacious cases, ruptured. Basically, it comes down to “having to state that neither analysis nor analyst is an omnipotent rescuer, as the patients in their
illusion needed to believe” (Amati-Mehler & Argentieri, 1999, p. 301). The intervention is intended to inject “optimal disillusionment” (Gedo & Goldberg, 1973) in the clinical interaction and demands
that the analysand learn to give up magical thinking. The self-object related fantasies as well as the unconscious instinctual pleasure associated with monotonous repetitions, screaming fits and
sexualized conversation can only then come to surface. Putting an end to all this might be a bit traumatic to the patient but it might also constitute a turning point of the analytic process provided, of
course, the analyst’s holding functions are in place and the effect of such a confrontative intervention can be analysed.
All in all, listening is good. Listening patiently for a long time is better. But listening forever to material that is all too familiar or highly instinctualized constitutes a collusion with the patients’
sadomasochism and narcissism. Such listening is contrary to the purposes of psychoanalysis.
Notes
1. Sandler and Sandler’s (1998) concept of “free floating responsiveness” addresses this point. It suggests that not only does the analyst listen in a relaxed, open-minded manner, he responds similarly as well. In their own words, the analyst “will, unless he becomes aware of it,
tend to comply with the role demanded of him, to integrate it into his mode of responding and relating to the patient. He can often catch this counter-response himself, particularly if it is in the direction of being inappropriate. However, he may only become aware of it
through observing his behavior, responses, and attitudes after these have been carried into action” (p. 55).

2. I had mentioned it in an earlier essay (Akhtar, 2009, pp. 135–146) but with lesser clinical detail and theoretical elucidation.

3. The point here is not what those speculations were but that the blocking of her “manic” talk allowed them to occur.

4. Freud’s recommendation of giving a “sharp reprimand” (1916, p. 248) to patients who leave the door open as they enter the analyst’s office is essentially in the same spirit. The aim of what he recommended and what I suggesting here is the same, i.e., to “force” a behavioral
discharge back into the realm of thinking and conversation.

5. Such instinctual discharge with talking must be distinguished from “affectualization” (Bibring, Dwyer, Huntington & Valenstein, 1961), which denotes a characterological tendency to overemphasize the emotional aspects of an issue in order to avoid a deeper, rational aspect of
understanding. This type of habitual deployment of “emotionality as a defense” (Siegman, 1954) is more diffuse than the specific instinctual discharge via speaking.

6. Not included among these indications are situations where “refusing to listen” occurs as a part of the analyst’s aborting a session altogether. The latter might become necessary if the analyst feels physically very ill during the session or if it is discovered that the patient (e.g., a
single mother) has left a young child unattended at home in order to come for her analysis.

7. Among aspects of psychoanalytic enterprise, the couch is similarly vulnerable to idealization, giving rise to the belief that no psychoanalytic work can be done unless the patient is in a recumbent posture.
Chapter Five
Giving advice1

Anton Kris

The analyst’s neutrality with respect to conflict may be suspended in situations the analyst feels are (a) emergencies for the patient—e.g., suicidality, psychosis, toxic state, etc.; (b) emergencies for someone potentially vulnerable to the patient’s destructiveness—e.g., the
analysand’s children; (c) emergencies for the analyst—e.g., physical or psychological threats.
—Axel Hoffer (1985, p. 786)

The analytic treatment of adult patients who are parents often comes upon problems in regard to their child. In some of these instances, the evidence of difficulty or the signs of impending trouble
run well ahead of the current analytic focus or matter in question. The analyst, however, may be keenly aware of potentially adverse effects on the development of a child or of the family as a
whole. While such concerns may be far from the patient’s attention or interest as an analysand, they are vital to the patient’s interest as a parent. Interventions closer to child guidance than to
psychoanalysis may be called for in the context of analysis. I shall try to describe and illustrate the technical problem that confronts the analyst in these situations.
Ordinarily the analyst does not give advice to his patients in analysis. Although he regularly makes use of his knowledge of child development, he does not generally function as an “expert” or as
an “educator” in the analytic situation. As a participant in the analytic method his aim is to help the patient express in words, without reservation, all thoughts, feelings, wishes, sensations, images,
and memories, i.e., to facilitate free association (Kris, 1982). The analyst’s responsibilities include not only the function of interpretation and the willingness to experience the drama of the
transference. The analyst also is responsible for his own neutrality in regard to the patient’s conflicting wishes and attitudes and for his personal anonymity (not out of slavish devotion to secrecy,
but because the analysis is intended to focus on the patient). The analyst, in my view, has no right to exert authority in the treatment and holds no brief to give advice or make decisions. He must
harness every impulse and action to serve his primary aim: the help the patient pursue and expand the free associations. While analysts vary in their conception of the analytic stance, there is wide
agreement that the analyst should not ordinarily give his patients advice. Before I proceed to a consideration of the circumstances in regard to patients’ children in which I believe the analyst is not
only justified but obligated to intervene in such a way on the basis of his expert knowledge, I want to draw two distinctions.
What I shall describe cannot, I believe, be tucked away under the rubric of dealing with the patient’s “acting out”, even in a broad sense of that term. When the analyst recognizes acting out (the
patient’s expression of thought, feeling, wish, and, especially, memory in actions rather than in words), he does so principally on the basis of his position in the joint venture of analysis. The analyst’s
capacity to observe and to maintain perspective is, naturally, much less subject to regression and so much less influences by inner pressures than is the patient’s. Confrontation of acting out does not
require an alteration in the analyst’s aim and ordinary functions, nor does the analyst do so as an external authority. The analyst draws the patient’s attention to the occurrence of acting out in order
to facilitate expression of current associations in words. When the analyst addresses problems in regard to patients’ children, at a time when those problems are not the present focus of free
association, however, the analyst operates authoritatively as an “expert”, as an educator rather than as a participant in the analytic method. His immediate aim is not to facilitate free association but
to promote action outside the analysis.
Similarly, I do not regard the child guidance kind of intervention as a modification of ordinary psychoanalytic technique adapted to patients’ psychological weaknesses or developmental
deficiencies. These interventions are not made because the analytic process would fail to advance without such unusual assistance. They are made because of the analyst’s sense of urgent need for
action outside the analysis. They depend upon the analyst’s relatively greater knowledge and his freedom to assess correctly situations that concern the development of patients’ children.
Naturally, in all these instances I regard it as preferable to approach the problem by way of the ordinary analytic focus on free association and the interpretation of the patient’s unconscious
conflicts. The extraordinary measures I shall illustrate are required when the analyst expects the time course for that approach to take too long vis-à-vis the risks for the patient’s child or when the
parent’s failure to recognize the child’s problem cannot be expected to yield to such an approach. I shall leave aside, for the moment, the way these considerations relate to the analytic process and
to the nature of trust in the analytic situation. The question of values, it seems to me, can best be approached after the clinical problem has been defined. It is most important, however, to emphasize
that when I refer to the analyst’s concern for risks to the child’s development, I do not claim certainty in prediction. Far from it. The state of the art is based on insufficient knowledge of outcome,
which remains the focus of much-needed clinical research. The clinician, accordingly, tempers his concern with restraint, but he needs no claim to certainty in order to respond to present
circumstances.
Clinical illustrations

Case 1

I want to begin with a simple instance—simple in the sense that it caused barely a ripple in the analysis. A woman returned to analysis after delivering her first baby and proposed a new schedule to
fit with her job. I had told her that I would do my best to meet her requests. The hours she chose, however, would have added an analytic session after eight hours away from home on two days. I
suggested that this would be unwise from the viewpoint of her relationship with the baby and the baby’s development. The patient rejected my suggestion, saying that she wanted to try her own
way, which would give her two full weekdays at home on which she would not have to feel guilty for leaving the baby. In some ways, she said, she wanted only to stay at home, though she liked
her work. The associations in the remainder of the session dealt with guilt for her good fortune in contrast to other members of her family. At the end of the hour told her that I found the schedule
she proposed unreasonable. I gave her a schedule that would not extend the time away from the baby on the two days she was to go to work for a full day, though it would require her to sacrifice
her wish to have the two full days at home without any interruption. “That’s so unlike you,” she said, amused. She returned to the theme of guilt, and I suggested that guilt over wanting to stay with
the baby and guilt over leaving the baby might be interfering with her maternal “instincts” in the matter of making a schedule. Subsequent references to this exchange were exclusively positive and
grateful.
I do not believe that the patient on her own would soon enough have recognized the strain that her plan might have introduced in her relationship with a baby in the first months of life. The
schedule she proposed, after all, represented a reasonable compromise, from her own viewpoint, for she had not yet begun to think for two. My insistence on avoiding the risk of serious difficulty
could not, however, claim to have been directly in the service of the patient’s analysis. On the contrary, it might have closed off an avenue for analysis, for I could not be certain what factors entered
into her proposed schedule, though guilt appeared to have been an influence along with insufficient knowledge of a baby’s needs and capacities. Had the schedule problem been outside the analysis,
I would, of course, have been limited to giving advice rather than insisting on the specific hours. I did, in fact, recommend that he reduce the two eight-hour days, but considerations beyond her
control dictated their length. My action and advice, which did not become the subject of analysis at any later time, were accepted and appreciated by the patient as they were intended. It did not
prevent successful completion of the analysis, and, in particular, the patient proved to be an excellent mother, readily capable of thinking for two. In retrospect, it appears that acute but transient
interference with healthy capacities resulted from the influence of chronic conflicts in a new developmental stage and required only the temporary assistance of my intervention. The chronic
conflicts, themselves, did require significant analytic resolution, though we did not happen to delineate their operation in the events described.

Case 2

In the first months of analysis the depressed and inhibited father of a three-year-old girl, Ruthie, mentioned his daughter’s watching him dress in the mornings before he came for analysis. Leaving
home so early, he would arrange his clothes in the living room the night before, so as not to disturb his wife. His daughter, hearing him get up, would regularly join him. After one such occasion his
associations included concerns about Ruthie watching television too much, but I found little evidence to support an intervention suggestion that he was concerned about her looking at him. Unsure
of my ground I remained silent on this matter, though I thought that it would be better for the little girl not to be exposed to her father’s nakedness under these conditions. An opportunity presented
itself one day, in the fourth month of analysis, when he began speaking of his past and present difficulties in making relationships. “My wife feels she could have done a lot for me. I didn’t have
much human contact,” he said. Then he recalled with pleasure his plans to build a fence on his property on the coming weekend. Soon he was speaking of throwing roadblocks in his own way in
projects he undertakes. I pointed out the sequence of thoughts, raising fences and roadblocks, excluding people, especially his wife. I suggested that similar fences in analysis were the result of inner
resistances to free association. His wife irritated him like his mother in some ways, he observed. He wondered whether his feelings for his wife were related to old sexual feelings for his mother but
recognized on his own that he was theorizing. “It’s clear to me that Ruthie has great sexual interest in me. She talks about having babies, with me as the father. Her attachment to Alice [his wife] has
shifted to me. A little boy came into the house, and Ruthie asked whether Tommy has a penis. She’s interested in all males. Tommy’s father would laugh. What if we tell Ruthie in 15 years? I hope
we can tell her gently not to say such things in public. I hope we can.” I noted that he made references to generalization, his own from mother to wife and Ruthie’s from himself to all males and
suggested that he was concerned that excessive harshness would lead to general inhibition. I added that the result depends not only on what the parents say but on how the child hears it. He
wondered what he himself may have “over-heard” as a child. Then he described getting Ruthie up at night to urinate, as he was gotten up. He remembered walking to the bathroom. How bright it
was. “Perhaps it’s better to walk,” he said, “but I carry Ruthie. She’s conscious but might make more effort to be dry if it were less pleasant.” At this point I said that I thought he was raising the
question of whether his relationship with Ruthie was too stimulating for her, watching him dress and liking to be carried to the toilet. I wondered if too much excitement interfered with her
developing control. He confirmed that she had mastered waking bladder control at age 2. Borrowing from the poet, I reminded him that just as good fences make good neighbours, children need
controls to negotiate with the outer world. He said that he would suffer if he made love to every woman in the street and, then, quickly recognized, “You were trying to tell me something more
than I was hearing.” I said that he seemed to hold a theory that his mother has not been gratifying enough to him and seemed to be acting on that with Ruthie, gratifying her in ways not helpful to
her. I added that without adequate controls in growing up, inner conflicts could be expected to result in inhibition. He did not know whether to tell Ruther that he would not be the father of her
babies, he said. I suggested that children need compassion for accepting reality. He now quoted a similar view from a child guidance book he was reading. I added that he could see he had been
thinking about these matters and connecting Ruther with himself. He agreed.
The following hour brought further associations to exhibitionism between generations, heterosexual and homosexual. He was taking care to diminish his own exhibitionism with Ruthie, though
he seemed to feel slightly put upon by me and not altogether certain I was right. One of the sources of these feelings, I suggested, might be my departure from neutrality. The day after that he
mentioned Ruthie’s great pride in having been dry at night. We heard no more of that problem, in regard to Ruthie, though the themes of exhibitionisms and problems of control and inhibition
remained central to the analysis.
In this instance I believe that my concerns for the welfare of the little girl and for the relationship of father and child justified an emphasis and directiveness that would not otherwise have been
warranted. So early in the analysis it would have been preferable to go slower, I believe, and, especially, not to say anything that might interfere with expressions of love. True, the patient was
himself concerned about his relationship with Ruthie to some extent, as evidenced by his reading. I had waited long enough for that. Nonetheless, the “expert” position that implied that his actions
might be harming his child could only be expected to encourage further inhibition. Or, at least, the fear of criticism and the sense of analytic interference could not be dismissed.
While I would do the same again, I cannot claim to know that this intervention of mind did not retard or interfere with the analytic process. Some analysts may well disagree with my decision.
They might have confined themselves to less didactic comments despite concern for the child’s development, waiting for the analytic process to develop so far that an interpretation of the patient’s
conflict over his relationship with Ruthie would suffice to bring about a resolution. Others, on the contrary, might regard my worries for Ruthie as excessive. The romance, they might contend, was
far from dangerous, and the family might have found a solution on their own had I stayed my guiding hand. Still others might view my doubts about my intervention as surprising. The analytic
method is not so delicate as all that: whatever damage might be done could not be of sufficient concern to warrant a risk for the child’s development; the patient felt free enough to express at least
some resentment subsequently; and I had acknowledged my unusual shift of aim in this instance.
There is room, here, it seems to me, for difference of opinion, but I believe the problems posed by such interferences with the free association method are ignored at the patient’s peril. Once again,
I think it important to recognize that we were not engaged in the analysis of acting out. The patient’s actions with Ruthie were influenced by a fantasy, I believe, in which he would provide her the
gratification that he felt deprived of in his relationship with his mother and with his wife. There was no evidence, however, that this was the result of thoughts and wishes stimulated in the analytic
process that were expressed in action in the relationship to Ruthie rather than in words in the transference. Furthermore, my intervention did not aim at promoting verbalization in analysis but was
aimed at increasing his awareness of his relationship with Ruthie so he could modify it.

Case 3

In the long treatment of a young man I had to opportunity to observe his engagement and marriage after much hesitation that fuelled the early years of his analysis. The birth of a daughter, Nancy,
brought him unambivalent joy, without parallel in his adult life. The little girl was the rare beneficiary of devoted attention from both parents, with an especially good mother. Both parents were at
their own best with her.
The exciting and loving relationship between father and daughter grew splendidly. Strong bonds between them were strengthened, from the father’s side, on their shared experience as first
children. There was the additional transference of his love for the second of his younger sisters, who had been his childhood love, the object of his displaced erotic love for his mother and of his
identification with mother in caretaking. He participated actively and willingly in taking care of his daughter. He revelled in Nancy’s love for him, the more as she could furnish it with words.
The birth of a much-wanted second child, Peter, when Nancy was just under two-and-a-half, found this patient curiously unable to respond to him. The analysis showed that Peter was for him,
unconsciously, the intruder, the first of his younger sisters. After several months, perhaps in part as a result of analysis, surely in part as a result of the little boy’s bewitching activity, the father’s
interest and pride were awakened. Peter was now the only boy in the family, like himself, dark-haired, with wonderful brown eyes, in the tallest percentiles, and well coordinated. The baby’s
mother was likewise entranced.
It would be quite incorrect to suppose that either parent deserted the little girl, except from Nancy’s point of view. Where she had at first been content to tolerate some loss of her mother, she had
retained her father’s relatively unaltered devotion. His rising interest in Peter, however, coincided with Nancy’s increasing erotic interest in him. More and more often familiar games with her father
would end unhappily with Nancy trying to run her hands over his genitals, which he would do his bet to stop. Memories of his own childhood were stirred, which was helpful for the analysis, but
Nancy began to lose her father, too, in a sense. That is, the attempt to solve her envy of her brother’s close relationship with their mother’s body by shifting from mother to father burdened the
growing Oedipal desires with excessive conflict. Increasing there were bitter quarrels with her mother, who, for her own reasons, was not as her best with a daughter in this phase of development.
Nancy began to sound frustrated and unhappy. She kept getting into trouble with both parents. My own concern was triggered when I heard the patient’s increasingly negative comments about her,
which seemed to go beyond the bounds of his unfriendly sister transference to her and to exceed his aversion to her sexual advances. I thought he was responding to an increasingly provocative self-
critical child, who was inviting rejection and punishment. This, for reasons we knew well, would be a specially difficult problem for him to respond to with love and tolerance. His relationship with
his father had been seriously marred by provocation and punishment throughout his childhood.
In the analysis, as I have indicated, the engagement, marriage, and life with the children brought us a very helpful, complex source of transference revival of the patient’s own troubled childhood.
The problem with Nancy did not seem to me to reflect current neurotic problems of her father. They did, however, need his help for solution, for it seemed to both of us that his wife could not do
more. I suggested to him that if he could not overcome the antipathy to Nancy, he and his wife should consider a consultation with a child analyst, who might be able to help Nancy over this
difficult period of her development. I outlined for him the sequence I have just sketched of the development of Nancy’s problem.
Whether I overestimated the degree of difficulty and underestimated the natural evolution of the problem and its resolution or whether my intervention was sufficient to serve as a stimulus for
the patient to manage better, I do not know. The outcome, in any case, was very soon the desired restitution of ordinary family life.
Unlike the other two examples I have given, this instance raises no doubt in my mind. My intervention promoted the patient’s identification with my attitude as an analyst, helping him to be a
good and understanding father and husband. The educational function of my “child guidance” intervention was closely interwoven with his own analytic interests.
Discussion

I have tried to delineate a kind of situation in analysis in which the analyst finds it necessary to abandon his ordinary position of neutrality and anonymity and to replace his usual aim of promoting
free association in the analytic situation with advice for action outside analysis. That is, when faced with a developmental crisis or emergency in the life of a patient’s child, the analyst may side with
his patient’s parental interests and act as an expert advisor providing child guidance. He relinquishes the fundamental analytic interest of the patient in favour of essential aims of greater urgency
which temporarily claim higher priority.
I want to emphasize that I am not focusing on some element of personal style. It is not, here, a question of many words or few, of affect freely shared or relatively emotionless interventions, or of
a light touch rather than a heavy one on the analyst’s part. The technical; alterations I have presented are substantively opposite to ordinary analytic technique. Yet many analysts would regard them
as far from unusual; some might even find them commonplace. It is consistent with the aims of analysis to seek an intervention as closely aligned as possible with the analytic process to prevent
irreversible damage to a child’s development. The nature and extent of such an intervention, as all other aspects of technique, derive partly from the analyst’s personal style and temperament, where
variety is apt to be the rule rather than the exception. Failure to intervene, however, would be a breach of trust.
Several frames of reference impinge upon the conception of trust in the analytic situation, in that portion of the bond between patient and analyst which Freud (1926) described as “no more than a
certain amount of respect, trust, gratitude and human sympathy” (p. 225). The analyst, whether he is conceived of by the patient as some sort of doctor, teacher, minister, or parent figure, is seen as a
person concerned with the patient’s general welfare. The patient is entitled to assume that the analyst concentrates on the realization of “health values,” guided by his “professional code,” as
Hartmann (1960) called it, following the “therapeutic imperative” (p. 55f.). How is the patient in retrospect to understand the analyst’s failure to act in regard to the patient’s child, when the process
of analysis, perhaps too late, has caught up with events within the family? How is the analyst to understand it? Suppose that such insight into the analyst’s failure to act develops midway in the
analytic process; the moral question has now become a technical one: such a failure on the analyst’s part could interfere with analysis prospectively, too.
There are related situations in which action is regularly taken by the analyst to secure the patient from harm or humiliation. In acting out, for example, where analytic process and external action
occur in phase with each other, the analyst has no hesitation in warning the patient of danger as a step toward interpretation. Such situations are generally characterized by their reference to the
patient himself and by the immediacy of their effect on rapport or alliance, as well as by their closeness to the current analytic focus. The relationship of parent and a child at risk warrants similar
management, I believe.
My emphasis, however, aims to highlight for the analyst who gives child guidance within analysis that to act in this manner, no matter how skilfully, runs counter to ordinary analytic technique
and may compromise the analytic process. To regard such interventions either as the analysis of acting out or as a matter of style, alone, would increase the risk of disturbing the analytic process.
Recognition of the suspension of the analyst’s usual aims and acknowledgment of this unusual procedure to the patient tend to diminish the disruptive impact.
Postscript

Returning to this paper after an interval of thirty years at the invitation of Dr. Akhtar, I find there is much that I still see the same way. The differences may be of interest to the reader. As the writer
of this paper, a man in his mid-forties, nearly a decade after graduation from analytic training, newly minted as a training and supervising analyst, I focused on the central place of free association in
psychoanalytic treatment. Though reasonably versed in psychoanalytic theory, I preferred to make initial clinical formulation in terms of the free association method (Kris, 1982) rather than follow
the prevailing tendency to formulate clinical events in terms of theory. In delineating advice as sharply as I could from ordinary analytic interventions, I was unaware that this was an early part of
the change in my views over the subsequent two decades, in which interpretation has come to be seen as only one of the analyst’s actions.
So, although I am no less cautious today about giving advice on any matter, I have become more aware, thanks to the writings of many colleagues, of the myriad actions by which the analyst,
often unconsciously, exerts an influence on the patient. To take the simplest example, when the analyst holds to the ordinary analytic stance, the patient will experience repeatedly the analyst’s
interpretive responses, attempting to understand rather than to approve or disapprove or dismiss the patient’s associations. That experience, which may be entirely new for the patient, or, in any
case, new within the context of aroused memory (transference), is based upon an action (repeated nonjudgmental responses) not upon the content of interpretations.
I came to understand that beyond the sense in which all interpretations are actions, some interpretations, for example those in which the analyst attempts to identify excessive self-criticism on the
patient’s part (Kris, 1990) amount to explicit endorsement of the patient, that is, a specific action. They convey the “affirmative attitude” recommended by Kohut (1972).
Why not, in keeping with that understanding, see the giving of advice as a similar action? On this point, my views have not changed. The adoption of an “affirmative attitude” counters the
patient’s punitive unconscious self-criticism (Kris, 1990) and thereby permits greater freedom of association. The aim of giving advice, however, runs counter to the main analytic aim of promoting
freedom of association.2
What, then, of the influence on the patient of other noninterpretive actions of which the analyst is unaware? Do they not, also, run counter to the aims of promoting freedom of association?
Surely, some of them do, and of those some may fortunately come to be understood and their effects thereby opened to revision. That, it seems to me, represents one of the tasks of ordinary
analysis.
At the time this paper was written, the problem of analysts’ self-revelation had not yet reached the importance that it soon attained. Giving advice is not identical with self-revelation, although, as
in all other interventions the analyst makes, something is revealed. We refrain from giving advice in order to foster the patient’s associative process, not because we wish to create the illusion of
utter anonymity (which had such a deleterious effect on psychoanalysis in the mid-20th century). Advice tends to undermine the uncertainty that analysis thrives on. When uncertainty exceeds
useful bounds, however, whether caused from within the patient or brought about by some external event, anxiety may be beyond the reach of ordinary interpretive interventions to sustain the
analytic process. Advice, among other actions, along with interpretations, may then, paradoxically, restore the patient’s ability to strive for greater freedom of association. The last thirty years have
brought me considerable experience with the effect of my impingent on the patient’s right to ignore the realities of my personal life, through illness of my own and in my family. I have come to
believe that self-revelation on my part (perhaps, better, limited self-revelation) permits patients to return to their own determinants of free association at these times, because the circumstances
otherwise tend to create an artificial distortion.
The analyst’s judgment, whether explicit or implicit, must determine the intervention of the moment, but always one must be aware that unconscious motives of the analyst’s
(countertransference) may lead to misperception and unwarranted action at a time when the patient can well tolerate the tension. Giving advice, even under those conditions, may produce beneficial
effects, at least temporarily, but its express aim is to change behaviour through the authority of the analyst rather than through analytic understanding. In doing so, the action of giving advice may
directly interfere with the process of free association. The paper claims that the stakes in serious disturbances to a child’s development warrant the risk of this sort of intervention, and I continue to
hold that view.
Notes
1. Editor’s note: this paper was originally published under the title “Giving advice to parents in analysis” in Psychoanalytic Study of the Child 36: 151–162, 1981. It is being reprinted here with the permission of the author and the Yale University Press. The title has been abridged
here to bring it in consonance with those of the other chapters in this collection. Of greater importance is the fact that the author has provided a freshly written addendum containing his reflections on the paper some thirty years after its initial publication.

2. In this paper and another, subsequently, I wrote, incorrectly that it runs counter to the analyst’s “usual aim of promoting free association” (p. 160) rather than freedom of association. It was several years before I understood my own meaning.
Chapter Six
Interpreting in the form of action

Marc Jacobs

There can be no acting or doing of any kind, till it be recognized that there is a thing to be done; the thing once recognized, doing in a thousand shapes becomes possible.
—Thomas Carlyle (1840, p. 6)

For obvious reasons, the activity, behaviour and attitude of the therapist have long been a topic of intense scrutiny and debate in the field of psychoanalysis. Technical recommendations regarding
the analytic stance have ranged from the therapist acting like a “blank screen” (Freud, 1912) and only gingerly departing from a technically neutral stance (Eissler, 1953) to creating an atmosphere of
“benevolent neutrality” (Stone, 1961) and even providing a “corrective emotional experience” (Alexander, 1956; Alexander & French, 1946). Other more contemporary and progressive views have
also evolved over the past few decades (Chused, 1991a; Renik, 1995, 1996; Viederman, 1991). These views take aim at the concept of analytic neutrality, criticizing it as a false ideal, unattainable, and
therefore, a technical stance that actually impedes psychoanalytic work (Renik, 1996). Yet another way of conceptualizing the therapeutic stance is to view it as an actual interpretation itself, or what
I will be calling interpretation through action (IA).
In this contribution, I will take up the concept of IA, and describe the different ways in which it has been defined and used in the past. I will then offer my own conceptualization that builds upon
those prior descriptions but adds relevant ideas taken from our current understanding of psychoanalytic technique and theories of change. Lastly, I will present an example from my clinical work
where an IA helped to resolve a difficult impasse in the analysis. My overarching purpose here however, is to begin a conversation about the concept of IA, not to have the last word on it.
Interpretive action and related concepts

Although the concept of IA has at times been subsumed under the therapeutic attitude (Sampson, 2005; Shilkret, 2006; Weiss, 1993), it has mostly been used to describe a specific aspect of technique,
i.e., an interpretation delivered nonverbally. As I will propose, IA can have particularly important clinical utility, in that it can take the form of either a therapeutic stance or of a specific intervention.
Like the corrective emotional experience (CEE), IA is experiential in its emphasis, and also like the CEE, can lead to, or be accompanied by insight as well. Much of the controversy that surrounds IA
centres on this last point, that is, can IA actually lead to structural change (with or without insight)?1
Only a handful of authors have previously discussed this topic (Ogden, 1994; Shilkret, 2006). As a result, I believe that IA has still not yet received any “formal” recognition as a concept in the field
of psychoanalysis/psychotherapy. What consensus does exist about IA appears to be more around placing limits on its use, either in more severely disturbed patients, or in those instances where
verbal interpretation has failed. With greater refinement of the meaning and use of IA (including broader application) could also come a greater willingness amongst analysts to consider the
legitimacy of this kind of intervention. It is my contention that when properly applied, IA has the potential to offer clinicians a useful therapeutic tool, or, at minimum, another lens through which to
view their work.
In his 1994 paper on the concept of IA, Ogden (1994) defined IA as “the analyst’s use of activity to convey specific aspects of his understanding of the transference-countertransference, that cannot
be communicated to the patient in the form of verbally symbolic speech alone at the juncture in the analysis when the interpretation-in-action is made” (p. 135). He goes on to spell out other
conditions for the use of IA that are both restrictive, and quite specific. For example, whenever the analyst uses IA, his understanding of the state of transference and countertransference must
simultaneously be silently formulated in words in his mind. In addition, the IA must be generated within the context of the experience of analyst and analysand in the intersubjective analytic third.
By conceptualizing the use and the therapeutic action of IA in this way, I believe that Ogden has unnecessarily limited its clinical utility and applicability.
At the other end of the spectrum, clinical researchers from the San Francisco Psychotherapy Research Group (SFPRG) have termed a type of behavioural interpretation, or interpretation through
action as, “treatment by attitudes” (TBA) (Sampson, 2005; Weiss, 1993). On first blush, TBA might appear to be nothing more than what is currently meant by the positive elements of the
therapeutic alliance, e.g., helpful, open, and nonjudgmental attitudes on the part of the therapist that are meant to build trust and facilitate more open communication (Bordin, 1979; Greenson, 1965).2
However, TBA as they describe it, is seen as just one aspect of a larger clinical theory they have developed called “control-mastery” (Silberschatz, 2005; Weiss, 1993). According to this theory,
patients are highly motivated to “master” their conflicts, or to disconfirm their “pathogenic beliefs”; in Casement’s (1991) terms, they have “unconscious hope” for further growth and development.
They attempt to do this by assessing whether or not the conditions are safe enough for this task, or, in “control-mastery” parlance, they “test” the situation with the therapist. For example, if a
patient holds the pathogenic belief that in order be accepted, s/he must be passive and compliant, then s/he will (unconsciously) pull for (test) the therapist to behave in a more active or authoritarian
manner. If instead, the therapist holds back, releases control, and allows the patient to more freely express his/her own ideas and opinions, then the therapist has “passed the test”, (and begun the
therapeutic process of disconfirming the patient’s pathogenic beliefs).3 For patients, testing almost always goes on at the unconscious level, and this is equally true with respect to whether the
therapist passes the test. That is, the therapist might only become aware retrospectively that s/he has passed a test, after observing some change in the patient’s behaviour, or in his/her production of
new or deeper material. The major goal in control-mastery case formulation is to understand the patient’s “unconscious plan”, i.e., which pathogenic beliefs are the patient trying to disconfirm, and
what unconscious test will s/he use to disconfirm them?
In its later work (Sampson, 2005; Silberschatz, 2005) SFPG has extended the application of this theory to the attitude or stance of the therapist, i.e., “treatment by attitudes”. According to their
view, this attitude is more specific than the more generally positive (and generic) ones that emerge from the concept of the therapeutic alliance. With TBA, the therapist must adopt a very specific
attitude in order to counter the patient’s pathogenic belief. (The authors give one example of the importance for the therapist to adopt a hopeful attitude to counter the patient’s mother’s attitude of
hopelessness about her). However, Shilkret (2006) also suggests that for some very disturbed (narcissistically vulnerable) patients, e.g., those who experience interpretation as itself a narcissistic
injury, TBA may necessarily become the primary form of treatment.
Likewise, adult patients who have experienced severe and/or repeated physical/sexual abuse as children may develop particular psychological impairments that can later, as adults, present
challenges for standard interpretive work in psychotherapy/psychoanalysis. Specifically, these adult patients may be hampered in their ability to “mentalize”. That is, they may lack the capacity to
understand their own minds, as well as the minds of others, i.e., their feelings, motivations, and intentions. They operate out of what Fonagy, and others term a “teleological stance” (Bateman &
Fonagy, 2004; Fonagy & Target, 2008). By this they mean a kind of “means-to-an-end” way of thinking which develops towards the last quarter of the infant’s first year of life (9–12 months). During
this period, the infant begins to understand the intentions of others in physical terms, by relying on observations of the behaviours of other people (Csibra & Gergely, 1998; Gergely & Csibra, 2003).
The infant understands another person’s intentions by observing his/her physical actions (and/or the constraints to those actions) that lead towards particular goals. For example, if a chair is placed
between the infant and his mother, the infant will understand that the mother’s intention is to reach him/her by making the observation that mother is walking around the chair that is obstructing
the path to him. About such adult patients in psychotherapy, Fonagy and Target say, “… changes in mental states are assumed to be real only when confirmed by physically observable actions that
are contingent with the patient’s wish, belief, feeling, or desire … In therapy, someone who is functioning in the teleological mode may put pressure on the therapist to show concrete evidence of
concern by deviating from the therapeutic protocol, for example, by offering extra sessions …” (Bateman & Fonagy, 2008, p. 61).
Here I agree with these authors in characterizing a group of patients whose level of functioning, or severity of psychopathology dictates alternatives to standard technique, including IA. However,
what Ogden, Shilkret and others are implicitly recommending is that the use of IA be reserved solely for those clinical situations, i.e., as interpretations of “last resort”. This is where I differ. I am
instead proposing that the use of IA be more broadly considered as a therapeutic intervention, especially when paired with conventional interpretative work. I say this because I view IA not as a
“poor man’s” verbal interpretation, or as something only to be used in “sicker” patients who cannot tolerate anything more. Rather, I am viewing it as an entirely different type of intervention.
Given that IA is by definition nonverbal, why would we expect its indications or its impact to be identical with conventional (verbal) interpretation? Owing to this difference, IA has the potential to
have an entirely different impact, which could potentially be additive (rather than substitutive) to the patient’s experience. I do agree with prior authors who say that at particular junctures in the
psychotherapeutic process, IA may be the only way for patients to understand some conflict, defence, or fantasy. However, this need not be attributed to some deficit in the patient, but rather to a
deficit in our customary medium of communication itself. At times, language becomes insufficient to convey the necessary understanding to any patient, irrespective of their level of
functioning/psychopathology. This issue was brought home to me during the latter phase of one of my first psychoanalytic cases. I believe that an in-depth presentation of clinical material from that
analysis will serve to better illustrate the unique characteristics of IA, and how it might be viewed as a more conventional, rather than as some highly unusual psychotherapeutic intervention.
A detailed case report

The patient

At the time of the evaluation, Mr. B. was a graduate student in his early thirties, working on his doctoral thesis in economics at a major university. He was living with his girlfriend of four years, R.,
an accountant. Mr. B. was referred for analysis by his therapist, who had been treating him in a psychodynamically oriented psychotherapy (twice/week) for four years. The therapy had been
interrupted when the patient took a leave to join R. on assignment in another state. During the time that they were away there, he had been unsuccessful in finding employment within his narrowly
defined field, forcing him to completely rely upon R. for financial support. He grew increasingly uncomfortable with this arrangement, resentful of her, and bitterly disappointed about his “failed”
venture. He returned to the area several months before she was to complete her assignment, feeling like a failure, as well as feeling quite anxious and depressed about his future. In discussions with
his therapist, they both agreed that psychoanalysis might be indicated. The patient told me that therapy hadn’t been “enough”, and that he had always wanted to enter psychoanalysis for the purpose
of “realizing his potential and his power”, and of being able to “take control”.
Mr. B. had first been motivated to enter treatment five years earlier, having recently moved from the Midwest, and then completing his first quarter of graduate school. He described himself at
that time as suffering from a “mass of anxieties”, which he felt centred around a “nonexistent sexual identity”, a fear of involvement with women, and tremendous uncertainty about his
professional/academic future. He began psychotherapy around the same time that he began his relationship with R. (They had already known one another in college, but hadn’t gotten romantically
involved). Nevertheless, once begun, their relationship flourished over the next three years. That is, until she developed back pain of uncertain aetiology, which began to interfere with their sex life.
Although they made various adjustments that enabled them to have sex, it strained their sexual life and other aspects of their relationship as well. The patient complained that R.’s condition also
hampered the therapeutic progress he had been making with respect to his attempts at trying to feel less sexually inhibited. It reinforced his disturbing and admittedly pathological notion that when
he is having sex with a woman, he is hurting her. He told me that he cared deeply about R., and eventually wanted to get married, but he was worried that he might be “entrapping” himself if this
particular issue remained unresolved. Although he derived some benefit from his previous therapy, he found his therapist to be less helpful in the area of his sexual relationship with R., at times
feeling she was much more sympathetic to R.’s position than to his
Mr. B. presented as a very nice looking man, dressed conservatively, and unconsciously “preppie”; neat without appearing “groomed”. He physically carried himself in a somewhat stiff, almost
self-conscious manner, as if there might some penalty for making any unnecessary movements or turns. At times, he spoke almost theatrically with long “sighs”, pregnant pauses, and occasional
tears—leaving me to feel somewhat hesitant about interrupting him. During the evaluation (vis-à-vis) he also seemed acutely attuned to my every physical and facial expression, appearing to be
looking for any small clue about how I might be assessing him. This was later confirmed when he actually expressed grave concern about the evaluation—feeling “judged”, “scrutinized”, and fearful
of being seen as “unsuitable” for psychoanalysis. He impressed me as being exceptionally bright, articulate, and at times, even poetic.

His developmental background

Mr. B. was the oldest of four siblings, born to a traditional middle-class Irish Catholic family, and raised in a small working-class mid-western community. He grew up with both sets of his
grandparents living in the same small town. Mr. B. had one brother two years his junior, and two younger sisters.
Mr. B. described his father, a teacher, as a “warm, gentle, boyish jock”. In the past, he had perceived his father as not being very smart, but later amended this to say that he was not “intellectual”.
He thought his father had been warm and caring until around the time the patient reached high school. He then experienced their relationship as having “fallen apart”. This he attributed to his
father’s growing perception of his own intellectual inferiority compared to that of his rapidly developing son. He described this observation both with some remorse as well as disdain, not with any
self-satisfaction. He also remembered turning away from his father and towards his mother during that more conflicted time.
Mr. B.’s mother, a secretary, continued her education later in life, eventually attaining a master’s degree, and then becoming a high-level administrator at a community college. He described their
relationship in very hostile and conflicted terms. He complained that with his father’s withdrawal, he and his mother became “intellectual partners”, who also “locked horns” in emotionally high-
pitched battles. He resented what he saw as her using him as a substitute for his father, and was scathing in his descriptions of her attempts to control this thinking. He accused her of severely lacking
any nurturing or maternal qualities, and further described her as “selfish”, “hypocritical”, and “conflicted about her sexuality.” He described his parents’ marital relationship as “abominable”,
contemptuous of both his mother’s shrewish domination of his father, and his father’s cowardly and depressive withdrawal from her.
In describing his childhood he told me, “I used to think I had a happy childhood, but in retrospect, I don’t think I was happy.” He was obedient, smart and well-liked by adults. He was also popular
with his peers and early on was a leader. He attended Catholic grade school where he felt completely terrorized by the nuns. He was a “goody-two-shoes”, afraid to do anything wrong. He spoke
extremely bitterly of those Catholic school experiences, and with a kind of immediacy that made me think that he was still enrolled there. With no small sacrifice, his parents were able to send him
to a very exclusive and liberal private boys’ school. There, as a member of an “artsy intellectual clique”, he blossomed academically but felt socially awkward and inhibited. Although he had several
important platonic friendships, he never had a girlfriend with whom he had become romantically or sexually involved.
After high school he was accepted into a very prestigious university. His ambivalent attitude about the time he spent there provided a window through which to view some of his most central
conflicts. These emerged in the areas of aggression, competition and achievement. While secretly enjoying the status and privilege afforded by his affiliation with the renowned university, his
conscious experience was one of feeling undeserving and inferior. He felt extremely out of place, and thought he lacked the necessary social credentials that the other students had. He railed against
the university, believing that it only rewarded those people who were “seething with ambition”. He suffered through several months of depression and anxiety during his freshman year but was able
to complete his studies quite successfully.
Despite feeling attracted to women during college, he also felt inhibited and sexually unappealing. These feelings were only compounded by his failures during the few times he actually ventured
into the sexual arena. After graduating from college, he spent the next two years working outside of his field, until finally gaining enough confidence to apply to graduate school. His academic
performance during graduate school was outstanding and he was considered one of the department’s best students. He told me that at times, (though rarely) he actually was able to experience
himself as the “rising star” that his faculty and peers had predicted he would become. At the time of the evaluation, he had completed his M.A., passed his doctoral qualifying exams, and had just
begun the fieldwork for his dissertation.

The course of treatment

From the outset, one of the major themes of the analysis was the patient’s extremely ambivalent attitude towards his own aggression, as well as the conflicted manner in which he expressed it. A
particular telling example occurred early on, when I noted that he always came early to our appointments. He told me that he never wanted to be late, because I might interpret this as his having
some negative feelings about me or the analysis. I pointed out how he seemed to be taking great pains not to have any hostile intentions towards me ascribed to him. This ambivalence was also
demonstrated in his reaction formation (a polite, deferential manner of relating to me in the face of directly expressed contempt for my position of “power and privilege” as an analyst), or by his use
of idealization, devaluation, and doing and undoing defences. He told me, “You must get selected to be an analyst because you’re so different than the rest of us, like being born without original sin.
Analysis is either the most true and humble discipline, or the most presumptuous and arrogant”. He caricatured the analysis (thus disguising his hostility) by adhering obediently to its “rules”, e.g.,
diligently reciting traumas from his past, and then complaining that analysis didn’t seem to hold any relevance to his present life. As I began to interpret the conflicted way that he expressed his
hostility, he confessed, “the world of arbitrary power and privilege is the world I’ve always been dedicated to destroying. But it’s also the world I feel slavishly attracted to.” The fact that he did not
feel comfortable in either the world of privilege or the world of the “common people”, was a major theme in the analysis.
The patient also took great pains not to experience a relationship with me. His fear was that I would only use the relationship to “gain control and to dominate” him, thus leaving him to feel
“humiliated and used”. This was, in fact the central transference paradigm. He continually railed at me for the “cool and distant” way that I related to him. To him, I was the “consummate
professional”, “protected by my degrees”, and “smugly self-satisfied with my elite and undeserved position of authority and power”. He found support for these complaints embedded in the
uncomfortable “formality” of the analytic situation, governed by “my rules”, which only served to reinforce the “unequal relationship” between doctor and patient.
Any positive feeling he experienced towards me was quickly followed by a retreat, fearful of the submissive, and homosexual implications that he was somehow “in my power”. This conflict was
suggested early in the analysis when he reported a distressing dream about an “aggressive and diabolical” man, who threatened to force the patient to have sex with him. He told me, “I feel coerced
into having a relationship with you that I don’t really want. It’s new because I’ve never felt so involved with a man before. That makes me uncomfortable”.
The intensity of his response, and the centrality of his attachment to me, only heightened during the middle phase of his analysis. He reported one of his “scariest” dreams ever. He was situated in
the “middle of a war zone”, at the university where he was currently pursuing his post-doc. “Death squads” were killing people all around him, and he was going to be killed too, because his “politics
were all wrong”. In his associations to the dream, he told me how he felt like a “subversive” at this “elitist” university, with its “mainstream” department. He told me, “… it bothers me a lot how
inconsistent I am, playing off both sides—pursuing establishment success with anti-establishment ideas. Sooner or later people will see”.
 We continued to analyse his difficulties with his thesis, as well as his disappointment with his thesis advisor, L. His unrealistic expectations of L. (who “held the key” to his academic success)
revealed another important aspect of his transference neurosis. I interpreted his conflict in the following way: either he abdicates all of his power to, or gets all of his power from another more
powerful man, in which case he feels resentfully dependent, and ultimately disappointed with himself. Alternatively, if he asserts his own power, then he feels arrogant, subversive, and in danger of
a retaliatory attack. He experienced this line of interpretation as an “attack”, and a “wilful expression of my undeserved power”. When I interpreted this response as yet another effort not to feel
influenced by me he said, “I feel like I could make you so incredibly important to me, and like these feelings are being forced out of me, like there’s an explosion happening inside. I feel like I would
lose touch with reality if I surrendered control of my feelings, and that I’d become some kind of monster, crushing people and tearing them apart. Sometimes I feel like I am losing ground here,
going backwards. I am feeling more inept and dependent on you at the same time that I am feeling more competent outside of here.”
Writing and then revising his doctoral thesis had received much attention during the analysis. We made steady progress in analysing the particular ways in which he had protected his thesis from
attack. By expressing his thesis points in the framework and jargon of “the other camp”, he ultimately obscured the very position his thesis was to take. As to his relationship with R., we continued
to analyse how his sometimes “tyrannical” and bullying behaviour with her served to ward off feelings of weakness and inadequacy. We understood how his fantasies of being controlled sexually by
R. (he imagined her back symptoms to be a “psychosomatic attack”), were defensive, and internally derived. This piece of work allowed him to be more open and expressive of his love towards her,
and conversely, more receptive to the love she expressed towards him. They set plans to marry in the following year.
In spite of acknowledging a growing attachment to me, he continued to feel somewhat vulnerable, fearful, and at times, even contemptuous of me. For example, when I announced an upcoming
vacation, he took the opportunity to complain about the “bureaucratic” nature of the analysis, and my cold, business-like attitude towards both him and the work. I pointed out that it was difficult
for him to feel positively towards me as long as he felt that expressing gratitude, or acknowledging that I had helped him, was equated with my conquest of him, or conversely, with his surrender to
me. “It’s undeniably true”, he told me, “I am better off in my life because of you”. His gratitude was short-lived, however, as he once again became infuriated when I referred to myself as “Dr.
Jacobs” on a message I had left on his answering machine. He viewed this as reinforcing the already unequal nature of our relationship by asserting the prestige and power of my profession. He
accused me of “inviting dependency”, and then making a fool of him by throwing up these “barriers.” He also resented having to analyse his response, because that would be admitting that it was
“neurotic”. He told me, “Over the past few weeks I’ve become aware of feeling like I was surrendering, that my weaknesses were getting the better of me, that I was falling into a relationship with
you on your terms, and it violated my own sense of pride. I wondered how I could allow myself to feel this intimacy with someone I had so many complaints about. I feel like I’m making the same
mistake that I did in my childhood. I believed in the omnipotence of my love for someone, and theirs for me—my parents. And I did, like a slobbering puppy dog. That’s how I much I loved. I’m left
with regret that I could have been so stupid to give my unconditional love to people who didn’t understand it, and who weren’t worthy of it”.

An interpretation through action

Towards the end of the one-month break in the analysis, there had been some changes made to my academic schedule. This made it necessary for me to also change one of our upcoming
appointment times, and hence, to telephone him about the change. Naturally, I began to struggle with the issue of how I should refer to myself over the phone, i.e., as “Dr.”, or by first name. As
aware as I was of his intensely negative reaction to my using the title, “Dr.”, I did not want to alter my position solely for the purpose of avoiding a predictably angry response from him. Nor did I
want to maintain my position out of some rigid adherence to a formality that was relatively unimportant to me, or because of some distorted sense of “analytic neutrality” and/or the hazards of
“gratifying” patients. I also became aware of how I felt pulled to frame my dilemma as one of stubborn refusal versus humiliating submission, and noticed too how this particular framing mirrored
the patient’s all too familiar formula for avoiding and obscuring the dangers of intimacy. In the end, however, I believed that my indecisiveness was best explained by an ill-defined concern around
“gratifying” patients, which evoked in me an uneasiness of religious proportions, as though I were coming up against some kind of psychoanalytic taboo: “thou shalt not gratify!” The question then
became, what exactly was I gratifying? Was I gratifying the patient’s sadistic or aggressive impulses to dominate me? I didn’t think so. What I did know for certain was how the patient would
respond to my not changing, and merely continuing to refer to myself in the precisely same way as I always had—he would respond in precisely the same way as he always had. We had been
analysing this for quite some time, without any resultant change (insight?) in his feelings or reactions. What I did not know was how he would respond to my changing my stance. Couldn’t this
response be analysed too, regardless of whether or not I was gratifying an impulse? It seemed to me that in the absence of having either a new line of interpretation, or a new formulation about the
process between us (I had neither), I was barking up the same “psychoanalytic tree”.
It was exactly at this moment that the concept of IA could have been quite helpful to me. Nevertheless, I made the decision to change my stance, identifying myself as “Marc” on the phone, and
analyse whatever followed. Admittedly, I did so in more of a “last resort” kind of way, without understanding why this actually was exactly the right thing to do, i.e., that this actually was an
interpretation through action, and why it could be effective at a point in treatment where conventional interpretation could not. Predictably, he was quite please with the fact that I had “listened” to
him, and then said, “I have to say, I was very happy with our conversation on the phone the other day. I believed in you as a person, and that you have a fundamental respect for me”. He told me
that he no longer felt like I was “fending him off”. He then added, “I’m anxious because when I admit my positive feelings about you, I don’t feel comfortable with them”. This of course had been
interpreted to him many times, but he had only now come to appreciate it in a new way. He confessed to feeling awkward and ashamed that the issue had mattered so much to him. He also felt
guilty that he might have manipulated me into making the change, and added, “The hatred I’ve had for your indifference seems ironical because you are there, hovering over my every breath. And
yet, I felt unattended to”. He told me that it has always been difficult for him to express his wants, and that he has always felt guilty when he has gotten what he has wanted. He recognized this
attitude as “neurotic”, but added that it was changing. Clearly, a major shift had occurred in the analysis, and one that seemed directly tied to my action, i.e., responding to his complaint.

Its ramifications

Other things opened up for him as well. He noticed himself being more direct with R. in regards to expressing his desire for sex, rather than waiting for her to pickup on his defensively all-too-
subtle cues and then being angry and disappointed when she did not. Their relationship had deepened, in part, as a result of his increased capacity to express himself to her. With this defensive shift
away from his view of me as the powerful and arrogant tormenter, came the reawakening of his intense struggles with masculinity, aggression, and narcissistic gratification. The harsh criticisms he
had formerly attributed to me, were now seen by him as internal—projections of his own self-criticism. He acknowledged that he judges himself so harshly, and holds himself in check, to prevent his
becoming “bloated with a sense of grandiosity and disregard”. A few weeks later, he told me that he had became queasy en route to a session, and thought it was the result of his no longer trying to
ward me off. He expressed great concern about exploring his relationship with a man, because it would only serve to highlight his own “flawed masculinity”. He imagined that all along I had
intentionally been tough with him, exposing his weaknesses, as a means of making him more into a man, and more able to function in a world that requires aggressive behaviour. He reported a
dream of playing scrabble with me, and feeling at a disadvantage because he didn’t know the rules. Nevertheless, he played quite well, and I suggested that he must actually have known the rules,
as well as the strategy of how to play. I pointed out that being at disadvantage was more of a feeling, than an actuality, and that it was his feeling that (defensively) prevented his enjoyment of the
competition. Discussions about L. (the thesis advisor) during this period took on a different slant. They revealed how his disappointment with L., as a nurturing paternal figure, served to disguise his
envy, resentment, and fear of him as a competitor.
As his positive attachment to me continued to grow, it also raised fears in him that he was setting himself up for a terrible disappointment, since at the end of analysis he was not supposed to need
me anymore. He told me, “I feel so deeply how I was made to feel ashamed for wanting to be loved and cared for by my parents. I wish I hadn’t expected things beyond their abilities”. He also felt
as though they had “cultivated ambition” in him, only to become jealous of his potential, and resentful of their own limitations.
He and R. had finalized marriage plans, and in the last session prior to his wedding, he talked in depth and with great feeling about his complicated relationship with me over the years. “I’ve
developed trust in you because of your understanding of me, not because you agreed with me about everything. But there was a long time when I didn’t feel like you understood. I felt like you
were dismissive of how I felt. Now, for some time, I’ve felt that you grasp things in a much deeper way, which is quite wonderful and very helpful. I feel awkward about all that, because I feel
moved, and good, and hopeful, and in terrifying ways, affectionate towards you as well. And I also feel like I manipulated you. But I know that can’t be. I guess it’s because I’ve changed some
towards you, but you have also had an evolving understanding of me. It was always cast as my misreading you, when there also were ways that you were quite wrong. I know I have the right to
think these things. It just seems so outrageous to be talking this way to you.” He then expressed the wish that I could attend his wedding, particularly in light of my role in helping to bring it about.

Moving towards termination

After the marriage, he returned in a truly joyful state; as excited about the actual celebration as he was about his future with R. R’s expressions of love helped instil in him a sense of confidence, and
a feeling of masculinity. At the same time, he also expressed his love for me even more overtly, and his associations flipped back and forth between his desire for R., and his desire for me. He said, “I
feel that it can’t be true that I want to be loved by you, taken care of by you. How can that be? Where does it come from? It fills me with a physical dread to say it. You obviously know it’s true.
You’ve been saying it all along”. In the next breath, he described this “voracious” desire for R., and his fear that its expression would tyrannize and overwhelm her. He also felt a kind of wonder and
happiness in his capacity to express himself in this way to me. He then said, “How strange that I’ve been able to recast you from an arrogant willful tormentor to someone who is earnest and patient
—a guide and support for me”.
 After this, he reported an extremely crucial and disturbing dream. In it, he became sexually aroused. He was filled with a sadistic desire to brutalize and sodomize his younger brother, who
appeared in the dream as an innocent child. He felt crazed in such a state of desire, when suddenly, he stopped himself, aware that he would be destroying the boy’s humanness. He awoke with a
terrifying start, struck by the savagery of his feelings, and his lust to dominate. He thought back to his childhood, and the feeling then of living in a world where he felt crushed and controlled. He
believed that he had resorted to dominating his brother as his only means of feeling powerful. He told me, “I feel enormous regret for this. I was a tyrant with him, competitive with him in the
rankest way. I do feel like I can unleash this savage dominance that will be out of control. I’ve become very frightened of the feelings I have in coming here and trusting you. What happens to those
feelings of affection? Where do they go, and where do they stop? I feel provoked to hold you at bay, and not let you enter my life as a romantic or erotic figure. It’s so incredible to talk this way. I
guess I do feel a humiliation, a kind of loss of masculine self-respect by allowing myself to trust you like this. The counter-attack is this assault on my brother, who has recently ‘come out’, and
declared that he’s gay. It’s like I was punishing him for being what I feel I am in some sense. It’s as if by assaulting him, I could assert my power, and purge myself of my own sense of degradation
and humiliation. Maybe the attack was really on you, that you’re the object of my vengeful lusts. That’s unspeakable to me”. It is difficulty to communicate just how powerful the effect of this
sequence was on us both. In particular, it helped shed some light on why the negative transference/resistance to the transference/transference resistance had been so intense, and so persistent. It also
set the stage for the termination phase of the analysis.
Discussion

In presenting this case, I have attempted to show how particularly intense and frightening aggressive and homosexual fantasies threatened my patient’s positive attachment to me. This particular
resistance also obstructed some important thematic lines of interpretation. And in spite of apparently accurate, and at times, effective interpretive work, a negative transference persisted, or was
easily mobilized, such as when I referred to my self by “title” (Dr.). It was only after I dropped the use of my title, as he had on several occasions asked me to do, that his negative feelings about me
significantly abated. Following this (inter) action, a palpable shift in the process occurred, which subsequently allowed the analytic work to productively proceed to completion.
The question I am hoping to answer here is, “why did this shift occur?” What I am proposing is that it was the action I took (responding to his request to drop my title), or what I have been
calling an interpretation through action that enabled the analytic process to proceed effectively. What seems clear from the work that had preceded (and also followed) this intervention is that it was
not enough for him to hear me say that I respected him, or that his experience of me as an exploitative authority figure was a product of his past experiences. He needed something more than words
for this to have an authentic effect on him. He needed me to show him, to show him through my actions. Only after that, could he allow himself to take the risk that if he considered my earlier
interpretations, I would not then turn around and take advantage of his having revealed some part of himself that he believed to be both horrible and true. It was my action that provided him with a
different experience of me, and this in turn, made it safe enough for him to consider that his prior experience of me had been a distortion. More specifically, the IA showed him an aspect of me that
he had heretofore been unable to entertain, and against which he could now compare his strong negative and aggressive attributions, i.e., his transference fantasies. The IA actually accounted for
three different types of interpretations (a psychoanalytic “hat trick”, if you will).

First, it was a transference resistance interpretation. The transference resistance was expressed as his experience of me as a figure of authority trying to assert power and control over him for
my own sadistic pleasure. With such a resistance at work, it became necessary for him to ward me off, specifically my interpretations (my influence), which he feared would be used to
manipulate him for those purposes. The IA removed this resistance by showing him that I was willing to give up power and control (and/or that it had really not ever been my purpose or
desire in the first place).
Second, it was an interpretation of the resistance to the transference. The patient had been afraid that forming a relationship with me would unleash his own homosexual feelings, which
themselves were fused with lustful aggression. The IA showed him the possibility of a relationship with a man that was mutual, respectful, and nonsexual in nature.
Lastly, it was also a more conventional interpretation of impulse and defence. The patient had been afraid that his competitive strivings, if expressed, would get out of control, and become
overly aggressive and destructive. The IA showed him that after assertively expressing his needs/wishes to me, I had seen them as appropriate, and had not been overpowered or destroyed
by them. Importantly (from the standpoint of IA), these were not new ideas or insights. Rather, the IA allowed the ideas offered through many prior (verbal) interpretations to finally be
understood, and accepted.

My IA (nonverbally) restated exactly what I had been trying (with only partial success) to communicate through words. It also tied together several different ideas. This is what the IA said in words:
“your attribution to me as a privileged authoritarian, who wants to ‘lord my power’ over you, and to control and humiliate you for my own sadistic pleasure, is a projection of your own aggressive
urges. It is also a projection of your own harsh judgments about yourself. I am not that person, but you are quite afraid that you are. Importantly, you are not that person either”. The new
understanding or insight that resulted from the IA was crucial in changing the patient’s perception of me (and of himself). It allowed him to alter his stance with me, and then with other important
male figures in his life, e.g., his thesis advisor. To oversimplify, he could behave less defensively with these men, because he felt less fearful about attacking them, or of being attacked by them.
I am contending that the case material I presented from the analysis following the IA, which included major changes that he had made in his life, supports the centrality of the IA in this process.
However, I am surely not suggesting that had this interaction occurred in the absence of the interpretive work that preceded it, that it would have had the same effect. Nor am I suggesting that all
patients need an IA in order to achieve insight. For many, the experience of the infantile neurosis with the new transference figure of the analyst is experience enough. What I am saying however is
that to ignore (or worse, to avoid) such action is to miss a potentially powerful facilitator of the analytic process. Alexander (1956) and Alexander and French (1946) made this point explicitly in
discussing the value of the “corrective emotional experience”. This recommendation then became fraught with very real concerns about the use of manipulation and countertransference acting-out.
On the other side, however, when analysts make great efforts to actually avoid the kind of action I have been describing, on the grounds that it is improper technique, I believe they end up
sacrificing a potentially powerful therapeutic intervention.
Analysts might also be making another error. They might be expanding the concept of technique, at the cost of distorting its very purpose. Typically, analysts avoid action, and they do so for a
variety of reasons. Some do so for exactly the reason I stated in this case, i.e., they are (mistakenly) afraid of “gratifying an impulse”. (In this case, I was actually gratifying a need). This is not the
only reason however, and as a group, we analysts seem to be much more attuned (biased) to the consequences of action, than to the consequences of inaction (or passivity and nonresponsiveness).
This point has been discussed for over half a century, following Stone’s (1954) landmark paper, and yet it continues to dog us. It continues (I believe) because we brush off the accusation of bias,
while continuing to harbour those same biased beliefs, i.e., that the consequences of activity are greater than those of inactivity. I also believe that it is precisely because such bias still does exist, that
the concept of IA has received so little attention, and has been so little considered in our theories of technique and change processes.
Lipton (1977) also made this point eloquently in his paper, “The Advantages of Freud’s Technique As Shown in His Analysis of the Rat Man”, where he observed that ironically in “classical”
psychoanalytic technique.4 There seems to much more emphasis on the behaviour of the analyst rather than on his purpose. He explained that this shift in emphasis resulted from an overly inclusive
conceptualization of technique that incorporated the personal or “nonobjectionable” aspects of the analysts relationship with the patient which he believed Freud specifically excluded from its
purview. In its most exaggerated form, this expanded view of technique would incorporate the personality of the analyst under its domain. It would implore the analyst to actually be neutral or be a
blank screen, rather than adopting these metaphors as attitudes for listening.
Clearly, the field of psychoanalysis and its theories of technique and change processes have travelled a great distance since the time that Lipton and Stone were making their arguments. The
emergence of “relational psychoanalysis” (Mitchell & Aron, 1999) or “intersubjectivity” ( Jacobs, 1986; Stolorow & Atwood, 1978) has given analysts/therapists an important new perspective with
which to view and understand their work. It does so by placing greater emphasis on the two-person field, that is, the process that is occurring between analyst and an analysand, and the contribution
made by each member of the pair to this process, consciously and unconsciously, separately and together. What then emerge from this process are characteristic interactional patterns of behaviour,
which are referred to by some as “transference-countertransference enactments” (T-CT-E). Renik (1993a) explains that, “Just as transference enactment may be a necessary prelude to transference
awareness on the part of the analysand, so may countertransference enactment be necessary for the analyst to become aware of his countertransference feelings towards the patient,” (p. 137). That is,
awareness of the countertransference can occur only after it has been enacted. He goes on to say that “perhaps some form of enactment is a necessary precursor to insight-for analyst and analysand
alike” (p. 137). In the world of relational psychoanalysis, the concept of countertransference has at last been freed from its role as the “evil twin” of transference. This has opened the door to
important changes in the way analysts view their work.
But how does interpretation through action compare with transference-countertransference enactment? In the sense that T-CT-E’s are by definition unconscious enactments of an interpersonal
dynamic between analyst and analysand, the two are certainly different constructs. T-CT-E is an interactional pattern of behaviour between/by two people (therapist and patient), while IA is a
conscious intervention (made by the therapist). However, the two notions could certainly be conceived of as having a very strong relationship to one another. That is, after the pair (therapist/patient)
has (unconsciously) enacted a particular relational pattern, it could lead to an awareness of a particular dynamic. In turn, the awareness of that dynamic might suggest a particular IA. In my case, for
example, it could be argued that the patient and I unconsciously enacted a kind of power struggle. Eventually, I became consciously aware of my unwitting role in it, and then made an intervention
(changing my behaviour), which served as an interpretation through action.
The intersubjective point of view, as put forward by Benjamin (1999), does allow for such a relationship between T-CT-E and IA. She beautifully articulates the possibility for this compatibility
even though she is more specifically speaking to the issue of “intersubjective resistance” when she writes about the important role that action plays in resolving stalemates: “Intersubjective theory
formulates the problem of resistance in this way: it asks how is it possible to restore the process of identification with the other’s position without losing our own, rather than submit to or negate the
other,” (p. 204). What the inter-subjectivists are calling “the analytic third” is the space where mediation between the two opposing positions can take place. She says, “The intersubjective level aims
to transform difference from the register of power, in which one partner asserts his/her meaning, will, need over the other … to an understanding of the meaning of the struggle”. Benjamin
underscores the role of action in resolving that struggle. She warns that this fact too often goes unrecognized, i.e., that the “release from the complementary power struggle” results from some action
on the part of the analyst.
Specifically on this topic, I wish to conclude that T-CT-E and IA are distinct and separate constructs. IA is a type of (therapeutic) intervention, not an ongoing behavioural process. In most cases,
this should keep the distinction between the two clear. At times, the use of IA is completely unrelated to a T-CT-E, e.g., in those patients with more significant degrees of psychopathology.5
However, I am also acknowledging that at particular junctures, e.g., “stalemates”, T-CT-E may pave the way for IA; and, as in my case, where the IA was only understood post hoc (as an
interpretation), the distinction between the two may be much more difficult to discern.
Before concluding, I want to return to the issue I raised at the beginning that the essential nature of language differs in significant ways from that of action. This obvious truth also applies to the
differences between conventional interpretation and what I have called “interpretation through action” here. As such, patients quite expectedly may have very different experiences after gaining
insight from an (conventional) interpretation, than they do, for example, after having their sense of being cared for (or respected) evoked by some action (or attitude) taken by their therapist.
Conceptually, this does not seem controversial or complicated. Nor does it seem to be a particularly large leap to say that the converse could also be true. A patient could feel cared for (or respected)
following some insight they had attained from the therapist’s interpretation; and that same patient could also gain an insight following a particular action (or attitude of) initiated by the therapist. In
the case I presented, for example, my patent achieved an understanding (insight) about the location and impact of his aggressive strivings following a behavioural change (action) that I initiated. All
that I have said so far is that conventional (verbal) interpretations and IA are by nature different. They work differently, at times achieving different aims, at times the same aims; and at still other
times, reinforcing the aims of the other.
On the face of it, these claims appear simple (even obvious) and noncontroversial. What would happen, however, if I introduce the term “corrective emotional experience” (CEE) into the mix?
Historically, this has been the intellectual equivalent of yelling, “fire” in a crowded theater of psychoanalysts! Many believe that the concept of CEE created such a stir in the field of psychoanalysis,
because analysts chose to focus more on how such an experience might be misused, rather than on how it was already being used, as well as on the centrality of experience itself. In his excellent
review paper on the topic, Palvarini (2010) reminds us exactly what Alexander and French had to say about the role of CEE in the therapeutic process. That the task of psychotherapy is to “re-
expose the patient, under more favorable circumstances, to emotional situations which he could not handle in the past, and must undergo a corrective emotional experience to repair the traumatic
influence of previous experiences” (Palvirini, 2010, p. 175). He goes on, “Because the therapist’s attitude is different from that of the authoritative person in the past, he gives the patient an
opportunity to face again and again, under more favorable circumstances, those emotional situations which were formerly unbearable, and to deal with them in a manner different from the old” (p.
175). This can be accomplished only through actual experience in the patient’s relationship to the therapist. The patient is able to master or resolve the conflict in large part, “because the analyst
assumes an attitude different from … the parent … in the original conflict situation (Alexander & French, 1946, p. 67).”
The Vanderbilt psychotherapy research group, led by Strupp and Binder (1985) reached the same conclusions that Alexander and French had over years earlier: that patients need from therapists
both a new understanding (interpretation) and a new experience in order to change. For decades now, and coming from different disciplines, both within and outside the field of psychoanalysis,
analysts, clinical researchers, and theoreticians have all been sounding the same note with respect to the importance that experience plays in the psychotherapeutic change process. This is as true for
psychoanalysis as it is for cognitive behavioural therapy (and even pharmacotherapy)! 6
Conclusion

In this chapter, I have attempted to expand upon the definition and use of IA in such a way as to stimulate further discussion about the role it should play in our theories of psychoanalytic technique.
I have used a lengthy case example from one of my analytic cases to illustrate some of my points. In most ways, I have viewed IA as an intervention that represents just one component of the
experiential aspect of the therapist-patient relationship. During the process of developing my ideas for this chapter, I have also noted a tension between what feels to me like “stating the obvious”
versus “defending the heretical”. This is in part a response to those psychoanalytic theories of technique which have placed experience and insight in opposition to one another, rather than as
different and complementary processes. I believe that this unnatural either/or dialectic also hampers the expanded use of IA. It should now be obvious that I conceptualize a both/and relationship
between conventional interpretation and IA, a view that has been long espoused by many others, such as those in the field who view psychoanalytic technique through the lens of intersubjectivity.
I cannot conclude without acknowledging that the concept of interpretive action could also be misused in ways that Stone and Lipton suggest, particularly if it is misapplied to those actions of the
therapist that should not fall under the purview of psychoanalytic “technique” ( Jacobs, 1991). True, any/all actions by the analyst/therapist may have an (clinical) impact on the patient. However, this
is not the same as saying that every action is clinical, i.e., that every action has a clinical intention. Actions without specific clinical intent on the part of the therapist should not fall under the
purview of technique. By contrast, IA does (or should) require an intention. Ogden (1994) was even more specific about this. He instructs the therapist to silently and simultaneously formulate in
words what the interpretation is meant to convey by its action. Even though I am not recommending something as formulaic as Ogden is, I do think that the therapist must have some formulation in
mind (if not on the tip of the tongue) at the time of the IA. Otherwise, the use of IA could easily devolve such that any action taken by the therapist could later be rationalized as a post hoc
interpretation. In my case example, I did not know at the time exactly what the clinical impact of my action would be. I only knew that there would be one. I also did not know beforehand that my
action would transform into an interpretation. Nevertheless, there was a clinical intention to my action. Also, I gave the intervention a great deal of thought beforehand. This led me to conclude
that inaction (not responding to his request) would impede, if not greatly impair the psychoanalytic process. I also did formulate several tentative hypotheses about what his response to my action
(changing) might be, and the impact it might have on the process. Lastly, I was prepared to not know his response, and to spontaneously deal with it in the same way I had to all his other reactions
to me, namely, analytically. In contrast to Ogden, I was not able to silently recite the interpretation as I enacted it nonverbally. However, I did not “shoot from the hip” either, as in an “interpretation
through serendipity”. What I did do was formulate reasonable hypotheses, act in accordance with those formulations, and analyse the impact (on us both) afterwards. Only after those 3 steps had
been completed, could I reasonably conclude (admittedly, retrospectively) that an IA had actually occurred. I am also suggesting that this is not an unreasonable approach to IA. It is an approach this
is neither overly narrow and proscriptive; nor vague, or too broadly defined, (and possibly clinically irresponsible). It also very much takes into account how we work much of the time. Not
infrequently, we are making educated/informed conjectures about the impact of our interventions. However, to this uncertainty, we have also built in a degree of flexibility to respond to our patients
that accounts for, and is commensurate with the potential for error. I am merely making the point that we routinely apply such a “standard” to conventional interpretations, and I see no reason why
the same standard cannot be applied to IA.
Notes
1. This of course is part of the larger controversy concerning the role of insight in promoting structural change in psychoanalysis. For a thorough discussion of this issue, see Wallerstein’s (1986) book, Forty-Two Lives in Treatment, which describes a forty-year study of change
processes during long-term psychoanalytic psychotherapies conducted at the Menninger Clinic.

2. See in this connection, Akhtar’s (2009) triad of survival, vision and faith as the foundation of analytic attitude.

3. Here the tension between Sandler’s (1976) “role-responsiveness” and what Gabbard (2006) has referred to as deliberate “disidentification with the bad object” comes to surface.

4. Such technique is epitomized by Eissler’s (1953) position as stated in his paper on “parameters”.

5. See in this connection Kernberg et al.’s (1989) approach to setting up an initial contract with borderline patients.

6. By “experience”, here I am also including the “therapeutic alliance” (TA) (Bordin, 1979). Psychotherapy research over the past 2–3 decades has consistently demonstrated the importance of TA (relative to the “specific factors” of the different types of psychotherapy) in effecting
treatment outcome (Horvath & Symonds, 1991; Hoglend, 1999). When comparing the treatment response amongst several different types of psycho and pharmacotherapies conducted during the large multicenter NIMH collaborative treatment study of depression, Krupnick
and colleagues concluded that, “The results also showed significant relationship between total therapeutic alliance ratings and treatment outcome across modalities with more of the variance in outcome attributed to alliance than to treatment method. There were virtually no
significant treatment group differences in the relationship between therapeutic alliance and outcome, in CBT; IPT (a form of psychodynamic therapy); and active and placebo pharmacotherapy, with clinical management,” (Krupnick et al., 1996, p. 537).
Part III
Alterations of the Relationship
Chapter Seven
Talking about oneself

Alan Skolnikoff

With our help, the analysand is able to face, to bear, even to react to, situations which formerly were too much for him in his state of isolation and helplessness to which he had had to surrender unconditionally, even surrender with pleasure.
—Sandor Ferenczi (1930a, p. 226)

As early as 1915, Freud observed that young and eager psychoanalysts would be tempted to reveal their own thoughts and feelings to their patients in order to help the patient divulge more about
themselves. Freud damns this technique by saying that it achieves nothing towards uncovering what is unconscious in the patient. He recommends that the analyst show nothing to the patient
except what is shown to him (Freud, 1915a). The analyst’s abstinence and anonymity motivates the development of the transference and leads the patient to do analytic work (Freud, 1915b).
Exploring the development of Freud’s thinking, Schachter (1994) reports that Freud advanced his position on abstinence and anonymity in order to inhibit erotic longings for certain female patients
—the patient’s charms posed a danger for the analyst who might, under the sway of passion, abandon technique and succumb to sexual desire (Freud, 1915b). Self-analysis alone could not guarantee
control so severe rules of non disclosure and anonymity were instituted to protect the analytic enterprise.
Ferenczi was an analysand and then a junior colleague of Freud. He developed many ideas about analysis that countered Freud’s recommendation of anonymity and neutrality. Essentially, he
offered a different view of the analytic situation and self-disclosure. Thompson (1988) one of Ferenczi’s students, noted his two major contributions to psychoanalysis. First, the analytic situation is a
human one in which two human beings attempt a sincere relationship. Second, the analyst must give the love the patient needs. Ferenczi argued that honest emotional communication should be
maintained and self-disclosure would not harm the process. Instead of hiding behind “professional hypocrisy”, the therapist must disclose feelings that are evoked in him. This honesty reduces the
trauma of the analyst’s interpretations. His ideas on empathy and mutual analysis have influenced contemporary discussions about how and when the analyst might or might not self disclose in
order to benefit the analysis (Ferenczi, 1933a, 1933b).
He and Freud had a voluminous correspondence for many years with Freud strongly cautioning Ferenczi to avoid the pitfalls of too close an engagement with his patients. However, in a letter to
Ferenczi in 1928 (Freud & Ferenczi, 2000), Freud reflected that many of his early recommendations about technique were essentially what one shouldn’t do rather than what one should do. He
wanted to set aside many of these recommendations and leave much up to the individual analyst’s tact. Still, he never advocated unbridled freedom for the analyst because of the risk of taking
advantage of the patient’s dependency (Grubrich-Simitis, 1986). In the present, there is still considerable difference of opinion about whether and under what circumstances the analyst should
disclose. This decision is dictated by a number of theoretical and contextual factors which I shall outline.
The chapter’s objectives are to: (i) note progress in categorizing and delineating types of self-disclosure, (ii) compare and contrast three clinical theories that hold different views on self-disclosure
as well as offer an alternative way of looking at the concept, and (iii) discuss illness and self-disclosure, where I will offer clinical examples from my practice as well as from others.
Progress in categorizing types of self-disclosure

The dialogue on self-disclosure avidly continues since Freud’s early writings. Some classicists such as Shill (2004) promote Freud’s position as the golden rule and as an ideal way to establish an
atmosphere of emotional safety for the patient. At the same time there have been major advances in fine tuning categories of self-disclosure, thus making discussions more focused and productive.
Self-disclosure can be described as occurring in a variety of circumstances. Akhtar (1995a, 1995b) notes three forms:

Integral: Inevitable self-disclosure occurs all the time within the psychoanalytic situation and includes race, skin colour, age, appearance, natural quality of the voice, office décor and the style
of engagement, i.e., the subjects that the analyst chooses to talk about or avoid. Some authors refer to this as self-revelation. All of us know there is little we can do about this kind of
disclosure—it is part of every human interaction.
Situational: There is considerable agreement about situations where one is obliged to reveal some facts to protect the analytic process. For example, most agree the analyst should reveal if
illness is the reason for having to suddenly cancel a series of sessions. Also in this category is severe strain in the analyst caused by mourning a death in the family, or change in life
circumstances that affect their capacity to be fully engaged in the psychoanalytic situation. The decision of how much to disclose might differ with each patient depending on their life
situation or ego capacities. However, analysts diverge on the amount of information they disclose. For example, a cancellation of 2–3 sessions because of illness in an ongoing analysis would
find some analysts not giving the reason for the interruption because it might preempt the patient’s fantasies. Others, however, might feel that not disclosing the reason for the interruption
would provoke the patient’s mistrust.
Technical: This form concerns a deliberate decision to disclose in order to positively influence the patient’s treatment. There are differences about how often and in what circumstances
deliberate disclosures should be made. The analyst can do less to control integral and situational disclosures but deliberate self-disclosure emphasizes conscious choice.

Rachman (1998) furthers our thinking by offering guidelines for the use of self-disclosure by distinguishing between judicious and conspicuous self-disclosure. Most of us would agree that
conspicuous self-disclosures which are impulsive and gratuitous are to be avoided. In judicious self-disclosure the therapist corrects the traumatic past and the failed experience of seeking
relationships by empathizing with the patient. With his words, the therapist attempts to declare his emotions to satisfy the patient’s intense yearning for a sincere experience. Rachman’s “judicious”
and Akhtar’s “technical” self-disclosures have much in common by placing therapeutic gain as the objective of the disclosure. There are many elements that determine the use of judicious self-
disclosure and Rachman notes the following guidelines:

Its use should aid the therapeutic process;

It should be guided by empathy and not acting out;
It should come from a conflict free area of the analyst’s personality or one where he is aware of his conflicts;
The content of the disclosure should meet the needs of the patient and not further the needs of the analyst;
The disclosure should be given with care for wording and intensity during a period of a positive relationship or transference; and
The impact of the disclosure should be analysed with the patient; the analyst should be comfortable with what is disclosed and not convey to the patient a sense of rejection or annoyance.

By contrast, self-disclosure should be avoided when the following features are in evidence:

It meets the needs of the analyst rather than the patient;

Countertransference dominates; analyst and analysand are not in emotional contact;
Unresolved needs in the analyst may contribute to a malignant regression in the patient; and
There are elements of manipulation, control, and intrusiveness in it.
Three theoretical models

Ego psychologists

Different theoretical orientations take distinct points of view about self-disclosure. Ego psychologists whose clinical framework focuses on a one-person psychology (emphasis on the patient’s
psychology with the analyst in an anonymous, neutral role) feel most comfortable with relatively silent listening and undivided attention to the dynamics of the patient as they unfold. The analyst’s
attention is focused on resistances to free association and interpretation. This stance makes the need for self-disclosure minimal. For example, if the patient questions how the analyst arrives at a
particular intervention, the response of the analyst would be to reflect the question, reasoning that the patient will be able to associate to the underlying fantasies which produce the question. The
presumption is that the analysable patient has the capacity to tolerate the analyst’s silence and free associate because they can imagine his thinking and feeling without the need for feedback. In this
conceptualization, the analyst runs the risk of shifting the focus away from the patient’s conflicts to the real interaction by making a self-disclosure (for example, answering a question). Within this
theory, this disclosure might lead to a transference resistance.
Busch (1998), within an ego-psychological framework, describes what kind of patient stimulates the analyst to self-disclose. The less a patient is able to use free association to self-explore, the
more the analyst has to use their feeling state in responding to the patient, disclosing their feelings as part of the interpretive process. If this is necessary, it should be done in as objective manner as
possible. The disclosure should lead the patient to be able explore his own ego’s functioning.
Meissner (2002) believes that even if enactments (defined as an unconscious action that the patient and analyst engage in that is related to both of their conflicts) are inevitable, the analyst should
try to preserve neutrality as much as possible. The therapeutic alliance (the relationship that furthers the patient’s and analyst’s work together) is contrasted with the real relationship (the analyst-
patient relationship apart from the treatment). Self-disclosure should be used to aid the therapeutic alliance rather than the real relationship. The analyst should only answer the patient’s questions if
the answers might strengthen the therapeutic alliance. Analysts should self-disclose when they feel that they have committed obvious errors, but not reveal so much that the patient is burdened by
their personal concerns. Blanket recommendations of unrestrained or rigid nondisclosure or the insistence on total anonymity are imposing arbitrary rules that don’t help the analytic process.
There are some ego-psychologists who advocate a more deliberate form of self-disclosure that recognizes the ubiquity and importance of enactments (Chused, 1991b; Jacobs, 1999; McLaughlin,
1991). They discuss these behaviours with their patients as a joint contribution of patient and analyst. This is a clear departure from the analyst as “blank screen” Jacobs (1999) describes under what
conditions he would self-disclose. To clarify limits, he first describes the boundaries that should be observed. Analysts shouldn’t self-disclose to relieve their own tension. They must be aware how
their disclosure might be heard by a regressed patient. Jacobs decides to answer patients’ questions when not answering might be hurtful. Self-analysis is useful in understanding why one answers
certain questions and not others. The analyst should reflect on how the patient reacts to their questions being answered or not. These reflections form the basis of judging whether to make
subsequent disclosures. It is an individual matter about when and how to self-disclose or whether we engage in banter or more formal modes of speech.
Jacobs offers examples to show the complex nature of thinking about self-disclosing and monitoring its effects.

Example 1: A woman patient with considerable subtle aggression repeatedly attacked Jacobs without being aware of it. Over time he noticed how inhibiting her attacks were on him as well
as how hurt he felt by them. At one point when he was particularly affected, he spontaneously disclosed the effect her words had on him. She said she was surprised but agreed that it must
be true that she was so aggressive. They continued working with both feeling that Jacob’s disclosure furthered the analytic work. He felt that this disclosure had been useful in furthering the
treatment until years later when she revealed that at that time, his disclosure left her shocked. She became frightened of her own power to threaten him which led her to become more
inhibited and not examine her behaviour towards him. Jacobs wondered if his intervention was worth the price.
Example 2: Jacobs tried to interpret the nature of a young man’s emotional and silent withdrawal around slight hurts. Historically, the patient had a father that frequently withdrew and
remained silent for little apparent reason. A variety of interpretations that focused on the patient’s experience with the father in the past and present failed to help the patient experience any
relief. In one session, Jacobs was overwhelmed by how strong his own feelings of abandonment were when the patient withdrew and spontaneously disclosed to him how deeply he was
affected. The patient responded, “Now you understand how I feel. All the previous times you were discussing my situation, I didn’t think you got it” (p. 176). This led to dramatic progress in
the analysis with lessening of the patient’s withdrawal around minor hurts and being able to verbalize rather than enact them.

Although Jacobs doesn’t advocate self-disclosure, he vividly describes emotional situations or enactments with his patients that are clarified with self-disclosure. He differs with relational
psychoanalysts who actually subscribe to self-disclosure as an important part of their technique.

Relational psychoanalysts

The ego-psychologists, including those who acknowledge enactments, try to limit their deliberate self-disclosures unless the patient has limited capacity to fantasize or are unable to accept the
interpretations of their conflicts. They attempt to disclose as little as possible to avoid shifting the treatment away from the patient’s problem. In contrast, the clinical theory that extensively utilizes
self-disclosure is the intersubjective theory of the relational psychoanalysts (Ehrenberg, 1995; Orange & Stolorow, 1998). These analysts see themselves as operating within a two-person psychology
in which both the patient’s and the analyst’s feelings and behaviour are observed as part of the psychoanalytic process. They feel their position is more complex than the ego-psychologists whose
theory is governed by a one-person psychology, with a more exclusive focus on the patient’s productions and emphasis on the analyst’s relative anonymity and neutrality.
The relational analysts argue that in practice the patient’s productions and behaviour are much influenced by the analyst’s actual behaviours. If analysts are empathically involved with their
patients, they find it impossible to portray themselves as an anonymous blank screen. They believe if they remain abstinent and neutral, the patient experiences them as only intellectually involved
and too detached to be able to offer enough emotional help to resolve their conflicts.
How does this point of view apply to self-disclosure? Orange and Stolorow argue that working within the intersubjective framework, the analyst always has to consider how he and the patient
jointly understand what is going on. This joint effort shifts away from maintaining the analyst’s stereotypic neutrality.
Ehrenberg asks that when an analyst is aware of a countertransference towards the patient, under what circumstances are these feelings discussed? When is a discussion of these reactions
therapeutic for the patient as contrasted with self-indulgent or conspicuous for the analyst? Sometimes the analyst doesn’t know at the time of disclosure, but only as treatment progresses can
helpfulness versus hurtfulness be assessed.
Renik (1999) describes the analyst’s style as another factor determining the extent of self-disclosures. He sees his own style as being more active and exhibitionistic than reserved and therefore, he
is more willing to engage in an interchange with his patients. He feels that all analysts should try to “play their cards face up” rather than hide their feelings. In the open climate that he advocates, he
gives an example of how a patient felt free to criticize his intervention by accusing him of holding back what he was really thinking. He had been unaware of holding back but went on to agree with
the patient’s interpretation and offered his reasons for initially being reticent. This interchange is quite different from a classical mode because Renik was willing to consider the patient’s reaction as
valid and he, in turn, responded by giving his thoughts about his motivations for being reserved. Renik states,
… the benefit of an analyst’s willingness to self disclose is that it establishes the analyst’s fallible view of his own participation …. something that analyst and patient can talk explicitly about together (p. 529).

Within a classical analytic perspective, the focus would be on analysing the meaning of the patient’s criticism of the analyst’s intervention. Although this strategy might be meaningful in
understanding an aspect of the patient’s mental functioning, it steers clear of the possibility that the criticism was justified. Even though Renik posits that judicious self-disclosure is valuable and
should be done more often, he believes that certain feelings should be withheld. He gives the example of a female patient wearing a sexy dress on a summer day who asked him how she looked. He
told her that she looked “terrific” but didn’t mention that he also was excited by her because she would interpret this disclosure as seductive.
Goldberg (1987) discussed the place of apology in psychoanalysis and psychotherapy. He describes the complex interaction of the analyst’s theory and the patient’s capacity to tolerate frustration
leading to the analyst’s decision whether to apologize (similar to a self-disclosure) for a mistake. Will the patient have the capacity to analyse the interaction with the analyst if the analyst doesn’t
apologize? If not, an apology might further the therapeutic alliance. When the analyst has to decide whether to apologize or not, they often have to wait to see if their decision was correct.
Rachman (1998) has a number of suggestions about the timing and appropriateness of self-disclosures. If the analysand observes a previously unspoken and unacknowledged attitude in the
analyst, the analyst should reflect whether he has contributed to the patient’s feeling. The analyst should be able to accept the subjective experience of the analysand. Instead of the classical position
of analysing resistance, the analyst and patient together should search for subjective meaning. It is important to accept the truth of the analysand’s observations rather than interpret or question
them. Examples: “You are right, I’m angry.” “I wasn’t aware of it, but you’re right. I have been tired during this session”. It is always important for the analyst to differentiate personal issues from
those of the patient so as not to blame the patient for the analyst’s feelings.

Neo-Kleinians
Another theory governing self-disclosure comes from a neo-Kleinian perspective. This involves the analyst reporting to the patient an emotion he feels as a result of the patient’s projection
(projective identification). Marcus (1998) gives a clinical example: One day during a session with a male patient he felt intensely sad. The patient wasn’t reporting any sadness and the analyst was
unaware of sadness that was coming from his thoughts. Marcus assumed that the patient was projecting the feeling into him. The analyst told the patient of his sadness and said that although it
might be his own feeling, he thought the sadness was coming not from the patient’s words but from his tone. The patient replied that he was not sure whose sadness it was but that he was glad the
analyst was feeling it and not him.
In the following sessions, however, the patient shifted to a sad topic. He described an early deficient relationship with his mother without affect. He had been told that when he was one year old,
his mother had to have a bilateral mastectomy, following which she withdrew her affection from him. As he described this history with his mother, the analyst again felt intensely sad while the
patient continued to feel removed from his emotions. The patient had been told of this history of his mother’s illness and didn’t remember the events or the feelings connected to them. The analyst
continued to feel sad and kept telling the patient about it. After several sessions the patient “took back” part of the sadness. With this new sad feeling, he could reconstruct his emptiness and sadness
in response to this early deficient relationship. Then, for the first time, he was able to discuss with his mother this period in their lives. Now, they were both able to experience the deep sadness of
those lost years.
With extensive experience disclosing his feelings to his patients, Marcus became increasingly convinced how helpful this had been for his patients. He came to feel that he didn’t have to be too
concerned about what he revealed either unconsciously or deliberately. Most often, the disclosure was helpful to the analysis and if it were a mistake it could be analysed as any other error. At first,
he agreed with the majority of analysts (Renik, 1995; Gabbard, 1996) that freedom to self-disclose did not include sexual feelings, but then had some clinical experiences that made him change his
mind with specific patients. On certain occasions, he found revealing sexual feelings to be helpful to the patient and their progress in treatment.
He reports the following clinical example: A thirty-nine-year-old woman, seen for nine years in analysis, was as usual complaining about him. She was always angry, feeling that all he wanted to
do was to take her money and make her dependent on him. As she seemed to continue to complain in one session, he noted that he didn’t feel attacked. He was also aware that she seemed softer
and more attractive and he had sexual feelings for her. This led him to ask if she was aware of other feelings besides her anger. She was embarrassed and wondered what he meant. He responded
wondering if she was having sexual feelings. She said it was true and it made her very embarrassed to admit it. She wondered what prompted him to ask. He replied that he was having a sexual
response to her even though she was expressing anger. He added that he believed that his sexual feelings were his way of detecting her sexual feelings. This led the patient to say she was angry with
him for not having sex with her and wondered if they both wanted it, why weren’t they having sex? He replied that while sex might be momentarily satisfying, it might damage her growing trust
and prevent her from exploring her deepest feelings. She asked if it didn’t make him angry to want sex but not to be able to have it. He responded that even if frustrating, it could lead to growth for
both of them.
Marcus felt that this exchange led to considerable progress. The patient was able to feel powerful instead of a helpless victim of parental neglect. She could now better tolerate the analyst as a
frustrating parental figure in the transference. Marcus concludes that as long as he was not seductive and certain that he would not act on his sexual feelings, he could risk disclosing them. Earlier in
his career, he recalled a stalemate with a female patient. In following the prohibition against disclosing sexual feelings, he didn’t tell her of his loving and sexual feelings towards her when she had
asked him directly how he felt. She had told him that she imagined him being attracted to her. At the time he remained silent. Retrospectively, he realized how withholding he had been in not
validating her perceptions of him.
How can one reconcile Marcus’ position about disclosing sexual feelings to certain female patients with the general admonition not to disclose those feelings? This takes us back to Freud’s initial
warning: if the analyst responds to the seduction of his female patients, he is in danger of being seduced away from the analysis and will succumb sexually. Marcus defends his disclosure by being
clear in his own mind and with his patient that despite his sexual feelings, he would not have sex with her. From his description of his interaction with this patient, it appeared that that her capacity
to postpone gratification was limited. I believe that by disclosing his sexual responsiveness and at the same time frustrating gratification, he gave her a “corrective emotional experience”. Instead of
the frustrating father in the transference which she couldn’t tolerate, he became the more complex loving but frustrating analyst who supported her learning to tolerate disappointment. Some would
argue this is not analysis because the transference is not analysed. Or, this patient can’t be analysed because she doesn’t have enough capacity to tolerate frustration. Moreover, many analysts might
not be able to deal with the disclosure of sexual feelings without the fear that they would act on them. Marcus’ clinical description is not meant to suggest a blanket recommendation to disclose
sexual feelings in response to patient’s demands. It seems likely that his patient didn’t have the capacity to fantasize about sex without undue frustration about not being able to act. What appeared
to be most embarrassing about revealing her sexual feelings was the expression of her neediness. It seems convincing that Marcus’ disclosure helped his patient.

An attempt at synthesis

Can we resolve some of the different points of view on self-disclosure offered by the above clinical perspectives? In a review of self-disclosure, Billow (2000) takes the focus away from theories that
strongly recommend it as well as those that caution against it. Whether spontaneous or deliberate, self-disclosure should be studied for what it reveals and what it hides. He expands thinking about
self-disclosure by applying it to all of the analyst’s deliberate or spontaneous words and what emotional attitudes they reveal or hide. He wonders how the patient reacts to disclosures at the
moment they are spoken and over time. To reveal the complexity of assessing the analyst’s behaviour, he describes a fantasy to illustrate the dimensions of this assessment. Here is the fantasy: a
candidate analyst seeks supervision to determine the right response to a patient’s request at the end of a session “Is it all right to take some out-of-date magazines from the waiting room to use for
my work”? The analyst responded in a classical mode, “You know your request … may seem casual, but everything that takes place here has some meaning that sometime emerges as we leave time
for reflection. Let’s take some time and come back to your question in another session …” (p. 68) The candidate then sees a few supervisors of different clinical persuasions, who tell the candidate
that what he is doing is either right or wrong or what they would have done instead. He feels alternately comforted or anxious by their suggestions, all of which are convincing. He then goes to yet
another supervisor who focuses on his supervisory experience. Is he learning something new? Is he developing any convictions about what he is doing or should be doing? Are he and the patient
doing the right thing? Does this supervisor know what he is doing? The young analyst supervisee wonders. He thought his latest supervisor was a relationalist but he wasn’t sure. What did he want
him to do? Maybe the answer is for him to act according to what he thinks is right at the moment and then learn from his subsequent interaction with the patient whether he was right or not. He
both likes and doesn’t like the freedom and ambiguity associated with this approach.
The conclusion from this fantasy is that much of what the analyst says or does is ambiguous and often doesn’t follow a particular theory. All disclosures, whether they are spontaneous or
deliberate or the products of a recognized enactment, are to be studied in the context in which they are occurring as well as retrospectively as they potentially acquire new meaning. Even a detailed
clinical description that stays close to the data of a self-disclosure can be understood as a partial description of the analyst’s intellectual and emotional experience at that moment. It is not the actual
or whole experience itself. How can we integrate what appears to be disparate theories? The ego-psychologists with their focus on one-person psychology and their preference for anonymity and
neutrality appear to have a much different approach than the relationalists’ emphasis on interaction in the intersubjective field with a two-person psychology. The theoretical approaches that dictate
whether or not to self-disclose appear to be irreconcilable, but if we observe what is actually done in clinical practice the differences are less.
Here are some examples where clinicians of different theoretical orientations might agree about self-disclosure. Both ego psychologists and relationalists might agree that those patients who have
the capacity to fantasize about the analyst’s thoughts and actions without extensive feedback from the analyst, are probably less likely to need the analyst to self-disclose and might even be
distracted by gratuitous self-disclosures of their analyst. They might also agree that those patients who don’t have sufficient ego-capacity to fantasize about the relationship with the analyst and not
able to easily free associate to periodically analyse themselves are more in need of self-disclosures from the analyst regarding the analyst’s thinking, emotions and experiences. Another area of
agreement concerns those patients who are prone to provoke enactments even in analysts who carefully maintain neutrality and anonymity. Further, patients who have trauma as a prominent
feature of their backgrounds usually require self-disclosure from the analyst to resolve their conflicts. For all events that require a decision about self-disclosure, it is important for the analyst over
time to observe the patient’s reaction. This empirical approach will further our understanding of the use of self-disclosure.

Self-disclosure and illness

Here, I will focus on a specific type of self-disclosure, e.g., illness in the analyst. I will give examples of how three analysts managed their own serious illnesses within their practices. It is rare in the
psychoanalytic literature to find research on the impact of the analyst’s illness on the patient. We are fortunate that Galatzer-Levy (2004) has done such research and the results of that work will be
reported here. I will also report on myself as well and examine how I coped with illness and report two cases where I used different rationales of disclosure.
Akhtar’s distinction between situational and deliberate self-disclosure is relevant to this discussion. In most cases, if not all, the analyst suffering from a serious illness is forced to depart from the
usual anonymity of the analytic situation because of the exigencies of treatment. Is there a litmus test for what should be revealed to the patient? Keep that question in mind as you read the cases. In
respect to deliberate and judicious self-disclosure, how do you determine “What is in the best interests of the patient’s treatment?” Can the analyst be objective in answering that question?
There are three categories of illness that can pose different responses from the analyst. The first category is the situation of a short acute illness that can’t be anticipated but involves the analyst
cancelling sessions or choosing to work when ill. Under these circumstances, self-disclosures might be either spontaneous or deliberate. Many analysts elect not to disclose the reason for the
cancellation or their transient impaired function. If the patient brings up either questions or observations concerning this illness, the analyst may reflect them back to the patients. Other analysts
might simply disclose their short illness to the patient, feeling that it serves the alliance to disclose the reality of the analyst’s functioning. The second category is the emergence of an illness which
doesn’t appear life-threatening but involves considerable changes in scheduling or cancelling of sessions. Here again, some analysts will avoid self-disclosure unless the patient confronts them with
accurate observations and/or questions about their health. Finally, the third category would be where the analyst has a chronic illness that is life-threatening. An analyst who works with their
patients under those circumstances often has a heavy burden in maintaining their analytic focus.
Schwartz (1987) had an acute illness that fell into the second category. He suddenly had to be absent from his practice for four to six weeks but anticipated correctly that he would have a complete
recovery. He called his patients to tell them that he would have to be absent because of illness and told them that he would return in six weeks and then would reschedule appointments. He returned
after four weeks recovered from his illness. He decided not to self-disclose further information about his illness with his patients but rather focus on their fantasies about it. This was effective in
deepening the exploration of their transferences. What is clear from his descriptions is that his illness didn’t interfere with his analytic capacities.
Pizer (1997) made a courageous attempt to conserve the analytic frame with her patients during the course of prolonged treatment for breast cancer including chemotherapy. Her illness puts her
in the third category: a chronic illness that was life-threatening. She disclosed to all of her patients that she had breast cancer, experiencing it as an inescapable self-disclosure. At the same time she
monitored the effect of her disclosure on her patients. She gave her patients every opportunity to plan ahead and express whatever feelings they had about her being ill. She was surprised at how
strong and capable she felt considering her illness.
One patient responded to her disclosure as follows: “I feel really bad about feeling helpless and I don’t want you to make anything out of it.” Pizer answered: “What to make of it? Here I am
telling you my condition and at the same time rejecting your repeated offers of help”. Later the patient complained, “Yes, I’m aware of the transference implications, but I’m so angry!!” Pizer’s
clarification: “Look, if five years ago when you came here, I gave you the choice of seeing an analyst that would get cancer and one that wouldn’t, which one would you choose? I know who I
would choose” (p. 457). She explained that if she were not ill, the patients’ statements of helplessness and anger would have led to inquiry rather than disclosure. I’m impressed with how resourceful
Pizer was in responding to her patients’ strong reactions to her illness. In the disclaimer about the patient preferring an analyst without cancer, it is impossible to know to what extent her patients
felt obliged to stay with her out of a sense of guilt. This sense of obligation would probably have an impact on the course of the analysis with patients, inhibiting their anger or frustration.
Morrison (1997), having had recurrent breast cancer, has written about her struggle to determine how, when, and what to disclose to her patients. This illness puts her in the third category: a
chronic illness that she knew would end her life. Her article was published posthumously three years after her death. She saw patients for the most part in once a week psychoanalytic therapy.
During her final reoccurrence, although she thought she had disclosed to most, she had only told four of her eighteen patients that she was terminally ill. One patient she finally told was typical. A
female patient who had a long history of sexual abuse didn’t recognize her therapist’s absences, signs of fatigue, and occasionally falling asleep as signalling any illness. Morrison had to tell her. The
awareness that her therapist’s illness was traumatic permitted her to get more emotional in describing the history and current effects of her sexual abuse. As we might imagine, many tribulations
were embedded in the therapist’s work. She had to help each of her patients deal with information about her illness and their potential loss. She wondered: Would she accept new patients? Did her
self-disclosure permit patients to decide to continue or end treatment? The therapist had respect for the concept of timelessness in treatment. By discussing her ideas about how long she was going
to live, would she take away the open-endedness of therapy? She found herself not wanting to impose additional loss by stopping the treatment of two patients who had suffered severe losses
themselves. If a patient was going to terminate, should she tell them the extent of her illness? She didn’t tell a new patient of her illness until the fourth session. She gave the patient the choice of
therapy with her or being referred to someone else. The patient decided to work with her despite her serious illness. Morrison answered the question of her capacity for neutrality by stating that her
ability to observe her own mind remained intact.
We can raise a number of questions and concerns about therapists such as Morrison who elect to work even though they are aware of their dwindling physical strength and occasional
inattentiveness. It is difficult to imagine Morrison being able to consciously and deliberately control her disclosures throughout her illness. Nevertheless, she reports that despite her illness, she was
able to conduct herself well. Reservations arise concerning her personal motives not to disclose the extent of her illness. Why did she disclose her illness to only four of her eighteen patients,
although she thought she told almost all of them? It is not unlikely that she sought to maintain her practice as long as possible despite the possibility she might be ineffective. She might have
countered this accusation by saying: she felt an obligation to her patients not to abandon them; she enjoyed her work which was emotionally life sustaining; and she needed the income from her
practice. Despite her courage, one must ask if it was always in her patients’ best interest that she continued their treatment. It is difficult to judge who could answer this question since we have no
reports from her affected patients.
Reviewing patients’ reactions, Galatzer-Levy (2004) gathered empirical data that revealed how ten patients were affected by their analysts’ terminal illnesses. After acknowledging the heroic
analysts who have described their work in the face of life-threatening illness, he sagely noted that the patients’ perspective has been given short shrift. He then reviewed the clinical experience of
ten patients who sought more analytic treatment following the death of their analysts. Several reported that their dying analysts had an “understandable” denial of the severity of their illness. The
patients’ collusion in this denial often affected them adversely. Difficulties arose during the illness and after the analyst’s death involving significant boundary violations. These boundary violations
concerned the analyst engaging in role reversals with the patients feeling they had to protect their analysts.
Galatzer-Levy (2004) gives specific examples of what patients recalled concerning situations around their analyst’s illness and death and their reactions to it. The patients observed signs or things
about their analyst that led to rational concern about their capacity. They tried to make a direct reference to these observations but also tried to limit how much they told their analyst. No patient
got a clear description from the analyst about their illness. Evidence such as marked weight loss, impaired mental function or incontinence were met with denial, rationalization, or an interpretation
of the patient’s motive for trying to perceive the analyst as ill. Although reassurance was not used as part of an analyst’s technique, the analysts nevertheless reassured their patients that they were
not observing signs of a life-threatening illness. The ill analysts made grandiose statements tinged with humour such as “I will live forever”. The patients were fairly convinced that their analyst was
more ill than the analyst let on and sometimes protected the analyst by not confronting them with questions about their health. Many patients were involved in an analytic community where they
were tempted to ask other analysts questions about the health of their analyst. They felt humiliated thinking that friends and colleagues knew more about their analyst’s health than they did. They
wanted to find out more about their analyst’s status but were conflicted about asking others since this would compromise their analyst’s privacy. When they found out about the illness from another
source and reported this to their analyst, in every instance the analyst expressed anger at the source which the patient experienced as disguised anger at themselves for having inquired.
The ten patients described by Galatzer-Levy represent a select sample and one could view these patients as those whose analysis failed for unknown reasons. Many questions are raised by this
research: were the analysts not able to maintain adequate analytic treatment because of their illness? Was the patient unable to deal with the trauma of the impending and final loss of the analyst
because of their underlying pathology? Among those patients who didn’t seek further treatment, were there some who were successful in working through the trauma of their analyst’s terminal
illness? How can the patient and the analytic community learn more about the limitations of the seriously ill analyst’s competence? These questions are not answered but direct our attention to the
general problem of how patients and the analytic community can evaluate the functioning of individual analysts.

From personal experience

In an extended analytic community, we often disclose information to friends and colleagues about our personal life, political persuasions and affiliations. There is the fear that some of that
information will inadvertently be revealed to our patients thus interfering with our desired anonymity. Even our social life is somewhat constrained by the wish not to be seen by our patients
outside our offices. The wish not to be exposed is often most acute around our becoming ill and not wanting our patients to know about it unless we tell them. In the examples that follow, I was
concerned about how to hide or reveal my illness to my patients. I will give two clinical vignettes, one where I made a decision not to disclose and a second, a decision to deliberately self-disclose. In
both cases, although I thought carefully about the reasons for my actions, I was unable to predict the immediate or long-term impact of these disclosures on the treatment. First let’s consider the
decision not to disclose:

Clinical Vignette: 1
One night before a full day of patients, I became ill with acute gastroenteritis. I had both vomiting and diarrhea for a couple of hours. By morning, one hour before my first patient, my symptoms abated but I felt weak. I decided to call all my patients and cancel appointments
for that day. I told them that I was ill but would be able to return to work the next day. I couldn’t reach my 10:00 am patient, but felt that I would be well enough to conduct the analytic hour with her. We had been meeting for two years and though she consciously desired to
get deeply emotionally involved in the analysis, conflicts around autonomy made this difficult. She never missed a session and always came to her appointments on time.
I thought over whether I should cancel the session when she came in or disclose to her at the beginning of the hour that I was somewhat ill. I felt I wasn’t seriously ill and was confident I could get through the hour. Because my patient had never cancelled, I believed I
should do the same. I was proud that I almost never cancelled for any reason, let alone illness. The hour was uneventful. The patient discussed conflicts with a colleague and I felt able to listen and make some appropriate interventions. In the next hour, she was very critical of
herself. Because she was part of the extended analytic community, she knew some of my other patients. At lunch one of them told her that I had cancelled his session because of illness. What disturbed my patient was her inability to detect that I was ill. She prided herself on
picking up subtle cues of illness in others. She associated to her mother who always tried to hide illness or sadness from her. Then she began to question why she missed these cues with me- was she avoiding carefully observing me? Did she just assume, unlike her mother, I
was always healthy? This association led to a deeper exploration of her fear of dependence on me if she became more involved in her analysis. I was pleased that I hadn’t disclosed my illness to her. If she hadn’t heard from another patient of mine that I was ill, there wouldn’t
have been this opportunity to explore her fear of dependence. No doubt there would have been other instances in future sessions where this issue would take center stage but my illness provided a good occasion to jump start the inquiry.

Let’s now examine the decision to disclose:

Clinical Vignette: 2
I had seen a young professional woman in a seven-year analysis several years before. Intense maternal and paternal transferences were analysed leading to a resolution of many of her conflicts. She was able to marry, have a child and be successful in her professional life, all
of which seemed problematic at the outset of our work. Because of the nature of her occupation, she was acutely aware of others’ general physical presentation. During the course of the analysis, she began to carefully observing my movements and behavior at the beginning
 and end of each hour. She accurately observed as I walked to my chair behind the couch, idiosyncrasies in my gait and body posture. She also carefully listened to the quality of my voice to determine my mood, state of alertness, or health. Her observations were accurate.
After acknowledging (self-disclosure) the accuracy of her perceptions, we were able to gradually understand that the acuity of her observations helped with her need to anticipate the behavior of her mother and father. Specifically, she could always anticipate her mother’s
distracted emotional withdrawal. Her father worked as a physical laborer and was often in pain after work. She observed the changes in his posture which was the result of joint or muscle pain. She learned to anticipate his angry verbal and sometimes physical outbursts.
After we fully understood these connections, she no longer was as acutely aware of my physical states. However, when she became anxious around interruptions of our sessions, she returned to being intensely aware of my movements.
Fifteen years after a successful termination, she returned to treatment. Anxieties about her work, and a troubled relationship with her daughter dominated our sessions. She was only able to commit to twice-a-week psychotherapy. The process shifted away from a focus on
transference possibly because of the diminished frequency and meeting face to face.
In the months prior to our resuming treatment, I had been seriously ill and required chemotherapy treatments. Fortunately, I was able to reschedule my patients, not miss any sessions and wasn’t aware of being compromised by the illness or treatment. I felt fully able to
engage in my work and judged that disclosing to my patients that I had been ill would shift the focus away from their problems.
However, I made an exception by deciding to disclose my illness to this patient. I had two reasons. Because of her acute awareness of others’ physical states, I feared that she would observe subtle cues that might reveal that I had been ill. Also, we had acquaintances in
common. One of them might tell her of my illness. I worried she might find out about my illness before I told her. She might feel betrayed impairing our treatment alliance. I further imagined this could feel like her childhood situation where her mother and father wouldn’t
tell her enough about their feelings. Thus I told her that I had been ill, had chemotherapy but had recovered and felt able to continue my work as before.
To my surprise, she was shocked. She hadn’t observed any changes. To her I seemed the same as I had always been. At this point, there was a shift in the treatment. She became solicitous about my health hoping that I would stay well. She reviewed her fears of
abandonment that she had from early childhood and talked about earlier anxieties during the analysis fearing she would lose my support for a variety of reasons. She began to make rapid progress with the problems she presented at the beginning of this treatment resolving
anxieties at work and repairing a guilt-prone relationship with her daughter. Although she had been fearful of terminating the analysis or even contemplating ending her current therapy she now seemed confident about ending. I wondered with her if my disclosure caused the
shift. If I became ill, she would be on her own and have to muddle through alone. She saw it somewhat differently. My telling her of my illness, made her feel that she could manage on her own. After all, I seemed fine despite my illness. She didn’t feel obliged to stay with
me. She was reminded of the pleasure she had leaving home when she was 18. She would miss her parents but she had the freedom of living her own life. A follow-up five years later, showed that she maintained her gains.

In this example, the disclosure of my illness did not have the effect that I imagined. I thought my patient would be more upset about the possible loss of my help. Instead, it became a signal to
consider coping without me. Assuming that her deciding to terminate was not to avoid fears of my vulnerability, my disclosure led her to greater autonomy.
Conclusion

Deliberate self-disclosure, how it is used or not used, is a central issue raised in discussions among adherents of different clinical theories. Freud’s original intent was to try to avoid disclosure as a
method of warding off the dangers of sexual boundary violations. As one reviews recent literature, we begin to put away absolute provisos about self-disclosure. We can put deliberate self-
disclosure or nondisclosure in the psychoanalytic context of all interactions between patient and analyst (Billow, 2000). As the psychoanalytic dialogue develops and deepens we must recognize the
greater involvement patient and analyst have with one another. In this context, questions raised by patients who are able tolerate the analyst’s silence and use their fantasies to imagine answers,
sometimes ask questions motivated solely by their wish to better understand the analyst’s hidden feelings and thoughts. For example, “You always respond to me when I ask about A, but never
about B”. What is the correct response for the analyst? It depends on the analyst; his clinical theory; his customary style; the history of the analytic process and how the patient and analyst
understand each other in the real relationship and the therapeutic alliance at the moment of the question. Ideally, a spontaneous or deliberate disclosure should be given with the analyst having the
conviction that the patient’s reaction can ultimately be understood by both of them and most importantly that the disclosure aids and abets the patient’s understanding.
As one expands the definition of self-disclosure to include all interactions in an analysis, further questions emerge that transcend how clinical theory influences self-disclosure. How is the climate
established in each treatment for the patient and the analyst to work together? Apart from the verbal exchanges, how can one look more closely and describe the non verbal behaviour and other
contextual features that contribute to interactions? How does the analyst explain what they expect from the patient and what the patient can expect from them? How is the asymmetry of the
analytic relationship understood by both? Asymmetry concerns analysts control of schedules, fees and their relative activity or inactivity. How much do analysts teach their patients about concepts
such as transference, resistance, enactment and projective identification and how much do the patients experience these reactions without any explanation from the analyst? These questions may
clarify the setting for single events such as self-disclosure during the course of an analysis.
A difficult topic discussed concerns when to self disclose the analyst’s illness particularly when the illness becomes chronic or life-threatening. Both from the perspective of the analyst and the
patient, the problem of the analyst’s possible denial of illness with the collusion of the patient is difficult to monitor or avoid. Material from Galatzer-Levy’s work with the affected patients suggests
the need for the analytic community to heighten awareness of this problem.
In reviewing my two cases, one a non disclosure the other a disclosure about illnesses, I couldn’t predict what effect my action might cause. My decision had to do with thinking that my
intervention would protect both me and my patients in our therapeutic alliance. I was convinced then and now that I made the correct decision, but there are other possible explanations. With my
patient that I couldn’t cancel, perhaps I indulged my grandiosity when imagining my illness couldn’t affect my clinical performance. Maybe my patient was more upset by my hiding behind analytic
anonymity. When I told my other patient about my serious illness, we could also imagine that I wanted to avoid her perceptiveness that would lead her to discover signs of my illness. Perhaps I
wanted to tell her about my illness before she told me—“beat her to the punch” to relieve my discomfort.
Further clarification of whether self-disclosure is hurtful or beneficial might be achieved by more clinical investigation into the patients’ reactions to their analysts’ self-disclosures. The clinical
study of self-disclosure with clinical vignettes invariably leads us more deeply into questions about the underlying analytic process.
Chapter Eight
Touching the patient

Andrea Celenza

To touch the coarse skin of a tree is thus, at the same time, to experience one’s own tactility, to feel oneself touched by the tree.
—David Abram (1996, p. 68)

A new patient1 extends his hand at the end of our first session. He has never had treatment before and I don’t want to offend him. I shake his hand, establishing a ritual that defers the problem for
another day. I am uncomfortable with the handshake, though. It is not my practice2 and I wonder if the touching will lead to other expectations of tactile contact. Even if not, I know the meaning of
this innocent gesture (at least that’s what I surmise at this moment) could change, for him as well as for me. A simple social convention now could take on more complex meanings as intimacies
deepen over time. I do not know him well enough yet to speculate about his wish to make contact in this way. We go on like this for several weeks, ending each session with a handshake.
A month into the treatment, he begins a session with a statement that he must tell me about his sexuality and that he is embarrassed to face me while he does this. I ask if he might prefer to use
the couch and explain to him that one of its functions is to bypass that feeling of shame: he might feel more able to speak when he doesn’t have to look at me. He lies down and almost immediately
tells me about his enjoyment of sadomasochistic scenarios with women. Some include enemas, some include whips. All involve the woman penetrating him anally with her fingers and other objects.
He admits he likes the pain.
We continue to focus on his sexual desires for the rest of the hour. He tells me about many liaisons and all the ways in which he likes to be touched, massaged, poked and slapped. Towards the
end of this hour, he says he feels exhausted but also relieved. He says he can hardly believe he was able to “get all this out” and that I am the first person he has been able to talk with about his
sexual proclivities. He thanks me for my listening and for the safe space my office gives him. I say, “This is why we should not touch. I want you to be able to continue to feel free to say whatever
comes up, especially as it relates to your body, and I don’t want you to worry that we must have contact in any way other than talking and listening to each other”. The handshakes cease and he
begins analysis a few weeks later.
There has long been a controversy about how to discuss the restraints of the analytic frame with our patients.3 There was a time when the frame of the analytic encounter was so much a part of
the culture that new patients already had a notion of what to expect and what not to expect. To the point of caricature, some patients were cultivated to expect very little, not only in the way of
touch, but even in terms of what their analyst might say (or mostly not say). Currently, however, analysts and therapists can no longer rely on a popular notion of “how to do therapy” and the
boundaries of touch have to be made explicit along with other matters of the frame, especially for a new patient like the one in the vignette above.
Touching, like uttering certain radioactive words (love and desire come to mind), is precarious. We can easily find ourselves in treacherous waters. So I begin this chapter with a detailed discussion
of what the nature of touch actually is, on a phenomenal, experiential level. I do not enter into this philosophical level of discourse as a digression but to pinpoint the exact nature of what is being
discussed in order to adequately address its various dimensions.
The phenomenal experience of touch

In consideration of touch as a phenomenal experience, we are immediately confronted with the reciprocal nature of tactility. It is not possible to touch without being touched and by virtue of this
essential fact, discussing the prospect of touching in therapy brings up the mutual aspects of the therapeutic endeavour as a whole. In contradistinction to the simultaneous asymmetric aspects of the
frame (e.g., the unequal distribution of attention where a defining feature of the analytic set-up is the sole focus on the patient), there are reciprocal dimensions of the analytic frame, and touching, if
permitted in whatever form, falls into this category.
Like the relational structure of the therapeutic encounter itself, touch is reciprocal and participatory. It is an example of the transitivity of direct perception. To touch is also to feel oneself being
touched, just as to see is also to feel oneself being seen (Abram, 1996, p. 69). In its mutuality, touch, thereby, carries with it a responsibility. Because it is participatory, there is a responsibility to clarify
the boundaries and meaning. Yet, it is not always possible to know or verbalize what is conveyed in the act of touch … it is ambiguous and plastic yet concrete and circumscribed at the same time.
On a concrete level, we cannot avoid registering the feel of the other’s skin, the scent of their body and the warmth (or coldness) of their touch. The experience of touching someone is more than
a feeling of pressure; it is an encounter with another person’s being and his/her nature. It is, therefore, an intimate form of engagement, however brief, conventional or ritualized.
Touch puts one in contact with another body—we do not touch another person in the abstract. When we touch someone else, we touch their body yet at the same time we touch their being and
vice versa; indeed, bodies and being are inseparable (Abram, 1996; Merleau-Ponty, 1962). The act of touching reminds us that we are embodied; any kind of physical contact is body to body. These
two levels of experience, our being and our body, are always one, there is no separateness between the experience and expression of being as well as its containment in one’s body (see, e.g., Foehl,
2009; Folkmarson Kall, 2009; Merleau-Ponty, 1962). Even without actual touching, we present ourselves to others through our embodiment. In this way, “The body is the very means of entering into
a relation with all things” (Abram, 1996, p. 47).
Because touch is reciprocal and because we participate in it, there is the possibility of disclaiming one aspect or another of this complex interchange. We can focus on our own meanings or
intentions while denying the others’. Often I have heard, “That hug was not erotic, I had no intention of crossing that line” or, “I am very clear on the boundaries … I hugged her in a platonic way”.
In these expressions, there is no admittance of the other person’s experience nor intent, or how he or she might attribute a different meaning to the very same action. Because of the essential
reciprocity in touch, the analyst or therapist must account for one’s own and the other’s potential experience. It is not enough to be clear about one’s own intent and there is a responsibility to refrain
from engaging in actions that might be misconstrued. The paradox of touch means that it crosses the border between one person and the other. To touch is to give and receive sensation at once and
we cannot deny one aspect of the process in order to rationalize or justify our own participation.
Meanings of touch in the clinical context

I have touched a few patients. Two were dying of cancer and I visited them each several days before they passed away. One was lying in bed, his body leaden with morphine and unable to move; I
stroked his face and told him what he had meant to me in a very personal revelation. The other had just been diagnosed with cancer and had been told he had only a few months to live. We hugged
at the end of that session and indeed he died a few months later. Unlike Dr. Aaron Green—Malcolm’s (1980) infamous and rigid protagonist—who failed to utter a word when his patient expressed
her distress over her child’s illness, it is inhumane to withhold a gesture of caring in dire circumstances. And, touch might be one such gesture.
I am certain these kinds of interactions have happened with all of us. Still, the question might be asked, “Why would touching be permissible in this circumstance?” In these final moments of life,
the boundaries of analysis or therapy have rightfully collapsed. With the awareness of death approaching, we face the bareness of our beings and engage with each other in more simple, existential
terms. Person to person, we want a moment of intimacy in an unfettered and unconstrained manner, to make contact with a person’s being without deprivation in the poignancy of these very
human experiences.
More often, however, I have had patients who want me to touch them at some point in the course of regular treatment. They want me to touch them (a hug, a handshake, or a kiss) as a symbol
that I care for them in a personal way, beyond my professional role and beyond their being my patient. “I need something concrete to let me know you really care for me,” they say in one way or
another. Perhaps it is a cup of coffee with me outside the office; perhaps it is a hug at the end of the hour. In the same vein, there are patients who want to be told how I feel about them (especially,
whether I love them or desire them sexually) and though I have little doubt in my own mind how I feel (usually in the positive direction), they want me to put these sentiments into words. The
fantasy about the spoken word is that it will feel more concrete, will “touch” them in a more palpable and lasting way than their silent speculations might. But words have their own ambiguity and
often do not last beyond their utterance.
I usually do not reciprocate a request for such signs of my caring, whether it might be a hug, handshake or loving phrase, but instead make it the very subject of a detailed analysis. Why do they
need such an overt sign of my affection? Why is their ability to detect what I feel for them, in a personal, authentic way (not beyond my professional role but embedded within it) not sufficient? Our
focus becomes their over-reliance on the concrete level of experience, overt expressions that indeed include words, in an effort to obtain a presumably permanent reassurance that they are loved,
wanted, or appreciated in a lasting way. I remind them, too, that any concrete sign or gesture will fall flat in the absence of a resonance with what they experience within our relationship on a
feeling level.
I remind my patients that words are at once ephemeral and ambiguous too, that persons can lie with words in a way they cannot with feelings. I encourage my patients to explore what they
know based on what they feel is between us so that words become less necessary, even thin compared to the depth of attachment between us. It is as if the treatment is designed to hone their radar
or antennae, directed at their own feeling experience of the relationship, including and especially, what they sense I feel about them.
Earlier in my career, I put how I felt about a patient into words and I regret it. This was a male patient referred to me during my internship year. He spent the first year or two letting me know
directly and vociferously that he had no use for me, that I was not helping him, and that he was intellectually (and in all other ways) superior to me. I hung in there through this grueling year and
did not let on that I actually (silently) agreed with him. He made me feel incompetent, unhelpful and painfully inexperienced as well as doubtful that I had any natural talent for this line of work. At
the same time, he never missed a session. And he got better, progressing in his career, social relations, and becoming more personally appealing. He had a sharp sense of humour and endeared
himself to me despite himself. He also paid me an unreasonably low fee and I colluded with this arrangement beyond his financial need for fear of unleashing a torrent of abuse about how I did not
deserve a penny higher.
After a few years, I mustered the confidence to broach the subject of raising his fee. Through a discussion with a well-meaning supervisor, we speculated that there was a strong, mutual
attachment despite all this angry tension on the surface. With the supervisor’s prompting, I said to my patient, “Because of the love that there is there between us (or some such awkward phrasing),
I’ve neglected to raise your fee and I think we should talk about it.” Well, the fee became a side issue very quickly, because all he heard was that four letter word. He came in the next day dressed in
a suit and high with expectations that we would begin dating. It was painful for both of us to come to terms with that.
It is probably not a coincidence that the patient for whom I felt the most intense desire to touch, to stroke his arm in a comforting and reassuring gesture that I hoped would say, “You’ll be all
right,” was a therapist whose license had been suspended for becoming sexually involved with a patient. Surprisingly, for me at the time, he was a most compassionate man who was relentlessly
self-critical over what he had done, especially the extent to which he had harmed his patient, a woman with whom he had thought he had been in love. He cried for six months in the treatment,
believing he had irreparably damaged her. He believed he deserved to be punished in every way and more. But the intriguing aspect of this phase of treatment, from my point of view, was the
intensity with which I felt a desire to touch him, to reassure him that he was all right, that he would survive and that he was good. I did not touch him but used this urge to understand the almost
bottomless longing he felt to be loved, manifested in my countertransference through a concrete gesture. Upon reflection, I surmised that my desire to touch him arose from a projective
identification, where he disclaimed his intense neediness and I resonated with it through my empathic relation to him.
Psychoanalysis is the science of hermeneutics—the examination and explication of meanings. Touch is nonverbal; it is a mute action—at best it fails to reveal meaning and at worst, obfuscates. We
make contact without explicating what we intend to convey. In this sense, it is anti-analytic by itself. We can touch when we want to avoid saying something disappointing, to bypass a feeling or
particular meaning. A hug can be coercive as well as seductive, circumventing the opportunity to make meanings explicit, especially with the arousal of tension or negative affect (Celenza, 2007).
To touch or not to touch, historically

The relatively scant literature on touching in psychoanalysis has evolved from Freud’s turn away from the “pressure technique” (where he would place his hand on patients’ foreheads) to the
opposition of language with action (1914), and the wholly nondirective “free associative technique” (1924), the latter comprising the fundamental rule of psychoanalysis. Despite Ferenczi’s (1930b)
misgivings and experiments, the proscription against touching became the general rule. This rule eventually came to be modified in the case of the severely disturbed patient (Balint, 1952; Little,
1990; Winnicott, 1965) where greater participation on the part of the analyst (both verbally and in terms of minor touching, such as handshakes, pats on the back or hugging) might be considered
permissible.
Currently, there is general consensus that the decision to touch or not touch should be made on a case-by-case basis (Galton, 2007; Ruderman, 2000).4 Since psychoanalysis revolves around the
exploration of meaning (constructed, discovered, or some combination), any action that “simply does” without exploring potential meanings is properly deemed anti- or at least nonpsychoanalytic.5
Despite that words themselves are now viewed as performative (i.e., as actions that “do”), psychoanalysis remains ultimately a talking cure even as its hermeneutic purposes delve into the nonverbal
and unformulated (as in, for example, Stern’s (1997) conception of unformulated experience). Further, there has been tremendous anxiety around the potential misunderstandings of the meanings of
touch, especially along seductive and sexually titillating lines; psychoanalysis has a long history of eschewing “actions without specifying meaning” that might be misconstrued.
Amidst the controversy over “to touch or not to touch,” might simply be raised the next question: “To touch or what?” The alternatives are more than simply not, or the absence of tactility, but to
do, ask, or say something else. The trade-off for not touching is usually further exploration of the patient’s feelings and interpretations (meanings) of them.
The oft-cited Casement paper

Perhaps the alternative to touching is not the absence of tactility but the awareness of the presence of something else. In 2000, an issue of Psychoanalytic Inquiry was devoted to the discussion of
Casement’s (1982) seminal International Review of Psychoanalysis paper, “Some pressures on the analyst for physical contact during the re-living of an early trauma.” This paper is a clinical report of
an analysis with a patient, Mrs. B, who pressured her analyst to hold her hand during the reliving of an early trauma. Mrs. B felt that were the analyst not to hold her hand, she would be re-
traumatized because the original trauma involved her mother fainting during a frightening surgical procedure when the patient was seventeen months old.
Since its publication, this paper has generated much discussion and the controversy seems to revolve around the meanings (for the patient) of whether the analyst would remain alive (concretely
present, as opposed to fainting as the patient’s mother had done) or collapse (like the mother indeed had) during Mrs. B’s reliving of the fear and pain of the surgical procedure. Casement’s touch,
thereby, signified a reassurance that he was still there and the repair of the trauma was viewed alternatively as Mrs. B’s need to correct the original trauma (by having the analyst hold her hand). In
1982, Casement reasoned that what Mrs. B actually needed was to endure a reliving of the experience without the analyst holding her hand, shoring up her internal strength revolving around her
ability to bear the reliving of the traumatic experience on her own. Presumably, the mechanism, in theory, is based on the tenet that identification comes about as a result of (nontraumatic) loss
(Freud, 1917) and this position stood as exemplifying the Middle School/Object-Relational theoretical stance. In other words, the analyst’s frustration of the patient’s wishes induces a desired
regression that stirs up pathological formations of the original trauma. These, then are reworked in the presence of the benign analyst (McLaughlin, 2000).
Several authors have taken up positions in relation to Casement’s original theoretical perspective. The conclusions of the seven authors published in the Psychology Inquiry issue devoted to the
paper’s discussion (Breckenridge, 2000; Fosshage, 2000; Holder, 2000; McLaughlin, 2000; Pizer, 2000; Ruderman, 2000; Schlesinger & Applebaum, 2000; Shane, Shane & Gales, 2000) will be briefly
summarized here. Most authors concur that judicious, thoughtful and socially appropriate touch is permissible with the proviso that the meanings of the action are discussed in the context of the
treatment (Breckenridge, 2000; Ruderman, 2000; Fosshage, 2000). Others view judicious touch as a developmental necessity with particular patients and during developmentally appropriate phases in
the treatment (McLaughlin6, 2000; Schlesinger & Applebaum, 2000; Shane, Shane & Gales, 2000). Both McLaughlin (2000) and Pizer (2000) tied their objections to Casement’s proscription against
touching to the certainty with which Casement presented his theoretical formulations. Holder (2000) stood alone in asserting that he “neither believes that physical interactions with our patients—
whether children or adults—can generally lead to the recovery of preverbal experiences and memories” nor does he think we can “undo what some of our patients have suffered during the very
earliest periods of their lives”.
In the later discussion (2000) of his own earlier paper, Casement expanded on his explication of the meaning “holding his patient’s hand” had on her and returned the significance of psychic
presence to the scene. In the ensuing treatment subsequent to the sessions revolving around holding the patient’s hand (and subsequent to the publication of his earlier paper), Casement further
elaborated that it was the mother’s psychic collapse that was crucial in the original trauma, not the concrete holding (by the patient’s mother or the analyst) that both he and the patient seemed to
be fixated upon at the time. He clarified the essence of the patient’s need thus: It was not that the patient needed to re-experience her intense feelings (of neediness and rage) in the absence of
concrete holding, but that the patient needed to re-experience her intense feelings in the psychic presence of the mother/analyst. Indeed, holding her hand might have given her the reassurance she
needed to know that her mother/analyst could tolerate, bear and contain her feelings. Or it may not have. The concrete is a poor substitute for psychic presence, though it is one that is often made.
Conclusion

It is here that the basic philosophical issue of embodiment pertains. If we think of our presence to the patient as always at once a kind of “body/being”, one always carries the other, then to separate
these experiences of otherness into concrete (or physical) versus psychic (or emotional) is a false dichotomy. Through this lens, the question, “To touch or to be with” is a false choice since you
cannot have one without the other. We move from the body to embodiment with this realization. The alternative to actual touching is the experience of being with, a different kind of presence,
indeed an augmented, feelingful/corporeal presence and not at all an absence.
Dichotomous thinking and the objectification of the Enlightenment-era epistemology has led us to pose such false choices. What we do when we actually touch a patient is provide a concrete,
sensate experience of being with, one where it behooves us instead to help our patients explore the sensate, emotional potential in their own bodies (in relation with us) with more acuity. The goal is
to have a feeling sense that may or may not include tactility or verbal representation. As our patients’ acuity to their own sensate/emotional experience deepens, the desire for actual tactility usually
diminishes in felt urgency. Many other aspects of body/being will emerge on multiple levels, as well.7 As one patient was fond of noting, “Your gaze touches me, like the heat of the sun”.
There is no substitute for being known, seen or touched in this feelingful, sensate way. When this level of phenomenal experience is sharpened and deepened, tactile experience becomes less
important, indeed a poor substitute for feelingful engagement. Touching is different for terminally ill patients—that is the unusual circumstance. In ordinary situations, we do not actually touch the
patient but virtually touch them with nonverbal expressions or words that attempt to capture the intensity of feeling.
I do not mean to resurrect the prudery or wooden anonymity of the blank screen caricature, but to encourage a profound appreciation for the complexity of the analytic relationship, including the
multitude of meanings and modes of relating emergent at any one time. As I have been emphasizing in this chapter, when we touch our patients we do not only make contact with their physical
body but with their entire being. This being includes the child despairing for the holding mother and also the woman enticed by the penetrating empathy of the analyst (and oh, how seductive
understanding is!) as well as the lonely adult contacting the adult person of the analyst. To consider anything less or only one of these dimensions is an oversimplification of the analytic relationship.
If we deem touch necessary in a healing moment, it is our responsibility to consider the meanings in an inclusive, multidimensional way.
Notes
1. This chapter addresses issues (both theoretical and technical) revolving around the treatment of adults only; I do not address issues related to child work which would raise different theoretical and technical concerns.

2. In a discussion of the ways in which actions perform interpersonal functions, Danckwardt and Wegner (2007) comment upon the various meanings of a handshake at the start or end of a session. While common in Germany, where they practice, shaking hands with patients is
not customary in the United States.

3. Freud (1913) established the “beginning phase” as one where the patient adjusts to the unfamiliar situation of being in analysis; Etch-egoyen (2005) allowed for the judicious answering of “naïve questions” to facilitate collaboration; and Thoma and Kachele (1994) suggest some
demystification without compromising anonymity and neutrality.

4. There have also been an array of empirical studies on the neurobiological functions and psychological meanings of physical touch. Essentially, these studies demonstrate the importance of the sensory system in human development and the necessity of tactile stimulation for
healthy, affectional relationships (Bowlby, 1952; Harlow, 1971; Montagu, 1986; see Fosshage, 2000, for a useful review).

5. Toronto (2001) offers an opposing view, stating that although all touch has some erotic component, sensible guidelines may be posited to allow for the judicious use of physical touch in treatment. She offers an example where “minor physical contact” with a patient “worked”
at a time when the treatment was at an impasse. In support of this argument, she reasons that physical touch “taps into a period of one’s life wherein physical contact was primary, a life sustaining link to the mothering one” (pp. 52–53). This is an example of the many well-
founded rationales that analysts rely upon when deciding to use physical touch for therapeutic purposes. Unfortunately, these rationales do not determine the meaning of the touch for the patient and do not prevent the misconstrual of the analyst’s intentions.

6. McLaughlin (2000) presented a compelling argument for developmentally appropriate touch in an example with a patient, Mrs. M, where in one instance, holding her hand is viewed as necessary to the reworking of a pre-Oedipal trauma and in another, as unnecessary when
reworking a more Oedipal level moment. Interestingly, in the latter instance, the offer to hold her hand was rejected by the patient herself.

7. See Charles (2001), for a discussion of cross-modal interpenetration of meanings derived from early infant research and Kogan (2003), for an analogous discussion. Additionally, the concept of free-floating responsiveness (Sandler & Sandler, 1998) includes the body (in Akhtar,
2009).
Chapter Nine
Giving mementos and gifts to the patient

Andrew Smolar

The child knows no money apart from what is given him—no money acquired and none inherited of his own. Since his faeces are his first gift, the child easily transfers his interest from that substance to the new one [money] which he comes across as the most valuable gift in
life. Those who question this derivation of gifts should consider their experience of psycho-analytic treatment, study the gifts they receive as doctors from their patients, and watch the storms of transference which a gift from them can rouse in their patients.
—Sigmund Freud (1917, p. 131, italics added)

While some papers do exist on gifts offered and/or given by an adult patient to the therapist (Smolar, 2002), gift exchange from therapist to patient has not been addressed in the adult
psychoanalytic literature. For one, although concrete gift exchange in common in the child psychotherapeutic setting, it is not all that common with adults. When therapists have offered gifts to
patients, they have been reluctant to report it, partly out of deference to the tradition of “abstinence,” and partly because its occurrence has suggested significant countertransference difficulties.
Contemporary relationists have begun to think differently about such exchanges between therapist and patient, viewing them and other extra-verbal transactions as potentially useful. Moreover,
they think carefully about their own motives—conscious and unconscious—when they give something beyond what the patient has come to expect within the therapeutic relationship. It is this kind
of intervention, sometimes received by the patient as a “gift,”1 that I will also consider in this contribution, alongside the more tangible and “actual” gifts and mementoes given by the therapists to
their patients.
Tangible gifts

It has been my observation that therapists usually speak in hushed tones about the idea of giving concrete items to patients, reflecting its forbidden nature and its infrequency. Many of us have had
the experience of a patient’s borrowing a book or magazine, and failing to return it, for one reason or another. And many of us have had the experience of reducing our customary fee for a patient,
either at the outset of treatment (for reasons such as a psychoanalytic candidate’s desire to begin a control case, or such as when we agree to treat a colleague’s or friend’s family member for a
reduced fee), or mid-treatment when our patient is beset by unpredictable misfortune, such as the loss of a job, or the contraction of an illness that has had significant financial repercussions (for
more on this subject, please see Chapter One). What I mean to discuss here, though, is not such an instance, but rather the therapist’s knowingly and intentionally giving something to a patient that
he thinks will have meaning for the patient. It then becomes a technical matter for the therapist to pay close attention to how the gift can be woven into the therapeutic process.
Freud’s practice

Freud (1915a) gave a stern warning that analysis “be carried out in abstinence … a fundamental principle that the patient’s need and longing should be allowed to persist” (p. 165). This reflected his
effort to develop psychoanalysis into a credible scientific treatment, to temper countertransference forces, to avoid the crossing of therapeutic boundaries that he knew could be fluid, and to
maintain the purity of transference development and analysis. However, Freud did not follow his own rules of neutrality, abstinence, and anonymity (Lynn & Vaillant, 1998) and frequently gave gifts
to his patients. The following is a list of such occurrences and their contexts.

“The Rat Man” (whose real name was Ernst Lanzer). His analysis began in 1907, and lasted less than one year. In a cryptic note entry on December 28th, Freud writes that the patient was
hungry and refreshed with a meal (of herring). Langs (1980) points out that the meal occurs at a phase in the analysis during which the patient is dealing with traumatic memories and
disturbing feelings towards Freud, perhaps precipitated by a seductive postcard sent by Freud to the Rat Man. In subsequent sessions, neither the card nor the meal is analysed, and the
patient’s material reflects his fears about what it means to ingest part of Freud, and about what danger might unfold between the two. In response to this material, Freud gives the Rat Man
another gift, this time a book. Langs (1980) points out that the Rat Man’s responses continue to reflect associations that Freud interprets along genetic and transferential lines, but also reflect
his acute concern about Freud’s deviations.
Smiley Blanton. His analysis lasted, discontinuously, from 1929 until 1935. One day Blanton (1971) mentioned that he was saving money to buy a copy of Freud’s works. The next day Freud
gave Blanton a copy of his Collected Papers, in four volumes. Following this exchange, Blanton reports a series of elaborate dreams over several days, and in his associations to the dreams,
Blanton links Freud’s giving him these books to a number of military metaphors (Blanton, 1971, pp. 41–42). Freud interprets that the dreams have become increasingly obscure since he gave
Blanton the books: “You will see from this what difficulties gifts in analysis always make (Blanton, 1971, p. 42).”
Edith Jackson. Her analysis lasted, discontinuously, from 1930 until 1936. Freud gave her an antique stone which she had set in a ring (Lynn, 2003), and Jackson told Paul Roazen (Roazen,
1995) that Freud gave rings to all of his female patients. He also gave Jackson a puppy, Fo, a daughter of Freud’s dog Yofi.
Roy Grinker. His analysis was conducted in 1932. Freud gave him a signed photograph of himself at the end of his analysis.
Joseph Wortis. His analysis lasted from 1934 to 1935. On the day of his last session, in the context of discussing his feeling that the analysis had not gone well, Wortis reported a dream in
which he asked Freud for a “favor, perhaps a photo (Wortis, 1994, p. 164).” Freud then tells him he does not have a photo, but he does have books, and gives Wortis a copy of his New Series of
Psychoanalytic Lectures, with his signature. There is no indication, from Wortis’ memoir, that this gift is discussed during the remainder of the session.
Subsequent psychoanalytic literature

For the most part, this literature emphasizes guidelines applicable to the non-psychoanalytic setting, and in many instances, to the psychotherapeutic treatment of sicker patients. Brown and
Trangsrud’s survey of doctoral psychology students (2008) indicated that twenty-five percent had given their patients tangible gifts, such as books, journals, picture frames, and stones, all of them
modestly priced. Zur (2007) writes that it might be therapeutic for the therapist to affirm the patient’s accomplishments at important points in the life-cycle—through small, culturally sensitive, and
appropriate gifts—either symbolic or concrete. He points out that these gifts may be psycho-educational, serve as transitional objects, be adjuncts to therapy, and/or strengthen the therapeutic
alliance, particularly if the therapeutic frame is not psychoanalytic. Epstein (2004) writes that she has given modest gifts to patients at different times during treatment, and that the gift occur-rences
involved substantial thought on her part, with the benefits outweighing the risks.
Literature pertaining to the analytic approach to treatment is relatively silent about gifts from therapist to patient. A striking exception is that of Eissler (1949) who advised that the analyst
treating a delinquent patient give him some money at the outset of their work. He argued that for the delinquent, money has taken the place of love, and therefore, and it should be given in the
hope of facilitating a rapid therapeutic alliance. Moreover, the money must be given by the analyst with strength, surprise, with the intent of reaching the patient’s unconscious, and without a feeling
on the part of the patient that he has manipulated the analyst into it.
Eissler’s intriguing recommendation notwithstanding, psychoanalytic literature over the subsequent five decades contained few, if any, clinical vignettes of an analyst giving a gift or a memento to
a patient. Akhtar (1994) has reported upon a patient who began to collect toy zebras as she felt more internally integrated as a result of their work. What he did not include in the published report
but told me privately (personal communication, January 18, 2011) is that when this happened, he was tempted to buy a toy zebra for her which he saw in a curiosity shop. He hesitated to act upon
this impulse, however. His reasoning was that he could not ascertain the impact such a gesture would have upon his patient. Would her new-found integration be consolidated or would she feel
infantilized, taken over, and—given her masochism—even mocked? Moreover, he feared that giving her spontaneously discovered icon further “reality” might compromise the “transitional”
(Winnicott, 1953) nature of the phenomenon. As a consequence, he decided not to give her this gift.
In contrast, Settlage (2001) has described giving his patient Ilana a flower vase from his office desk. This transpired after she gave him a hand-thrown pottery bowl. The context of this gift
exchange was that it occurred in the last two sessions before Settlage’s geographic relocation. Although the two knew of this plan to move from the beginning of the analysis, Ilana was “woefully
upse” as the end of in-person meetings approached. Settlage writes that:
“She was aware that her gift expressed the wish that our relationship would never end. I was now aware of her impaired object constancy and wanted to mitigate the impact of my leaving. In the last session, I gave her a pottery bud vase from my office desk. She later told
me that she kept it on her office desk” (p. 23).

It seems to me that Settlage’s way of managing her gift to him, which was to give her a similar article—with the additional fact that it came from his desk—may have muted the intensity of her
feelings related to his leaving. Did the therapist have unresolved feelings of guilt about his having initiated treatment with Ilana two and one-half years earlier, despite their having discussed his
impending re-location? Did the therapist’s gift to Ilana “mitigate the impact of [Settlage’s] leaving” in such a way that was countertherapeutic?
I provide this example of gift exchange not to criticize the therapist, but to demonstrate how thorny a gift from therapist to patient can be, particularly if it arises in the context of a termination
that fuels a couter-transference reaction on the part of the therapist. Here, it does not seem that the therapist has taken sufficient time to process the meaning of Ilana’s gift to him before he presents
her with a gift. Moreover, there is no evidence from Settlage’s case description that the two return to discuss this important exchange at a later time in the analysis, which was ultimately conducted
over the phone.
More recently, Eichen (personal communication, February, 2011) offered me a clinical vignette. While treating a 30-year-old woman with pre-Oedipal pathology who had interrupted her twice-
weekly treatment several times, she gave her a book about knitting, an avocation that had poignant, life-long significance given the patient’s mother’s psychic fragmentation. Eichen hoped, through
bestowing the book, to provide a maternal synthetic function. She believes the gift was somewhat successful, as the patient returned for the important time of becoming a mother herself.
The experience of child analysts

Documentation of the exchange of gifts from therapist to patient is to be found with greater frequency in the child analytic literature. Levin and Wermer (1966) comprehensively address the
potential of such concrete gifts: (a) Gifts specifically aimed at fostering the development of the therapeutic alliance (A. Freud, 1928). Examples of such gifts would be birthday presents, given at the
beginning of therapy, or additions to play therapy equipment that have personal significance to the child. (b) Gifts to establish an atmosphere of “giving,” sometimes absent in the familial
environment (Sylvester, 1945). There have been numerous case descriptions of children raised in environments of deprivation and neglect, and small tokens described and underscored as acts of
“giving” by the therapist may serve as juxtaposition to the home environment, and thus as a constructive springboard for discussion. I can recall giving a piece of candy to a latency-age child I
treated, only partially understanding that there had been little of it in the many foster homes he had inhabited, until he began to tell me about those circumstances. (c) Gifts as concrete rewards for
developmental advancement, sometimes with specific symbolic meanings (such as a toy gun marking a gain of masculine power) (Rank, 1946). (d) Gifts as transitional objects to sustain the patient
during a therapist’s (Kaufman, 1964) or the child’s absence. An adult patient of mine describes that his adolescent analyst gave him a short affirmative letter to take with him, including specific
advice for overcoming seasickness when he travelled by boat across the Atlantic with his family. He recalls that the instructions were not helpful, but the fact that he could carry her in his breast
pocket—close to his heart—was sustaining during the separation. I can also recall allowing an adolescent patient to take a picture of the two of us on the last day of our meeting. His request was a
surprise, and we were able to understand it as having several meanings: it was a way he would be assured of remembering me and our work together, which was important, given that his father
had left the family for a period of time, and he was afraid that his father did not remember him fully; the end of the treatment was necessitated by his mother’s moving him and his siblings to a new
location, and he was not happy about it, and a concrete reminder of his “old” life in the form of a photo was a way he could wave his objections at his mother; the photo of me and him reminded
him of the paternal presence he had been able to borrow from me, and it represented a transitional dosage until his father returned. (e) Gifts to counteract excessive superego pressure within the
patient (Isaacs, 1933). An example of such a gift would be a book about a subject of leisure given by the therapist to an anxious, academically driven student. (f) Gifts as symbolic suggestions about
the power of the analytic process (such as a telescope or a compass). (g) Gifts to overcome a specific arrested skill. I have, for example, given an adolescent patient suffering from writer’s block a
paper with suggested techniques for overcoming the block. (h) Gifts to facilitate mastery of ego activities central to the therapeutic task (A. Freud, 1963). Levin and Wermer (1966) give the example
of a diary in which an adolescent patient can elaborate on feelings she is learning to identify and verbalize.
In summary, reflecting on Freud’s practice, the adult psychotherapy literature, and the experience of child analysts, tangible gifts seem to be predominantly offered under several circumstances:
(a) by all therapists at specific phases of treatment, most specifically during the initial phase to bolster the therapeutic alliance, at moments of life-cycle or therapeutic achievement, and during
termination. As noted in the group therapy literature, and in Settlage’s case, some specific factors surrounding the way the termination is handled by both therapist and patient, including most
notably the therapist’s ability to work with his countertransferences, would leave us inclined as observers to view the gift-giving as more or less therapeutic; (b) by therapists of children and
adolescents, to bolster the alliance, to mark progress, and to fill developmental gaps; and (c) by all therapists, occasionally, as transitional objects or developmental facilitators. Interestingly, this use
of the gift, within group and individual treatment modalities, within treatment frames that vary in terms of the therapist’s supportive/analytic stance, and with patients with varying degrees of ego
strength, seems to be a common thread.
Group therapy literature

The group therapy literature offers a number of examples of therapists’ giving gifts to group members. Writing about the more conventional gift exchange, such as among members or from a
departing member to the therapist, Rutan and Stone (1993) caution that departing members may bring gifts as transitional objects meant to help the group remember them, or as a celebration of
group therapy experience. Extending this idea, Shapiro and Ginzberg (2002) describe termination rituals, and factors that facilitate or interfere with the termination process in group psychotherapy—
such as whether the termination and accompanying ritual are planned far in advance, whether the ritual is coordinated with group members and the leader, and whether the ritual reflects the
therapeutic norms of the group. In so doing, they give a poignant example of the leaders’ participating in a several month group-wide discussion about the choice and meaning of gifts to be offered
to and by the departing member. The therapists give the departing member a compass and miniature hand, each metaphorical for personal themes of reciprocity and individuation that had been
explored in therapy.
Gayle (2009), in demonstrating how group structures change over the developmental life-span of a group, provides an example of the leader’s participation in changes in the group frame—such as
in the time and place of meeting—and the emergence of a transitional ritual, in which the group holds sessions with a dying patient in a hospice setting, and provides the patient with a pillow to
hold, one that is adorned by ribbons with their expressions of gratitude. Fieldsteel (2005), during the last group session of her group’s life—a termination process she had initiated—brings a bottle of
wine for the group, stating that “the [person] who [is] leaving usually [brings] the beverage” (Fieldsteel, 2005, p. 272), and she encourages the members—each of whom had brought a bottle of
champagne—to hold onto the bottles “for the next important [celebration] (Fieldsteel, 2005, p. 273).” She goes on to speak to each member about what they had shared in their work together, and to
the group-as-a-whole about her feelings about ending. This gift and termination strategy seems fraught with countertransference complications. For one, the gift is provocative, and there is literally
no time for the group to process it. Moreover, taking into account several aspects of the way Fieldsteel worked through the ending, it seems to me that the gift and termination strategy emphasized
feelings of celebration at the expense of her guilt, and the group’s sadness and anger. In summary, the group literature seems to emphasize the association between termination and gift offerings,
both among patients and from the leader to patients, and it clarifies factors that determine whether, on balance, the gifts serve therapeutic purposes.
Intangible gifts

Various discussions of technique in the adult psychoanalytic literature touch on ways to promote repair with patients who have suffered early developmental deficits. These technical interventions
have not been called “gifts” per se, and are, depending on the case and approach chosen by the therapist, considered a basic part of therapeutic technique. Ferenczi (1929, 1931) wrote of treating
patients without remuneration if they met a financial crisis, of seeing patients at their homes if they were too ill to travel, or of extending the length of sessions; in short, of “indulging” them for a
period of time, especially if they had been injured by early developmental trauma. Alexander (1958) describes the therapist’s active and, at times, unorthodox interventions, informed by an
understanding of the patient’s transference distortions, and aimed a creating a “corrective emotional experience” for the patient. Gedo (1988) writes about the task of the analyst’s creating a holding
environment in which he can attend to a patient’s “apraxias,” or developmental deficits. He points out that “an apraxia can seldom be repaired through direct instruction (especially instruction in
some didactic manner), but through specific technical means.” Hoffman (1998) writes of a new kind of relatedness developed between analyst and patient, co-constructed along several lines of
tension, and potentially powerfully affirmative of the patient’s self-worth. Akhtar (1999b) points to the distinction between a patient’s needs and wishes, and technical implications of such
differences. Pine (1998) and Killingmo (1989) describe a heavier proportion of supportive and clarifying interventions indicated for treating adults with a greater degree of developmental deficits. I
intend to broaden this literature by examining circumstance in which these and other techniques may be applied to enhance the therapeutic process.
The gift of a transitional object

Rachel is a patient whom I have been treating in twice-weekly psychotherapy for many years. Her sensitivity to aloneness, chronic feelings of emptiness, primary defence mechanisms of splitting
and dissociation, affective instability, and a profound identity disturbance, among other symptoms, caused me to conceptualize her diagnosis as borderline personality disorder (DSM-IV, 1994). As
her feeling of gloomy abandonment surged in anticipation of my vacation, she asked me whether it might be a good idea to purchase a stuffed bear she would name “Andrew” that she could think
about and hold during my absences. This phase of treatment was marked by Rachel’s struggle with her hateful and loving feelings about me, which included her fear that she might hurt me and that
I might hurt her. She also thought that I was possibly the only one who had every genuinely cared about her. I was aware that she was struggling painfully to integrate these positive and negative
images, and that the struggle was accentuated by my absences. I was also aware that the bitter divorce proceedings then in active litigation had further unleashed these feelings of abandonment. It
seemed to me that her effort to work with these mixed feelings was important to her progress, and that her being able to keep me concretely alive during my absence would move us forward.
I also asked Rachel why she felt compelled to ask my permission for her purchase and naming of the bear. She replied that she was embarrassed for needing me so much, and that she wishes she
could tolerate my absences without feeling so upset. She also said that it felt “slightly weird” to replace me with an inanimate object and worried that I would feel insulted by her gesture. I told her
that I thought her need to have me in bear form, especially during my absences, made sense at this phase of our work together, that it represented progress for her to be able to identify strong
loving and hateful feelings toward me, and that the bear might facilitate her integrating those feelings. Rachel felt great relief at my giving her license to use me in this way, and experienced the
bear as a “gift” from me to her.
The gift of self-disclosure

Alex, a 38-year-old man, has been in twice-weekly psychoanalytically oriented therapy for four years. Emerging conflicts included a hostile dependency on his mother, and intense rivalry with his
two younger brothers. After a recent summer vacation, he admitted that he was, for the first time, curious about where I had gone on vacation. I asked if he could tell me about how this curiosity
had evolved, and how he understood its emergence in the context of the issues we had been discussing. Alex recalled how certain subjects were dangerously off limits in his family of origin (for
example, there had been no acknowledgement of his parents’ separation when he was eleven, during which time he didn’t see his mother for months; nor had there been any explanation of his
father’s absence while undergoing medical treatment for cancer when Alex was fourteen). Alex, therefore, felt not sure he could ask me about my vacation and stated that it was only because he
had been feeling gradually closer to me that he could even tell me about his reluctant curiosity.
I should add that I was acutely aware of the fact that Alex’s physical boundaries had been breached often by his mother (for example, she would barge into the bathroom when he showered as an
adolescent). We had been working steadily on his difficulty gauging boundaries in many relationships, and I was aware that my response to his inquiries would be filtered through his struggle about
the boundary between the two of us. I was also aware that I was feeling paternal toward him, hoping to be a better “father” than his stoic, furtive father had often been.
I knew I had several choices: I could give him no details, emphasizing that I was interested in understanding his past experience, and his fantasies about where I had gone. I could answer all of his
questions, giving him full access to my personal whereabouts, and possibly to details about my personal relationships. Or I could answer some of his questions, but not others, and in so doing explain
why some of his questions felt off limits, thereby potentially altering his experience of his parents’ silence about their relational instability and tenuous availability to him.
I opted for the latter approach. I first noted what a significant step this was for him to be able to ask me about my whereabouts, pointing out that his family’s culture had not allowed this kind of
curiosity. I then told him that I would answer some of his questions, but not all of them, and that I would explain my rationale for selecting which ones I would answer. I encouraged him first to
explore where he thought I had gone, how he thought I had spent my time, and what kinds of details he wished to know. In brief, what emerged was that he wished to know whether my hobbies
were like the ones his father (who had died two years earlier) had enjoyed, and whether they were compatible with his. He also wanted to know that kind of father I was to my own children, and
whether he could count on me for paternal stability. After discussion of this transference material, I let him know where I had gone on vacation, and confirmed that I enjoyed outdoor activities. I
told him I was not comfortable providing details about my family. I also explained that telling him about my outside relationships at that moment felt peripheral to his primary interest, which really
seemed to be about the two of us. I finally told Alex that I hoped our discussion could be a different experience for him, one where he was not discouraged from asking questions, one where we
could feel closer, but also one where I could maintain some privacy while attempting to address his needs. This, I said, seemed very different from the way his mother managed their interactions.
Alex was grateful for my words, and said they were “like a gift.” He said that my letting him know clearly that his questions were valid allowed him to reveal the depth of his curiosity. He added
that I seemed more “real” to him. He was also relieved that I had not told him too much. Since his family’s boundaries had been so inconsistent, he said, he was still learning how to decide what
interpersonal revelations were appropriate.
The gift of extra time

Rebecca is a 32-year-old woman with a possible history of paternal sexual abuse. She presented with a fear of being alone, episodic panic attacks—which responded relatively quickly to medication
—and a vigilant fear of nocturnal darkness. Rebecca was eager to get to the bottom of her difficulties quickly; she settled enthusiastically into a twice-weekly psychotherapy. Gradually, over the first
two years, she developed trust in me, and recognized the degree to which she had been neglected by her mother. She began to recall instances in which her father told her to join her unstable
mother in bed, to hold and reassure her. She also began to remember the sting of her mother’s various criticisms of her body, and of her mother’s prediction that Rebecca would be hospitalized for
psychiatric problems someday (as her mother had been).
During the second year of treatment, Rebecca underwent a complex infertility work-up, culminating in in vitro fertilization. As I prepared to leave for my traditional summer break, she was
devastated to learn that she was in fact not pregnant. Her disappointment about the result was superimposed on the hormonal imbalance that had also occurred during the preparation for in-vitro
fertilization. At the same time, Rebecca was feeling acutely alienated from her father, and worried that she could not tolerate my vacation, especially given the fact that her husband planned to be
on a business trip at the same time. I discussed with her the possibility of her seeing my colleague while I was away, but Rebecca did not feel she could talk with a stranger about such sensitive
issues. Rebecca had not previously panicked so much in anticipation of one of my vacations. She felt fearful at the thought of going two weeks without a safe place to talk. Moreover, she worried
something would happen to me, as she had worried as a child, when her father would go away on business.
Because of these circumstances, I offered to speak with Rebecca by phone for specific blocks of time during my vacation. I billed Rebecca for the time at her customary rate, and made it clear this
was unusual, but not extraordinary practice. Rebecca recognized this offer as a gift, and noted her genuine gratitude, with an apology for infringing on my “well-deserved” vacation. We did not
speak about the gift at length subsequently, although the offer did seem to help promote the therapeutic alliance. The work proceeded somewhat predictably by phone. By the time I next went on
vacation, Rebecca was much less anxious, and did not need contact with me. We have not since that time instituted any unusual contact during interruptions in our work.
The gift of physical touch

Judy, a 47-year-old woman, presented for treatment of ongoing depressive symptoms after completing an “unsuccessful” analysis seven years earlier. She pointed to an “unresolved, cold”
relationship she had suffered with her analyst as the source of its unsatisfying outcome. Because of the sour taste that remained, she was pessimistic about our chances of working well together. We
began to meet twice weekly, and formed a bond relatively easily. It became clear fairly quickly that Judy was sharply self-critical, and that she experienced herself as toxic and potentially destructive
to those close to her. We were able to establish that her times with both her parents—most notably, her rageful, alcoholic father—and with her former analyst, were replete with fears that some or all
of the participants could be poisoned or killed by Judy’s voracious desires, or anger when those desires went unfulfilled.
I found that Judy’s needs required that I not be too quiet, and that I take the initiative in talking with her openly about her anger when she felt it. Judy contrasted this approach with that of her
former analyst, whose restrained, passive stance infuriated her and also caused her to withdraw, sometimes by leaving sessions early. In the third year of our relationship, it dawned on Judy that
there were elements of her marital relationship that were strikingly similar to her relationship with her parents in childhood. Judy began to question in earnest whether she wished to stay with her
husband. She became despondent over the possibility of leaving him, and wondered if she could take care of herself. After one notably painful session, as Judy was about to walk out the door of my
office, I spontaneously—and with the intent to soothe her—touched her shoulder. She recoiled slightly as she made eye contact with me and left the office. Afterward I wondered, should I have
resisted my impulse to demonstrate special warmth to Judy? Had I been feeling competitive with her husband, or too intent on correcting her parental environment? In the next session, she
explained that she partly appreciated my physical gesture, which she experienced as a gift, but withdrew to my touch, “because it [felt] like there [was] a pit of need inside [her] … and if [she
allowed] some of it to come out, it could be endless …” I apologized for alarming Judy, and then encouraged her to talk about her “pit of need.” She went on to discuss how she had never felt there
was a safe haven for her to explore her basic needs, never at home with her hostile parents, not with her husband, nor in her prior analysis, and then only cautiously with me.
The gift of developmental presence

Sarah, a 22-year-old college student, initially presented to me for help managing antidepressant medication that had been prescribed for panic attacks she had suffered following her mother’s death.
Not long after we stabilized her medication, it became clear that longer-standing conflicts from the separation–individuation phase of early development were complicating her grief for her mother.
Gradually, over four years of once-to-twice weekly psychotherapy, we clarified the peripheral role her loving father had assumed in her family, the previously unrecognized negative feelings she
had about her mother before she came ill, and the intense, sometimes destructive sibling rivalry she had with her brother, her mother’s favourite. Although she was at first intimidated sitting with
me, she developed an explicit fondness for me, and developed a capacity to mock me playfully. Her comfort with me by the time we terminated seemed characteristic of the budding stage of
maturity evolving between a young adult and her parent.
During the last year of Sarah’s therapy, she met a man and settled into an intimate, albeit sporadically conflictual, relationship with him. We spent talking about his strengths and weaknesses, his
passive style in negotiating disagreements with her, and ultimately whether he was an appropriate partner for marriage. As Sarah decided to marry her boyfriend, and as she began to make plans
for the wedding, she spoke to me about all the details, including the wedding hall, the dress, the flowers, the menu, the Church ceremony, and the inevitable familial tensions that arose. It began to
feel like I was her surrogate mother, revelling in wedding minutiae with my precious daughter. Sarah began to dream of her mother, who in her dreams at times arrived late for the wedding, at
times facilitated its smooth presentation, at times bristled about Sarah’s various arrangements, and at times was absent but hardly missed. These different scenarios highlighted the degree to which
Sarah missed her mother, but also depicted her mother as critical, meddle-some, and disappointing, sides of her mother she had incorporated during the therapy. It also brought into sharp focus the
developmental meaning of her marriage, as she wondered about her ability to become a woman without her mother’s actual presence.
When Sarah invited me to attend the wedding, it seemed obvious that I should attend. For one, the wedding had functioned as an impetus for the culmination of Sarah’s acute grieving, and as a
development yardstick for her stepping into adulthood. It also marked the end of our work together, as Sarah would be moving to another city with her husband right after the wedding. As such,
discussion of the wedding, and my participation in it, raised specifically the subject of termination, linking me again to her mother, both of us becoming objects she would have to leave. This fact
mitigated against my concern that my attendance would contaminate the transference and derail the ongoing work. The most important factor in my deciding to go was the fact that I had filled in
for Sarah’s mother during this phase of her life, and we had discussed my role as a transference object and as facilitator of her development explicitly in our work together. In our discussion of how
Sarah would experience my presence, she distinguished clearly between her comfort with my going to the ceremony, but not the reception, which she considered “the family’s party.” She was also
moved by my willingness to be with her at her wedding, as she assumed correctly that this went beyond my ordinary practice. Although I acknowledged that my attendance was somewhat unusual,
I did not discuss at length my reasons for making an exception, save my stating that it seemed to be consistent with the role I had played with her during our work together.
Her wedding ceremony was poignant. There were several moving references in the ceremony to Sarah’s deceased mother. I made eye contact with her once during the ceremony, and she flashed
at me what I thought was a grin of pride. I greeted her and her father on the reception line following the ceremony, and wished them well. Sarah expressed briefly her gratitude for my attending
the ceremony.
Discussion

I have given clinical examples of the therapist’s offering part of himself in ways that went beyond what the patient had come to expect within the therapeutic relationship. These offerings ranged
from verbal interventions, to additional time spent with the patient, to my presence at a patient’s wedding. It is interesting to consider why the patients experienced these interventions as gifts. After
all, in not one case did I present the patient with a tangible item. I return to the word “gift” which emphasizes that the thing is given without the expectation of reciprocation. This part of the word’s
definition contains, I believe, the essence of the patient’s experiences: that my offerings were not contingent on their subsequent, reciprocal response. Nearly all of the patients I described had
suffered significant childhood neglect, rife with parental inconsistency and explosions of aggression, and some were victims of boundary violations. In such an environment, children learn to be
skeptical of special offerings, and come to suspect their parents of self-interest. The therapist should therefore expect the patient to have mixed reactions to his/her new offers; this would explain the
specter of hurt and abandonment that lurks close by in many of my clinical examples.
Questions are also generated about the efficacy of such interventions. How would Sarah’s therapy have proceeded differently, for example, if I had not agreed to attend her wedding? The
therapist does not have the luxury of conducting controlled experiments, and therefore must weight several factors in deciding how to intervene. I will discuss these factors, including transference
and countertransference considerations and developmental concerns, in determining when the therapist might intervene in some of these ways to therapeutic advantage.
For purposes of discussion, my interventions can be classified into two types: (1) they may be in response to a direct request from the patient, usually an amalgam of transference enactment, and
of an evolving new object availability provided by the therapist; (2) they may arise from within the therapist, often an amalgam of projective identification, of new object relationship, and
sometimes of a specific intent on the part of the therapist to facilitate developmental repair.
The therapist’s response to the patient’s request

In this instance, it is important for the therapist to locate the psychic source of the patient’s request. For example, in Rachel’s case, she asked for consent from me to purchase a bear she would name
“Andrew.” At that time in her treatment, I thought that her desire for a concrete representation of me reflected her progressive movement toward the depressive position (Klein, 1952). She
experienced my “permission” as a gift. In Sarah’s case, because of the role I had played in helping Sarah grieve for her mother, and because of the role I had played as a new object, I thought that
my actual presence at her wedding and our anticipating it in our work would prove to be therapeutic.
Several authors comment on the therapist’s response to a patient’s request for something unusual. Weiss (1964), a child analyst, describes the disruption of a case in which he responds positively to
his patient’s request for a toy mouse he has observed in the office. He argues that his granting the boy’s request disrupted the analytic frame, specifically by interfering with his ability to make
transference interpretations. From another point of view, Balint (1952) writes:
“At times when the analytic work has already progressed a long way, i.e., towards the end of a cure, my patients began—very timidly at first—to desire, to expect, even to demand certain simple gratifications, mainly, though not exclusively, from their analyst. On the surface
these wishes appeared unimportant: to give a present to the analyst or—more frequently—to receive one from him; to be allowed to touch or stroke him or be touched or stroked by him, etc.; and most frequently of all to be able to hold his hand or just one of his fingers …
Thus, if satisfaction arrives at the right moment and with the right intensity, it leads to reactions which can be observed and recognized only with difficulty, as the level of pleasure amounts only to a tranquil quiet sense of well-being (p. 231).”

Balint is writing about gratifications, including that of physical touch, which he views as potentially salutary. Casement’s seminal paper (1982), serving as focal point for the Psychoanalytic Inquiry
issue on physical touch (2000), argues for the therapist’s relatively abstinent approach to the patient’s request for him to hold her hand. Many authors in that volume do not agree, and argue for an
affirmative response in the following contexts and with the following contingencies: (a) at times of severe regression (Breckenridge, 2000; Fosshage, 2000; McLaughlin, 2000; Schlesinger &
Appelbaum, 2000); (b) at times when refusal may lead to a repetition of past, and notably preverbal, trauma (Breckenridge, 2000; Fosshage, 2000); (c) under circumstances in which the therapist is
comfortable with, and clear about, his motive in responding positively, and concurrent with his action, is able to maintain clarity of the therapeutic boundaries (McLaughlin, 2000; Gelb, 1982; Pizer,
2000); (d) under circumstances in which the patient has input into its initiation, cessation, or continuation (Gelb, 1982); (e) as a transitional action toward enhanced understanding of the patient’s
needs (Winnicott, 1963).
These exhortations for consideration of therapeutic, physical contact could be extended to other requests, such as to Rachel’s request for permission to buy a bear she could hold close while I was
away, or to Sarah’s asking me to be physically present at her wedding. Just as therapists reasonably worry about the risk of their patients’ interpreting physical contact as having sexual significance,
as initiating a “slipper slope” of intimacy, or as representing a deleterious boundary crossing, I worried about the regressive potential of the “Andrew” bear. I think the crucial point, with my cases,
and with the analytic material reported in the Psychoanalytic Inquiry, is for the therapist to take into account the phase of the therapy in which the request occurs, the level of intimacy established
in the relationship, and the quality of receptivity developed within the patient for exploration of the event. If, after open discussion with the patient, these variables fall favourably toward attempting
such an intervention, then taking the risk may facilitate deeper psychological learning.
I should underline a few caveats. It is important the therapist have the cushion of time to discuss such requests, as may be the case in psychoanalytic work. Frequent meetings, and the foundation
of a lengthy treatment relationship may remove some pressure from the therapist to have to respond immediately to a patient’s request for a gift or physical contact. I felt I was in such a relatively
comfortable position with Rachel and Sarah.
That said, it is also the case that when regressed, even within an analytic frame, patients typically blur time and other elements of reality when they ask for something, potentially creating a sense
of urgency within the therapist. In such an instance, the therapist may have to consider seriously the effect of gift refusal. Again, the therapist’s decision must turn on how able he/she is to explore
and interpret the transaction between the two with or without completing the exchange. If the exchange improves the therapist’s ability to interpret, as my planning to attend Sarah’s wedding
enriched the transference and termination material, then granting the request may very well be therapeutic. However, if the refusal in itself disrupts the work significantly, it might be inadvisable.
Not only was I concerned that an unwillingness on my part to grant Rachel the bear would have impeded her steps toward psychic equilibrium, but I was also worried that she might have been
thrown into a regressed state during my vacation.
It is worth mentioning here that patients commonly request many other things from their therapists during the course of therapy, such as fee reductions, medical advice, or advice regarding child
rearing. The therapist sometimes gratifies the request, and sometimes refuses to do so, evaluating it according to its timing and meaning within the context of the therapeutic relationship. I would
argue that the same considerations apply in these circumstances, namely, that therapists should, as best they can at that given moment, conduct a cost-benefit analysis of gratifying, or not gratifying,
the patient’s request.
All that said, if therapists feel coerced by the content or exigency of the request, and thus feel dislodged from their even-keeled position, they probably should refuse the request. It is here that
familiarity with situations, such as physical touch or other unusual requests, is helpful, for such previous experiences allow therapists the mental space from which to consider such requests in as
balanced a way as possible. Of course, some requests, such as a sexual invitation, can never be granted; patients often need explicit reminders of this boundary over and over again during the course
of therapy.
The patient’s request for information about the therapist’s personal life is common, and can be managed in a variety of ways. Susan Levine, a colleague, describes different types of self-
disclosures, and relates them to the “analytic persona” that the analyst finds him/herself shaping uniquely with a particular patient at a particular point in time. I think the therapist should be guided
by his balancing what he feels is most therapeutic in the moment. Within reason, this could include sharing a small part of him/herself, or a great part. In my interaction with Alex, I tried to balance
my commitment to transference exploration with the development of our “real” or new object relationship, while keeping in mind his specific difficulty navigating self-object boundaries. I would
argue that the “gift” I gave him was not information he gained, but the freedom to pursue it within the matrix of a new, reparative object relationship.
The therapist’s desire to offer something new

When the therapist feels the impulse to offer something unusual to the patient, he/she must stop and consider the source of that feeling. Has the patient been applying some pressure unconsciously
to the therapist that would result in such an idea? Might the idea reflect some give-and-take aspect of an old object tie? What does this seemingly spontaneous notion on the part of the therapist say
about the development of the new object relationship between patient and therapist? Is the intervention aimed specifically at a rupture in the patient’s childhood development? Is there a role for
altruism among the multiple therapeutic efforts of the therapist? Where is the line drawn between therapeutic spontaneity and countertransference error?
First, it is worth pointing out that some personal disclosures on the part of the therapist are not gifts per se, but may be necessitated by their impact on the course of treatment. Common examples
included the anticipation of birth to the therapist’s spouse (Guinjoan & Ross, 2000), a death in the therapist’s family, or illness to the therapist that is either deleterious to the therapist’s ability to
function, or likely to cause the therapist to be unavailable for some period of time (Fromm-Reichmann, 1960). The therapist must be aware of the significant effect such events are likely to have on
the course of treatment, whether he or she is working primarily with the transference relationship, or with the “real” relationship.
My clinical examples do not demonstrate such dramatic changes in my availability. In Rebecca’s case, because the timing of my vacation happened to coincide with her feeling alienated from her
father, with her husband’s absence, and with her finding out she was not pregnant, I thought she was especially vulnerable. My suggestion for phone contact felt like only a slight increase in the kid
of object availability I had been offering consistently during the course of our work together. Similarly, I think the patient, although acknowledging this felt like a “gift,” did not feel this was a
momentous offer. I think this explains why the work proceeded relatively seamlessly. Conversely, my gift of physical touch to Judy was too jarring, and opened her “pit of need.” If I was attempting
to present her with an alternative object choice to her husband or to her parents, she was not yet ready to accept it. Fortunately, we had already forged a strong alliance, and were able to process
both my action and her reaction in a helpful way.
I think, though, this points to an important principle related to the therapist’s gift: it should not be too great a gift. That is to say, it should not strike the patient as too eager on the part of the
therapist, too threatening to her defences, or too unusual given the range of behaviours she has come to know as characteristic of her therapist. This means that the therapist must retain a healthy
degree of restraint to balance his spontaneity, particularly when it comes to his range of actions, even potentially therapeutic ones. It means that he may have to refine internally his idea of giving,
that he may have to wait for the right time before raising it with the patient, or that he may discuss it as an idea only, never to be actualized.
These kinds of hypothetical gifts can be some of the most powerful ones. I once told a patient, for a complex set of reasons, that I could picture accompanying her to her daughter’s graduation,
although I knew and was explicit about the fact that we could not actually go together. She was moved to know that I had thought of being with her outside the office. Akhtar (1994), who describes
his treatment of a woman who collected stuffed zebras, told me that he later told his patient that he had considered buying her a stuffed zebra, and why he had not done so. Admission underscored
that he had been thinking about his patient while outside the confines of his office. Another colleague shared with her patient that while skiing herself, she had been thinking about the patient and
her anxious attempts to ski, and related an understanding of the control issues that skiing had raised for the patient. The gift of being thought of, in ways that impress the patient as slightly different
from what she has come to experience with the therapist, and in ways that seem to the patient to be different from what she has experienced in her past, can be a watershed moment in a patient’s
therapy.
I should point out that gifts of this kind do run the risk of being seductive or excessively stimulating to the patient. The patient may understandably be concerned about what other thoughts or
feelings the therapist may share with her. The therapist should be on guard for such apprehension, and might even as a matter of course inquire about this concern on the part of the patient,
especially if she has been a victim of boundary violations at the hands of parents or people in positions of authority. Such awareness is part and parcel of the restraint and exquisite timing required of
the therapist, and this was on my mind, for example, as I considered what to share with Alex.
I should also mention that although therapists may think they have been monitoring the sources of their desire to make a self-disclosure, and have an accurate reading of the patient’s readiness to
digest such a divulgence, they may be mistaken. In Gerson’s (1996) The Therapist as a Person: Life Crises, Life Choices, Life Experiences, and Their Effects on Treatment, several authors reveal their
own specific life crises—such as spousal death (Morrison, 1996), and significant life choices, such as the decision not to have children (Leibowitz, 1996)—to patients. Despite these therapists’ genuine
attempts to separate their own countertransferences and more general motivations from the psychic needs of their patients, they seem limited in doing so: they at times overvalue “authenticity” for
its own sake, without sufficiently taking into account the therapeutic framework and goals germane to each case (Smolar, 1998). It seems that the most decisive factors influencing a therapist’s self-
disclosure should be a rigorous understanding of the specific countertransferences operating at a given moment, blended with as thorough an understanding of the patient’s
developmental/transferential needs as possible. As Renik (1993a) has pointed out, however, sometimes the correctness of such a decision does not become apparent until after the “enactment” occurs,
and sometimes, it is never clear. Therapists must, however, be on guard for the possibility that the disclosure may be upsetting, excessive, or burdensome, and they should listen carefully for
evidence of such in the patient’s subsequent communications.
All things considered, it seems that when all aspects of the therapeutic process come closest to confluence—that is, when transfer-ential elements are in the therapeutic field, when developmental
gaps have been addressed, and when the “real” relationship has deepened and survived open conflict—therapists may be in the best position to offer something unusual. Sarah’s case illustrates this
point. The two sessions weekly, and lengthy duration of our relationship allowed for ample room for us to process my anticipated developmental presence. The meaning of Sarah’s wedding, and of
my place in it was reviewed from many points of view. Another example of such confluence, from my own analysis, occurred when my analyst spontaneously offered me a cough drop one day
when I had laryngitis. I recall that we discussed briefly its potential meanings, but mostly moved on with the process as it unfolded that day, undeterred and perhaps slightly facilitated by his
gesture.
However, when the above elements have not become fluent within the therapeutic vocabulary of the dyad, an unusual intervention from therapist to patient is a bit riskier. Although it could be
argued that Judy and I were able ultimately to put my touching her shoulder to therapeutic advantage, I think the groundwork for the physical contact had not been laid sufficiently. Moreover,
physical touch, when initiated by a male therapist with a female patient, may easily be misunderstood as a sexual advance.
Another example of a lack of confluence of the above therapeutic elements occurred when I attempted to lend a book from the bookshelf in my office to a mental health professional whom I had
been meeting once weekly. She was reluctant to take it, citing her fear of becoming too soft and dependent on me, a part of her psyche we had only begun to tackle, and thus, a powerful aspect of
the transference I underestimated.2
The paradox, of course, is that those patients with the largest developmental deficits may potentially benefit the most from such gifts, but they also struggle to trust the alliance and the motives of
the therapist, rendering unusual gestures risky and easily misunderstood. Overall then, I would recommend that the therapist consider these interventions for the following cases: (a) For those cases
in which they are essential to alliance-building, as with my gift of time to Margaret. A strong alliance is a prerequisite for the therapist to address the developmental deficits suffered by certain
patients, deficits that may begin to be filled by the kind of interventions I have described. (b) For those adult patients for whom the benefits seem to outweigh the risks. Only in well-developed,
durable treatments, ones that emphasize meaning-making, can the therapist evaluated the benefits and risks openly with the patient.
The literature regarding the altruistic intentions of the therapist is beyond the scope of this paper. However, it is worth considering how a gift intersects with the notion of altruism. Seelig and
Rosof (2001) address altruism in the patient, and they divide altruism into five subtypes, two of which—proto-altruism and generative altruism—they identify as adaptive. These also roughly describe
the therapist’s empathic, helpful efforts within the therapeutic relationship. Jacobs (2001) cautions us about what seems to be the therapist’s healthy altruism when he describes his offering his patient
Ms C the gift of an additional session. He later learns, in the context of a challenge from Ms C, that he has been irritated with, and more critical of, her than he realized, and what seemed like a gift
was actually an expression of frustration and impotence within both therapist and patient. As an extension of Seelig and Rosof’s (2001) work, it would follow that less healthy forms of altruism—
serving as a veil for underlying sadomasochism—may also be reflected by a therapist’s seemingly generous intervention. Thus, as I have argued earlier, therapists should be especially clear on the
source of their motives. Even if thinking a gift is growth-promoting, therapists should place it in some developmental context specific to the patient’s therapeutic narrative for it to be a therapeutic,
altruistic intervention.
The therapist’s reciprocating for the patient’s gift

I wish to discuss briefly the concept of the therapist’s reciprocating for a concrete gift from the patient, for two reasons: (a) it is probably more common that the therapist’s initiating the offering, so
it would be worthwhile to spell out the circumstances in which it might be therapeutically useful; and (b) its discussion reinforces some of the ideas I have formulated above, most specifically the
importance of the therapist’s blending an understanding of his/her countertransferences with other ongoing therapeutic factors as he/she decides how to intervene.
Since the therapist is so often in the position of giving emotional sustenance to the patient, it is expectable that the patient—through identification with the therapist, through a growing capacity
for gratitude, and through a desire to concretize her/his feelings about the therapist—will at some point consider a gift for the therapist. I think, though, that specific conditions are required for the
therapist’s return of a patient’s gift to constitute a therapeutic response. They include the following: (a) the passage of significant time between the exchange of the two items, during which the
psychic meaning of the original gift has been reviewed and woven into the broader process of the therapy; (b) the therapist’s internal monitoring of her/his response to the patient’s gift. The
therapist should be careful not to thwart the ongoing work surrounding the patient’s gift by giving one of his own; (c) the therapist’s sense that his words alone will not carry sufficient weight at a
particular time. I can imagine scenarios in child therapy, and with adults in certain states of regression, in which the patient may present the therapist with a gift while under strain or the pressure of
imminent ego collapse. In such a situation, the therapist’s words might not alleviate the regression. Such a clinical emergency might warrant an acute response, sometimes transmitted through a
concrete object belonging to the therapist; and (d) a patient’s cultural tradition that emphasizes reciprocal gift exchange (Stein, 1965, Akhtar, 1995). Obviously, many factors would determine the
degree to which the therapist felt such an exchange was necessary for the establishment of the treatment relationship. But I can imagine a scenario in which such an intervention could become a
necessary and binding strand of the therapeutic alliance.
Conclusion

In this contribution, I have attempted to discuss the concept of the gift, offered by therapist to the patient from the heart or from the hands. The literature from Freud onward reflects a growing
recognition that tangible gifts are in fact given to patients under certain circumstances. Some of the factors that seem to determine whether the gifts may be therapeutically advantageous are: (1) the
phase of treatment in which they are offered; (2) the ego functioning of the patient at the time the gift is considered, and as such, whether or not the gift is being used as a transitional object toward
some kind of developmental repair or advancement; and (3) whether the therapist has processed his countertransference reactions, particularly during the termination phase, rigorously.
I have also, through my own clinical examples, attempted to demonstrate how therapists can offer unusual parts of themselves as a viable option. I have wrapped some cautionary flags around
some of these interventions, pointing out some of the risks, especially when patients with ego weaknesses may be prone to misunderstanding the intentions of their therapists. I have concluded,
conservatively, that the therapist may, under certain circumstances, consider reaching out to the patient by revealing thoughts from outside the session, by uttering self-disclosures, by making
physical contact, or by providing extra-therapeutic presence. These interventions require several preconditions: (1) the therapist identifies an opportunity to strengthen the alliance; (2) the patient has
been prepared by a long-standing, meaning-making therapeutic relationship; (3) the gesture is not too great a deviation from the therapeutic norms that have been established, and is not surprising
to the patient; and (4) the therapist’s countertransferences have been analysed carefully. In my view, these pre-conditions aid the therapist in hypothesizing whether giving an intangible gift would
promote therapeutic growth, while limiting risk to the patient’s well-being.
Clearly, we have more to learn about this subject. Empirical studies may help us distinguish the gift that is facilitative from the gift that is therapeutically deleterious. More likely, however, it is
our clinical experience that will direct us. Therefore, documenting these engagements and their repercussions is essential to learning more about tangible and intangible gift-giving as potential
therapeutic actions.
Notes
1. The Oxford English Dictionary defines the word “gift” as follows: “something, the possession of which is transferred to another without the expectation or receipt of an equivalent; a donation, present” (Oxford English Dictionary, 1989). Stein (1965) outlines the derivation of
the word in several different languages, pointing out that connotations of the words for “gift” in Spanish, German, and Greek range from generous giving, to poisoning, to a binding of the receiver. She also provides a cultural history of gifts, noting that exchanges have not
been exclusively of tangible items, but also of rituals and courtesies, sometimes with reciprocation. This spectrum of meanings raises questions about what constitutes a gift from one person to another, and about how its rendering may influence the relationship between the
two parties.

2. I considered keeping the thought of lending her the book within the “what-if” realm of the relationship. In my experience, however, a question such as “how would it feel to you if I offered to lend you a book?” comes across as stiff and mechanical to a patient if patient and
therapist have not been working primarily with transference exploration. Thus, in this respect, it may be the case that the atmosphere of analytically informed psychotherapy, which may be more reality based, lends itself to actual gift offerings, while psychoanalysis may
promote “what-if” discussion of the therapist’s gift to his patient.
References

Abbasi, A. (2007). Who’s side are you on?: Muslim analysts analyzing non-Muslim patients. In: S. Akhtar (Ed.), The Crescent and the Couch: Cross Currents between Islam and Psychoanalysis (pp.
335–350). New York, NY: Other Press.
Abraham, K. (Ed.) (1924). The influence of oral erotism on character-formation. In: Selected Papers on Psycho-analysis (pp. 393–417). London, UK: Hogarth Press.
Abram, D. (1996). The Spell of the Sensuous. New York, NY: Vintage Books.
Aisenstein, M. (2010). Letter from Paris. International Journal of Psycho-Analysis, 91: 463–468.
Aisenstein, M. & Smadja, C. (2010). Conceptual framework from the Paris Psychosomatic School: A clinical psychoanalytic approach to oncology. International Journal of Psycho-Analysis, 91: 621–
640.
Akhtar, S. (1995a). Quest for Answers: A Primer of Understanding and Treating Severe Personality Disorders. Northvale, NJ: Jason Aronson.
Akhtar, S. (1995b). A third individuation: Immigration, identity, and the psychoanalytic process. Journal of the American Psychoanalytic Association, 43: 1051–1084.
Akhtar, S. (1996). “Someday …” and “if only …” fantasies: pathological optimism and inordinate nostalgia as related forms of idealization. Journal of American Psychoanalytic Association, 44: 723–
753.
Akhtar, S. (1999a). Immigration and Identity: Turmoil, Treatment, and Transformation. Northvale, NJ: Jason Aronson.
Akhtar, S. (1999b). The distinction between needs and wishes: Implications for psychoanalytic theory and technique. Journal of the American Psychoanalytic Association, 47: 113–151.
Akhtar, S. (2009a). Turning Points in Dynamic Psychotherapy: Initial Assessment, Boundaries, Money, Disruptions and Suicidal Crises. London, UK: Karnac Books.
Akhtar, S. (2009b). The Damaged Core: Origins, Dynamics, Manifestations, and Treatment (pp. 113–133). Lanham, MD: Jason Aronson.
Akhtar, S. (2009c). Comprehensive Dictionary of Psychoanalysis. London, UK: Karnac Books.
Alexander, F. (1948). Fundamentals of Psychoanalysis. New York, NY: W. W. Norton.
Alexander, F. (1958). Unexplored areas in psychoanalytic theory and treatment. Behavioral Science, 3: 293–316.
Alexander, F. G. & French, T. M. (1946). Psychoanalytic Therapy: Principles and Applications. New York, NY: The Roland Press Co.
Amati-Mehler, J. & Argentieri, S. (1999). Hope and hopelessness: Technical problem? International Journal of Psychoanalysis, 70: 295–304.
Amati-Mehler, J., Argentieri, S. & Cansestri, J. (1993). The Babel of the Unconscious: Mother Tongue and Foreign Languages in the Psychoanalytic Dimension, J. Whitelaw-Cucco (Trans.). Madison,
CT: International Universities Press.
American Psychiatric Association (1994). Diagnostic Criteria from DSM-IV. Washington, DC: American Psychiatric Association Books.
Arlow, J. (1986). Psychoanalysis and time. Journal of the American Psychoanalytic Association, 34: 507–528.
Arlow, J. (1995). Stilted listening: Psychoanalysis as discourse. Psychoanalytic Quarterly, 64: 215–233.
Bach, S. (1977). On narcissistic state of consciousness. International Journal of Psychoanalysis, 58: 209–233.
Balint, M. (1952). Primary Love and Psycho-analytic Technique. London, UK: Tavistock.
Balint, M. (1968). The Basic Fault: Therapeutic Aspects of Regression. London, UK: Tavistock.
Barredo, C. E. (2010). The analyst at work: Commentary on the work presented by Ingrid M. Geerken: A new discourse, a new love. International Journal Psycho-Analysis, 91: 495–503.
Bateman, A. & Fonagy, P. (2004). Psychotherapy for Borderline Personality Disorder (p. 61). Oxford, England: Oxford University Press.
Bateman, A. & Fonagy, P. (2008). Comorbid antisocial and borderline personality disorders: Mentalization-based treatment. Journal Clinical Psychology, 64: 181–194.
Beattie, H. J. (2005). Revenge. Journal of the American Psychoanalytic Association, 53: 513–524.
Benjamin, J. (Ed.) (1995). Recognition and destruction: An outline of inter-subjectivity. In: Like Subjects, Love Objects (pp. 27–48). New Haven, CT: Yale University Press.
Benjamin, J. (1999). Recognition and destruction: An outline of intersubjectivity. In: S. A. Mitchell, and L. Aron (Eds.), Relational Psychoanalysis, The Emergence of a Tradition (pp. 183–210).
Hillsdale, NJ: The Analytic Press.
Benjamin, J. (2004). Beyond doer and done to: An intersubjective view of thirdness. Psychoanalytic Quarterly, 73: 5–43.
Bibring, G. L., Dwyer, T. F., Huntington, D. S. & Valenstein, A. F. (1961). A study of the psychological processes in pregnancy and of the earliest mother-child relationship. Psychoanalytic Study of the
Child 16: 9–72.
Billow, R. M. (2000). Self disclosure and psychoanalytic meaning: A psychoanalytic fable. Psychoanalytic Review, 87: 61–79.
Bion, W. (1970). Attention and Interpretation. London, UK: Karnac Books, 1984.
Blanton, S. (1971). Diary of My Analysis with Sigmund Freud. New York, NY: Hawthorn Books.
Bordin, E. (1979). The generalizability of the psychoanalytic concept of the working alliance. Psychotherapy: Theory, Research and Practice, 16: 252–260.
Bowlby, J. (1952). Maternal Care and Mental Health: A Report on Behalf of the World Health Organization. Geneva, Switzerland: World Health Organization.
Breckenridge, K. (2000). Physical touch in psychoanalysis: A closet phenomenon? Psycho-analytic Inquiry, 20: 2–20.
Brenner, C. (2000). Brief communication: Evenly hovering attention. Psychoanalytic Quarterly, 69: 545–549.
Brown, C. & Trangsrud, H. (2008). Factors associated with acceptance and decline of client gift giving. Professional Psychology: Research and Practice, 39: 505–511.
Busch, F. (1998). Psychoanalytic disclosure ain’t what it’s cracked up to be, at least not yet. Psychoanalytic Inquiry, 18: 518–529.
Canter, M., Bennett, B., Jones, S. & Nagy, T. (1996). Ethics for Psychologists: A Commentary on the APA Ethics Code. Washington, DC: American Psychological Association.
Carlyle, T. (1840). Chartism. London, UK: James Fraser.
Carpelan, H. (1981). On the importance of the setting in the psychoanalytic situation. Scandinavian Psychoanalytic Review, 4: 151–161.
Casement, P. J. (1982). Some pressures on the analyst for physical contact during the re-living of an early trauma. International Review of Psychoanalysis, 9: 279–286.
Casement, P. J. (1991). Learning From the Patient. New York, NY: Guilford.
Casement, P. J. (2000). The issue of touch: A retrospective overview. Psychoanalytic Inquiry, 20: 160–184.
Celenza, A. (2007). Sexual Boundary Violations: Therapeutic, Supervisory and Academic Contexts. Lanham, MD: Jason Aronson.
Charles, M. (2001). Nonphysical touch: Modes of containment and communication within the analytic process. Psychoanalytic Quarterly, 70: 387–416.
Chused, J. F. (1991a). The patient’s perception of the analyst: The hidden transference. Psychoanalytic Quarterly, 61: 161–184.
Chused, J. F. (1991b). The evocative power of enactments. Journal of the American Psychoanalytic Association, 39: 615–639.
Connor, S. R. (2010). Hospice and home care. In: J. Holland, W. S. Breitbart, P. Jacobsen, M. S. Lederberg, M. L. Loscalzo & R. McCorkle (Eds.), Psycho-Oncology (pp. 284–287). New York, NY: Oxford
University Press.
Craske, M. G. & Barlow, D. H. (1993). Panic disorder and agoraphobia. In: D. H. Barlow (Ed.), Clinical Handbook of Psychological Disorders (pp. 1–47). New York, NY: Guilford Press.
Csibra, G. & Gergely, G. (1998). The teleological origins of mentalistic action explanations:a developmental hypothesis. Developmental Science, 1: 255–259.
Danckwardt, J. F. & Wegner, P. (2007). Performance as annihilation or integration? International Journal of Psychoanalysis, 88: 1117–1133.
Dimen, M. (1994). Money, love and hate: Contradiction and paradox in psychoanalysis. Psychoanalytic Dialogues, 4: 69–100.
Ehrenberg, D. B. (1995). Self disclosure: Therapeutic tool or indulgence? Countertransference disclosure. Contemporary Psychoanalysis, 31: 213–228.
Ehrlich, L. T. (2010). The analyst’s ambivalence about continuing and deepening an analysis. Journal of the American Psychoanalytic Association, 58: 515–532.
Eissler, K. (1949). Some problems of delinquency. In: Kurt Eissler (Ed.), Searchlights on Delinquency: New Psychoanalytic Studies (pp. 3–25). New York, NY: International Universities Press.
Eissler, K. (1953). The effect of the structure of the ego on psychoanalytic technique. Journal of the American Psychoanalytic Association, 1: 104–143.
Epstein, A. (2004). Should therapists give gifts to patients? Psychiatric Services, 55: 835–836.
Etchegoyen, R. H. (1991). The Fundamentals of Psychoanalytic Technique. London, UK: Karnac Books.
Etchegoyen, R. H. (2005). The Fundamentals of Psychoanalytic Technique. London, UK: Karnac Books.
Fenichel, O. (1938). The drive to amass wealth. Psychoanalytic Quarterly, 7: 69–95.
Ferenczi, S. (1911). On obscene words. In: E. Jones (Trans.), Contributions to Psycho-Analysis. (pp. 112–130). Boston, MA: Richard G. Budger.
Ferenczi, S. (1915). Letter from Sandor Ferenczi to Sigmund Freud, February 22, 1915. The Correspondence of Sigmund Freud and Sandor Ferenczi Volume 2, 1914–1919 (pp. 49–50). Cambridge, MA:
Harvard University Press. [Reprinted 1996].
Ferenczi, S. (Ed.) (1929). The principle of relaxation and neocatharsis. In: Final Contributions to the Problems and Methods of Psychoanalysis (pp. 108–125). New York, NY: Basic Books.
Ferenczi, S. (Ed.) (1930a). Thoughts on pleasure in passivity. In: Final Contributions to the Problems and Methods of Psycho-analysis (pp. 224–226). London, UK: Hogarth Press, 1955.
Ferenczi, S. (1930b). The principle of relaxation and neocathexis. International Journal of Psychoanalysis, 30: 428–446.
Ferenczi, S. (Ed.) (1931). Child analysis in the analysis of adults. In: Final Contributions to the Problems and Methods of Psychoanalysis (pp. 126–142). New York, NY: Basic Books.
Ferenczi, S. (Ed.) (1933a). On the confusion of tongues between adults and the child—The language of tenderness and passion. In: Final Contributions to the Problems and Methods of Psycho-analysis
(pp. 155–167). London, UK: Hogarth Press.
Ferenczi, S. (1933b). On the confusion of tongues between adults and the child. In: Final Contributions to the Problems and Methods of Psycho-analysis (pp. 155–167). New York, NY: Basic Books,
1955.
Ferro, A. (2005). Which reality in the psychoanalytic session? Psychoanalytic Quarterly, 74: 421–442.
Fieldsteel, N. (2005). When the therapist says goodbye. International Journal of Group Psychotherapy, 55: 245–279.
Firestein, S. K. (1969). Problems of termination in the analysis of adults. Journal of the American Psychoanalytic Association, 17: 222–237.
Fishkin, R. & Fishkin, L. (2011). The electronic couch: some observations about skype treatment. In: S. Akhtar (Ed.), The Electrified Mind: Development, Psychopathology and Treatment in the Era of
Cell Phones and the Internet (pp. 99–111). Lanham, MD: Jason Aronson.
Fliess, R. (1949). Silence and verbalization: A supplement to the theory of the “analytic rule”. International Journal of Psychoanalysis, 30: 21–30.
Foehl, J. (2009). Discussion of “Expression between self and other by Lisa Folkmarson Kall”. Paper presented at the Boston Psychoanalytic Society and Institute, Boston, MA, February 25, 2009.
Folkmarson Kall, L. (2009). Expression between self and other: A phenomenological understanding of intersubjectivity. Paper presented at the Boston Psychoanalytic Society and Institute, Boston,
MA, February 25, 2009.
Fonagy, P. & Target, M. (2008). Attachment, trauma, and psychoanalysis. In: L. Jurist, A. Slade, and S. Berger (Ed.), Mind to Mind (pp. 15–44). New York, NY: Other Press.
Fosshage, J. L. (2000). The meanings of touch in psychoanalysis: A time for reassessment. Psychoanalytic Inquiry, 20: 21–43.
Freud, A. (1928). The Psychoanalytical Treatment of Children. New York, NY: International Universities Press.
Freud, A. (1963). The concept of developmental lines. Psychoanalytic Study of the Child, 18: 2425–2465.
Freud, S. (1893). Katharina, case histories from studies on hysteria. Standard Edition, 2: 125–134.
Freud, S. (1895). Studies on hysteria (with Joseph Breuer). Standard Edition, 2: 1–323.
Freud, S. (1900). The interpretation of dreams. Standard Edition, 4–5: 1–626.
Freud, S. (1909). Notes upon a case of obsessional neurosis. Standard Edition, 10: 151–318.
Freud, S. (1910b). The future prospects of psycho-analytic therapy. Standard Edition, 11: 139–151.
Freud, S. (1912a). The dynamics of transference. Standard Edition, 12: 97–108.
Freud, S. (1912b). Recommendations to physicians practising psychoanalysis. Standard Edition, 12: 109–120.
Freud, S. (1913a). On beginning the treatment. Standard Edition, 12: 123–144.
Freud, S. (1913b). Totem and taboo. Standard Edition, 13: 1–161.
Freud, S. (1914). Remembering, repeating, and working through. Standard Edition, 12: 145–156.
Freud, S. (1915a). Recommendations on analytic technique. Standard Edition, 12: 109–120.
Freud, S. (1915b). Observations on transference love. Standard Edition, 12: 157–171.
Freud, S. (1917). On transformations of instinct as exemplified in anal erotism. Standard Edition, 17: 127–133.
Freud, S. (1918). From the history of an infantile neurosis. Standard Edition, 17: 1–222.
Freud, S. (1924). A short account of psychoanalysis. Standard Edition, 19: 189–209.
Freud, S. (1926). The question of lay analysis. Standard Edition, 20: 183–258.
Freud, S. & Ferenczi, S. (2000). The Correspondence of Sigmund Freud and Sándor Ferenczi: 1920–1933. E. Brabant-Gerö, and E Falzeder (Eds.). Cambridge, MA: Belknap Press/Harvard University
Press.
Fromm-Reichmann, F. (1960). Principles of Intensive Psychotherapy. Chicago, IL: University of Chicago Press.
Gabbard, G. (1996). The analyst’s contribution to the erotic transference. Contemporary Psychoanalysis, 32: 249–273.
Gabbard, G. (2006). Sexual and non-sexual boundary violations in psychoanalysis and psychotherapy. In: S. Akhtar (Ed.), Interpersonal Boundaries: Variations and Violations (pp. 39–48). Lanham,
MD: Jason Aronson.
Galatzer-Levy, R. M. (2004). The death of the analyst: Patients whose previous analyst died while they were in treatment. Journal of the American Psychoanalytic Association, 52: 999–1024.
Galton, G. (Ed.) (2007). Touch Papers: Dialogues on Touch in Psychoanalytic Space. London, UK: Karnac Books.
Gayle, R. (2009). Co-creating meaningful structures within long-term psychotherapy group culture. International Journal of Group Psychotherapy, 59: 311–333.
Gedo, J. E. & Goldberg, A. (1973). Models of the Mind. Chicago, IL: University of Chicago Press.
Gedo, J. F. (1988). The Mind in Disorder: Psychoanalytic Models of Pathology. Hillsdale, NJ: The Analytic Press.
Geerkin, I. (2010). La vita nuova. International Journal of Psychoanalysis, 91: 469–483.
Gelb, P. (1982). The experience of nonerotic contact in traditional psychotherapy: A critical investigation of the taboo against touch. Dissertation Abstract, 43: 248B.
Gergely, G. & Csibra, G. (2003). Teleological reasoning in infancy: The naïve theory of rational action. Trends in Cognitive Science, 7: 287–292.
Gerson, B. (Ed.) (1996). The Therapist as a Person: Life Crises, Life Choices, Life Experiences, and Their Effects on Treatment. Hillsdale, NJ: The Analytic Press.
Gill, M. M. (1983). Analysis of Transference, Vol. 1: Theory and Technique. New York, NY: Brunner/Mazel.
Goldberg, A. I. (1987). The place of apology in psychoanalysis and psychotherapy. International Review of Psychoanalysis, 14: 409–417.
Gorkin, M. (1996). Countertransference in cross-cultural psychotherapy. In: R. Perez-Foster, M. Moskowitz & R. A. Javier (Eds.) Reaching across Boundaries of Culture and Class (pp. 47–70).
Northvale, NJ: Jason Aronson.
Gray, P. (1982). Developmental lag in the evolution of technique for psychoanalysis of neurotic conflict. Journal of American Psychoanalytic Association, 30: 621–655.
Gray, P. (1994). The Ego and the Analysis of Defense. Northvale, NJ: Jason Aronson.
Green, A. (2002). Time in Psychoanalysis: Some Contradictory Aspects. London, UK: Free Association Books.
Greenson, R. R. (1965). The working alliance and the transference neuroses. Explorations in Psychoanalysis. New York, NY: International University Press.
Greenson, R. R. (1967). The Technique and Practice of Analysis, Volume 1. London, UK: Hogarth.
Greenson, R. R. (1974). The decline and fall of the 50-minute hour. Journal of the American Psychoanalytic Association, 22: 785–791.
Grubrich-Simitis, I. (1986). Six letters of Sigmund Freud and Sandor Ferenczi on the interrelationship of psychoanalytic theory and technique. International Review of Psychoanalysis, 13: 259–277.
Guinjoan, S. M. & Ross, D. R. (2000). Consequences of a male therapist disclosing the birth of his child. The Journal of the American Academy of Psychoanalysis, 28: 39–50.
Harlow, H. (1971). Learning to Love. New York, NY: Albion.
Hartmann, H. (1960). Psychoanalysis and Moral Values. New York, NY: International Universities Press.
Hartocollis, P. (1983). Time and Timelessness or the Varieties of Temporal Experience (A Psychoanalytic Enquiry). Madison, CT: International Universities Press.
Hartocollis, P. (2003). Time and the psychoanalytic situation. Psychoanalytic Quarterly, 72: 939–957.
Hoffer, A. (1985). Toward a definition of psychoanalytic neutrality. Journal of the American Psychoanalytic Association, 33: 771–795.
Hoffman, I. Z. (1998). Ritual and Spontaneity in Psychoanalytic Process: A Dialectical Constructivist View. Hillsdale, NJ: The Analytic Press.
Holder, A. (2000). To touch or not to touch: That is the question. Psychoanalytic Inquiry, 20: 44–64.
Horvath, A. O. & Symonds, B. D. (1991). Relation between working alliance and outcome in psychotherapy: A meta-analysis. Journal of Counseling Psychology, 38: 139–149.
Isaacs, S. (1933). Social Development in Young Children. London, UK: Rutledge.
Jacobs, M. (1991). Limitations of a theory of psychoanalytic technique: A case example. Presented at the San Francisco Psychoanalytic Society Grand Rounds, San Francisco, CA, April, 1991.
Jacobs, T. J. (1986). On countertransference enactments. Journal of the American Psychoanalytic Association, 34: 289–307.
Jacobs, T. J. (1999). On the question of self disclosure by the analyst: Error or advance in technique? Psychoanalytic Quarterly, 68: 159–183.
Jacobs, T. J. (2001). On misreading and misleading patients: Some reflections on communications, miscommunications, and countertransference enactments. International Journal of Psychoanalysis,
82: 653–669.
Jacobs, T. J. (2007). Listening, dreaming, sharing: On the uses of the analyst’s inner experiences. In: S. Akhtar (Ed.), Listening to Others: Developmental and Clinical Aspects of Empathy and
Attunement (pp. 93–112). Lanham, MD: Jason Aronson.
Jones, E. (1955). Sigmund Freud Life and Work, Volume Two: Years of Maturity 1901–1919. London, UK: The Hogarth Press.
Kanzer, M. (1958). Image formation during free association. Psychoanalytic Quarterly, 27: 465–481.
Kaufman, I. (1964). Personal communication to S. Levin and H. Wermer. In: The significance of giving gifts to children in therapy. Journal of the American Academy of Child Psychiatry, 5: 630–652.
Kernberg, O. (1975). Borderline Conditions and Pathological Narcissism. New York, NY: Jason Aronson.
Kernberg, O. (1984). Severe Personality Disorders: Psychotherapeutic Strategies. New Haven, CT: Yale University Press.
Kernberg, O., Yeomans, F., Clarkin, J. & Levy, K. (2008). Transference focused psychotherapy: Overview and update. International Journal of Psychoanalysis, 89: 601–620.
Kernberg, O. F., Selzer, M. A., Koenigsberg, H. W., Carr, A. C. & Appelbaum, A. H. (1989). Psychodynamic Psychotherapy of Borderline Patients. New York, NY: Basic Books.
Killingmo, B. (1989). Conflict and deficit: Implications for technique. International Journal of Psycho-Analysis, 70: 65–79.
Kirsner, D. (2007). Do as i say, not as i do. Psychoanalytic Psychology, 2: 475–486.
Klauber, J. (Ed.) (1968). The psychoanalyst as a person. In: Difficulties in the Analytic Encounter (pp. 123–139). New York, NY: Jason Aronson.
Klein, M. (Ed.) (1935). A contribution to the psychogenesis of manic depressive states. In: Love, Guilt and Reparation and Other Works—1921–1945 (pp. 262–289). New York, NY: Free Press.
Klein, M. (1946). Notes on some schizoid mechanisms. In: J. Mitchell (Ed.), The Selected Melanie Klein (pp. 175–200). New York, NY: Free Press.
Klein, M. (1952). Contributions to Psychoanalysis, 1921–1945 (pp. 587–599). New York, NY: Anglo.
Kogan, I. (2003). When words are used to touch. Psychoanalytic Psychology, 20: 117–130.
Kogan, I. (2010). A commentary on Mayer Subrin’s paper “Stumbling towards Termination”. International Journal of Psychoanalysis, 91: 263–271.
Kohut, H. (1972). Thoughts on narcissism and narcissistic rage. Psychoanalytic Study of the Child, 27: 360–400.
Kris, A. O. (1982). Free Association: Method and Process. New Haven, CT: Yale University Press.
Kris, A. O. (1990). Helping patients by analyzing self-criticism. Journal of the American Psychoanalytic Association, 38: 605–636.
Krupnick, J. L., Sotsky, S. M., Simmens, A., Moyer, J., Elkin, I. & Pilkonis, P. A. (1996). The role of the alliance in psychotherapy and pharmacotherapy outcome: findings in the National Institute of
Mental Health treatment of depression collaborative research program. Journal of Consulting and Clinical Psychology, 64: 532–539.
Kuehn, J. L. (1965–1966). Encounter at Leiden: Gustav Mahler consults Sigmund Freud. Psychoanalytic Review, 52D: 5–25.
Kurtz, S. A. (1988). The psychoanalysis of time. Journal of the American Psychoanalytic Association, 36: 985–1014.
Langs, R. (1980). The misalliance dimension in the case of the Rat Man. In: M. Kanzer and J. Glenn (Eds.), Freud and His Patients (pp. 215–231). New York, NY: Jason Aronson.
Langs, R. (1989). The Technique of Psychoanalytic Psychotherapy, Volume I. Northvale, NJ: Jason Aronson.
Leibowitz, L. (1996). Reflections of a childless analyst. In: B. Gerson (Ed.), The Therapist as a Person: Life Crises, Life Choices, Life Experiences, and Their Effects on Treatment. (pp. 71–87). Hillsdale,
NJ: The Analytic Press.
Levin, S. & Wermer, H. (1966). The significance of giving gifts to children in therapy. Journal of the American Academy of Child Psychiatry, 5: 630–652.
Lichtenberg, J. D. & Slap, J. W. (1977). Comments on the general functioning of the analyst in the psychoanalytic situation. Annals of Psychoanalysis, 5: 295–312.
Lipton, S. (1961). The last hour. Journal of the American Psychoanalytic Association, 9: 325–341.
Lipton, S. (1977). The advantages of Freud’s technique as shown in his analysis of the “Rat Man.” International Journal of Psychoanalysis, 58: 255.
Little, M. (1990). Psychotic Anxieties and Containment. Northvale, NJ: Jason Aronson.
Lowenstein, R. M. (1956). Some remarks on the role of speech in psychoanalytic technique. International Journal of Psychoanalysis, 37: 460–468.
Lynn, D. (2003). Freud’s psychoanalysis of Edith Banfield Jackson, 1930–1936. Journal of the American Academy of Psychoanalysis and Dynamic Psychiatry, 31: 609–625.
Lynn, D. & Vaillant, G. (1998). Anonymity, neutrality, and confidentiality in the actual methods of Sigmund Freud: A review of 43 cases, 1907–1939. American Journal of Psychiatry, 155: 163–171.
McLaughlin, J. (1991). Clinical and theoretical aspects of enactment. Journal of the American Psychoanalytic Association, 39: 595–614.
McLaughlin, J. (1992). Non-verbal behaviors in the analytic situation: The search for meaning in non-verbal cues. In: S. Kramer and S. Akhtar (Eds.), When the Body Speaks: Psychological Meanings
in Kinetic Clues (pp. 131–161). Northvale, NJ: Jason Aronson.
McLaughlin, J. (2000). The problem and place of physical contact in analytic work: Some reflections on the value of handholding in analytic situation. Psychoanalytic Inquiry, 20: 65–81.
Mahler, A. (1946). Gustav Mahler: Memories and Letters. B. Creighton (Trans.). New York, NY: Viking Press.
Mahler, A. (1959). And The Bridge Is Love: Memories of a Lifetime. New York, NY: Hutchinson Press.
Mahler, M. S., Pine, F. & Bergman, A. (1975). The Psychological Birth of the Human Infant: Symbiosis and Individuation. New York, NY: Basic Books.
Makari, G. & Shapiro, T. (1993). On psychoanalytic listening: Language and unconscious communication. Journal of the American Psychoanalytic Association, 41: 991–1020.
Malcolm, J. (1980). Psychoanalysis: The Impossible Profession. New York, NY: Knopf.
Marcus, D. M. (1998). Self disclosure: The wrong issue. Psychoanalytic Inquiry, 18: 566–579.
Meissner, W. W. (2002). The problem of self disclosure in psychoanalysis. Journal of the American Psychoanalytic Association, 50: 827–867.
Meissner, W. W. (2007). Time, Self, and Psychoanalysis. Lanham, MD: Jason Aronson.
Merleau-Ponty, M. (1962). Phenomenology of Perception. New York, NY: Routledge.
Milmaniene, J. E. (2009). Time and the end of analysis. In: L. Glocer Fiorini, L. and J. Canestri, J. (Eds.), The Experience of Time: Psychoanalytic Perspectives (pp. 117–132). London, UK: Karnac Books.
Milner, M. (1952). Aspects of symbolism in comprehension of the not-self. International Journal of Psychoanalysis, 33: 181–195.
Mitchell, S. A. (1993). Hope and Dread in Psychoanalysis. New York, NY: Basic Books.
Mitchell, S. & Aron, L. (1999). Relational Psychoanalysis: The Emergence of a Tradition. Hillsdale, NJ: The Analytic Press.
Montagu, A. (1986). Touching: The Human Significance of the Skin. New York, NY: Harper and Row.
Morrison, A. L. (1997). Ten years of doing psychotherapy while living with a life threatening illness: Self disclosure and other ramifications. Psychoanalytic Dialogues, 7: 225–241.
Morrison, A. P. (1996). Trauma and disruption in the life of the analyst: Enforced disclosure and disequilibrium in “the analytic instrument”. In: B. Gerson (Ed.), The Therapist as a Person: Life Crises,
Life Choices, Life Experiences, and Their Effects on Treatment (pp. 41–54). Hillsdale, NJ: The Analytic Press.
Nathan, P. (2010). The intervention: Mere Arltyewele (Settle Down Country)—bear the gap to close the gap. Paper presented at the 30th Psychoanalytic Psychotherapy Association of Australasia
Conference, Queenstown, New Zealand: A Basket of Dreams.
Norton, J. (1963). Treatment of a dying patient. Psychoanalytic Study of the Child, 18: 541–560.
Novick, J. (1997). Termination conceivable and inconceivable. Psychoanalytic Psychology, 14: 145–162.
Ogden, T. (1994). Subjects of Analysis. Northvale, NJ: Jason Aronson.
Olsson, P. (1986). Complexities in the psychology and psychotherapy of the phenomenally wealthy. In: D. W. Krueger (Ed.), The Last Taboo: Money as Symbol and Reality in Psychotherapy and
Psychoanalysis (pp. 55–69). New York, NY: Brunner/Mazel.
Orange, D. M. & Stolorow, R. D. (1998). Self disclosure and intersubjectivity theory. Psychoanalytic Inquiry, 18: 530–537.
Oxford English Dictionary (1989). 2nd Edition, Vol. VI, p. 503. Oxford, UK: Oxford University Press.
Palvarini, P. (2010). Is the topic of the corrective emotional experience still topical? American Journal of Psychotherapy, 64: 171–194.
Pasternak, S. (1986). Psychotherapy fees and therapist training. In: D. W. Krueger (Ed.), The Last Taboo: Money as Symbol and Reality in Psychotherapy and Psychoanalysis (pp. 152–157). New York,
NY: Brunner/Mazel.
Pine, F. (1998). Diversity and Direction in Psychoanalytic Technique. New Have, CT: Yale University Press.
Pizer, B. (1997). When the analyst is ill: Dimensions of self disclosure. Psychoanalytic Quarterly, 66: 450–469.
Pizer, B. (2000). Negotiating analytic holding: Discussion of Patrick Casement’s “Learning from the Patient”. Psychoanalytic Inquiry, 20: 82–107.
Poland, W. (2011). Personal Communication, February 4, 2011.
Pontalis, J. B. (1997). Ce Temps Qui Ne Passe Pas. Paris, France: Galimard.
Puget, J. (2009). The time of the past, the time of the right moment In: L. Glocer Fiorini, L. and J. Canestri J. (Eds.), The Experience of Time: Psychoanalytic Perspectives (pp. 75–96). London, UK:
Karnac Books.
Rachman, A. W. (1998). Judicious self disclosure by the psychoanalyst. International Forum of Psychoanalysis, 7: 263–269.
Racker, H. (1968). Transference and Countertransference. London, UK: Hogarth Press.
Rank, B. (1946). Case of Jerry Haskins. In: H. L. Witmer (Ed.), Psychiatric Interviews with Children (pp. 155–156). New York, NY: Commonwealth Fund.
Reenkola, E. (2010). Vicissitudes of female revenge: Female revenge with her body and for her body. Paper presented at COWAP Conference, Berlin, Germany, July, 2010.
Reik, T. (1953). The Haunting Melody: Psychoanalytic Experiences in Life and Music. New York, NY: Farrar, Straus, and Young.
Renik, O. (1993a). Countertransference enactment and the psychoanalytic process. In: O. Kernberg, M. Horowitz, and E. Weinshel (Eds.), Psychic Structure and Psychic Change (pp. 135–158).
 Madison, CT: International Universities Press.
Renik, O. (1993b). Analytic interaction: Conceptualizing technique in light of the analyst’s irreducible subjectivity. Psychoanalytic Quarterly, 62: 553–571.
Renik, O. (1995). The ideal of the anonymous analyst and the problem of self-disclosure. Psychoanalytic Quarterly, 64: 466–495.
Renik, O. (1996). The perils of neutrality. Psychoanalytic Quarterly, 66: 495–517.
Renik, O. (1999). Playing one’s cards face up in analysis: An approach to the problem of self disclosure. Psychoanalytic Quarterly, 68: 521–539.
Roazen, P. (1995). How Freud Worked. Northvale, NJ: Jason Aronson.
Roland, A. (1996). Cultural Pluralism and Psychoanalysis: The Asian and North American Experience. New York, NY: Routledge.
Rose, J. (1997). Distortions of time in the transference: International Journal of Psychoanalysis, 78: 453–468.
Rosenfeld, D. (2006). The Soul, the Mind and the Psychoanalyst. London, UK: Karnac Books.
Ruderman, E. G. (2000). Intimate communications: The value and boundaries of touch in the psychoanalytic setting. Psychoanalytic Inquiry, 20: 108–123.
Rutan, S. & Stone, W. (1993). Psychodynamic Group Psychotherapy (2nd ed.). New York, NY: Guilford Press.
Sampson, H. (2005). Treatment by attitudes. In: G. Silberschatz (Ed.), Transformative Relationship: The Control-Mastery Theory of Psychotherapy (pp. 111–119). New York, NY: Routledge, Taylor and
Francis Group.
Sandler, J. (1976). Countertransference and role responsiveness. International Review of Psychoanalysis, 3: 43–47.
Sandler, J. & Sandler, A. M. (1998). Internal Objects Revisited. London, UK: Karnac Books.
Schachter, J. (1994). Abstinence and neutrality: Development and diverse views. International Journal of Psychoanalysis, 75: 709–720.
Schachter, J. & Johan, M. (1989). Evaluation of outcome of psychoanalytic treatment: Should follow up by the analyst be part of the post-termination phase of analytic treatment? Journal of the
American Psychoanalytic Association, 37: 813–822.
Schlesinger, H. J. (2003). The Texture of Treatment: On the Matter of Psychoanalytic Technique. Hillsdale, NJ: The Analytic Press.
Schlesinger, H. J. & Appelbaum, A. H. (2000). When words are not enough. Psychoanalytic Inquiry, 20: 124–143.
Schwaber, E. (1983). Psychoanalytic listening and psychic reality. International Review of PsychoAnalysis, 10: 379–392.
Schwaber, E. (1995). A particular perspective on impasses in the clinical situation: Further reflections on analytic listening. International Journal of Psychoanalysis, 76: 711–722.
Schwaber, E. (1996). Toward a definition of the term and concept of interaction: Its reflection in analytic listening. Psychoanalytic Inquiry, 16: 5–24.
Schwaber, E. (2005). Pleasures of mind. Journal of the American Psychoanalytic Association, 53: 427–435.
Schwaber, E. (2007). The unending struggle to listen: Locating one’s self within the other. In: S. Akhtar (Ed.), Listening to Others: Developmental and Clinical Aspects of Empathy and Attunement
(pp. 17–40). Lanham, MD: Jason Aronson.
Schwartz, H. J. (1987). Illness in the doctor: Implications for the psychoanalytic process. Journal of the American Psychoanalytic Association, 35: 657–692.
Seelig, B. & Rosof, L. (2001). Normal and pathologic altruism. Journal of the American Psychoanalytic Association, 49: 933–959.
Settlage, C. F. (2001). Defenses evoked by early childhood loss: Their impact on life-span development. In: S. Akhtar (Ed.), Three Faces of Mourning: Melancholia, Manic Defense, and Moving On
(pp. 47–93). Northvale, NJ: Jason Aronson.
Shane, M., Shane, E. & Gales, M. (2000). Psychoanalysis unbound: A contextual consideration of boundaries from a developmental systems self psychology perspective. Psychoanalytic Inquiry, 20:
144–159.
Shapiro, E. L. & Ginzberg, R. (2002). Parting gifts: Termination rituals in group therapy. International Journal of Group Psychotherapy, 52: 319–336.
Sharpe, E. F. (1940). Psycho-physical problems revealed in language: An examination of metaphor. International Journal of Psychoanalysis, 21: 201–215.
Shilkret (2006). Endangered by interpretations. Psychoanalytic Psychology, 23: 30–42.
Shill, M. A. (2004). Analytic neutrality, anonymity, abstinence and elective self disclosure. Journal of the American Psychoanalytic Association, 52: 151–187.
Siegman, A. (1954). Emotionality: a hysterical character defense. Psychoanalytic Quarterly, 23: 339–354.
Silberschatz, G. (2005). The control-mastery theory. In: G. Silberschatz (Ed.), Transformative Relationship: The Control-Mastery Theory of Psychotherapy (pp. 3–23). New York, NY: Routledge, Taylor
and Francis Group.
Smolar, A. (1998). Book review: “The Therapist as a Person: Life Crises, Life Choices, Life Experiences, and Their Effects on Treatment.” Psychoanalytic Books, 9: 424–428.
Smolar, A. (2002). Reflections on gifts in the therapeutic setting: The gift from patient to therapist. American Journal of Psychotherapy, 56: 27–45.
Spero, M. H. (1993). The temporal framework and Lacan’s concept of the unfixed psychoanalytic hour. Psychoanalytic Study of the Child, 48: 115–142.
Spotto, D. (1993). Marilyn Monroe: The Biography. London, UK: Chatto and Windus.
Stein, H. (1965). The gift in therapy. American Journal of Psychotherapy, 19: 480–486.
Stern, D. B. (1997). Unformulated Experience: From Dissociation to Imagination in Psychoanalysis. Hillsdale, NJ: Analytic Press.
Stern, D. N. (1985). The Interpersonal World of the Child. New York, NY: Basic Books.
Stolorow, R. & Atwood, G. (1978). Faces in a Cloud: Subjectivity in Personality Theory. New York, NY: Jason Aronson.
Stone, L. (1954). The widening scope of indications for psychoanalysis. Journal of the American Psychoanalytic Association, 2: 567–594.
Stone, L. (1961). The Psychoanalytic Situation. New York, NY: International Universities Press.
Stone, M. H. (1972). Treating the wealthy and their children. International Journal of Child Psychotherapy, 1: 15–46.
Stone, M. H. (2009). Lying and deceitfulness in personality disorders. In: S. Akhtar & H. Parens (Eds.), Lying, Cheating, and Carrying On: Developmental, Clinical, and Sociocultural Aspects of
Dishonesty and Deceit (pp. 69–92). Lanham, MD: Jason Aronson.
Strean, H. (1981). Extra-analytic contacts: Theoretical and clinical considerations. Psychoanalytic Quarterly, 50: 238–259.
Strenger, C. (1989). The classic and the romantic visions in psychoanalysis. International Journal of Psychoanalysis, 70: 595–610.
Strupp, H. & Binder, J. (1985). Psychotherapy in a New Key: A Guide to Time-limited Dynamic Psychotherapy. New York, NY: Basic Books.
Sylvester, E. (1945). Analysis of psychogenic anorexia and vomiting in a four-year-old child. Psychoanalytic Study of the Child, 1: 167–187.
Szonyi, G. & Stajner-Popovic, T. (2008). Shuttle analysis, shuttle supervision, and shuttle life—some facts, experiences, and questions. Psychoanalytic Inquiry, 28: 309–328.
Tarnower, W. (1966). Extra-analytic contacts between the psychoanalyst and the patient. Psychoanalytic Quarterly, 35: 399–413.
Thoma, H. & Kachele, H. (1994). Psychoanalytic Practice, Volume 2: Clinical Studies. Northvale, NJ: Jason Aronson.
Thompson, C. (1988). Sándor Ferenczi (1873–1933). Contemporary Psychoanalysis, 24: 182–195 [Original work published 1934/44].
Toronto, E. L. K. (2001). The human touch: An exploration of the role and meaning of physical touch in psychoanalysis. Psychoanalytic Psychology, 18: 37–54.
Turner, C. (2010). Marilyn Monroe on the couch. London Telegraph, retrieved June 25, 2010, from: http://www.telegraph.co.uk
Ursano, R. J., Sonnenberg, S. M. & Lazar, S. G. (1998). Concise Guide to Psychodynamic Psychotherapy. Washington, DC: American Psychiatric Press.
Viederman, M. (1991). The real person of the analyst and his role in the process of psychoanalytic care. Journal of the American Psychoanalytic Association, 39: 451–489.
Volkan, V. D. (1976). Primitive Internalized Object Relations. New York, NY: International Universities Press.
Wallerstein, R. (1986). Forty-Two Lives in Treatment: A Study of Psychotherapy and Psychoanalysis. New York, NY: Guilford Press.
Warren, M. (1961). The significance of visual images during the analytic session. Journal of the American Psychoanalytic Association, 9: 504–518.
Weiss, J. (1993). How Psychotherapy Works: Process and Technique. New York, NY: Guilford Press.
Weiss, S. (1964). Parameters in child analysis. Journal of the American Psychoanalytic Association, 12: 587–599.
Winnicott, D. W. (1935). The manic defense. In: Through Pediatrics to Psycho-Analysis: Collected Papers (pp. 129–144). New York, NY: Brunner/Mazel.
Winnicott, D. W. (Ed.) (1947). Hate in the countertransference. In: Through Paediatrics to Psychoanalysis: Collected Papers (pp. 194–203). New York, NY: Brunner/Mazel.
Winnicott, D. W. (Ed.) (1954). Metapsychological and clinical aspects of regression within the psycho-analytical set-up. In: Through Paedetrics to Psycho-Analysis (pp. 278–294) New York, NY:
Brunner Routledge.
Winnicott, D. W. (Ed.) (1960). Ego distortion in terms of true and false self. In: Maturational Processes and the Facilitating Environment (pp. 140–152). New York, NY: International Universities Press.
Winnicott, D. W. (1961). The Time Factor in Treatment. Talk given to the Children’s Department of the West Sussex City Council.
Winnicott, D. W. (Ed.) (1963). Psychiatric disorder in terms of infantile maturational processes. In: The Maturational Processes and the Facilitating Environment (pp. 230–241). London, UK: Hogarth
Press.
Winnicott, D. W. (1965). The Maturational Processes and the Facilitating Environment: Studies in the Theory of Emotional Development. New York, NY: International Universities Press.
Winnicott, D. W. (1966). Ordinary devoted mother. In: C. Winnicott, R. Shepherd & M. Davis (Eds.), Babies and Their Mothers (pp. 3–4). Reading, MA: Addison-Wiley.
Winnicott, D. W. (Ed.) (1971). The use of an object and relating through identifications. In: Playing and Reality (pp. 115–127). London, UK: Tavistock.
Wortis, J. (1994). My Analysis with Sigmund Freud. New York, NY: Jason Aronson.
Zuckerman, J. & Horlick, L. (2006). The affective experience of the analyst in the extra-analytic moment. American Journal of Psychoanalysis, 66: 351–371.
Zur, O. (Ed.) (2007). Time and money: Managing time, fees, billing, and bartering. In: Boundaries in Psychotherapy: Ethical and Clinical Explorations (pp. 83–98). Washington, DC: American
Psychological Association.
Index

Abraham, K. 92
adult psychoanalytic literature 177, 185
affectualization 97
Alexander, F. 113, 130, 133–134, 185
Alma 38–41
American Psychoanalytic Association 17
analytic
listening 84
neutrality 113
“superego” 22
Appelbaum, A. H. 93, 194
authenticity 33–34, 44, 50, 52, 85, 198

Bach, S. 94
Balint, M. 90, 171, 193–194
Barredo, C. E. 68
bartering 3, 8–9
benevolent neutrality 90, 113
Benjamin, J. 85, 132
Bennett, B. 9
Billow, R. M. 152, 162
Blanton, Smiley 179
borderline paranoid addictive personality 42, 44
borderline patients 93, 136
borderline personality
difficulties 71, 73–74
disorder 186
Breckenridge, K. 172–173, 194
Brenner, Ira 3, 85
Brown and Trangsrud’s survey of doctoral psychology students 180
Busch, F. 145

Canter, M. 9
Casement, P. J.
International Review of Psychoanalysis 172
oft-cited paper 172–173
original theoretical perspective 172
“pathogenic beliefs” 115
Psychology Inquiry 172
Celenza, Andrea 165, 171
changing the frequency, length, and timing of sessions 65–80
Charles, M. 176
child analysts, experience of 182–184
“child guidance” intervention 107
child psychotherapeutic setting 177
childhood reminiscences 23
Chinese American Psychoanalytic Alliance (CAPA) 17
Chinese analysand 17–18
close process monitoring 85
cognitive behavioural therapy 134
Coltart, N. 72
complimentary countertransferences 88
concordant countertransference 88
confrontation of acting out 100
Conn, David 95
contemporary psychoanalysts 84
control-mastery 115
case formulation 115
corrective emotional experience (CEE) 113–114, 130, 133–134, 151, 185
countertransference 86, 88, 148, 170, 200
complimentary 88
difficulties 178
enactment 131
feelings towards the patient 131
forces 178
informative potential of 88
problems 4
reactions 10, 12, 202
responses 74

Danckwardt, J. F. 175
deferred payment 3, 14–15
developmental presence, gift of 190–192
dichotomous thinking 174
DiMaggio, Joe 43
Dimen, M. 8

ego
functioning 145
modulation 95
psychological framework 145
psychologists 85, 87, 144–147, 153–158
relaxation necessary 33
weakness 11, 202
Ehrenberg, D. B. 147–148
Ehrlich, L. T. 73, 78
Eichen 182
Eissler, K. 113, 136, 180
psychoanalytic literature 180
enlightenmentera epistemology 174
Epstein, A. 180
Etchegoyen, R. H. 70, 75, 79, 175
exposure therapy for phobic patients 31
extra time, gift of 188
extraordinary monetary arrangements 3
extra-therapeutic interventions 34

Fenichel, O. 4
Ferenczi, S. 31, 76, 79, 92, 141–142, 171, 185
“hippic” analysis 31
idea of raising the clinical temperature 76
Ferro, A. 69
Fieldsteel, N. 184–185
Foehl, J. 167
Folkmarson Kall, L. 167
forced termination 76
form of action, interpreting 113–136
Fosshage, J. L. 172–173, 175, 194
free-floating responsiveness 176
Freud, S. 3–4, 7, 15–16, 19, 28, 31–32, 34–42, 47, 59, 63, 70, 84, 86, 88, 92, 95, 97, 108, 113, 131, 141–143, 151, 161, 171–172, 175, 177–179, 182–183, 201
adult psychotherapy literature 183
anonymity and neutrality 142
clinical work in unorthodox places 34
conceptualization of leasing time 3
dog Yofi 179
feeding the Ratman 34
guideline 15
“On beginning the treatment” 28
practice 178–180
“professional code” 108
understanding 37
unorthodox decision 41
Wolf man’s analysis 76
Freudian model of leasing time 7
Fromm-Reichmann, F. 197

Gabbard, G. 136, 150

Galatzer-Levy, R. M. 154, 157–158, 163
Gayle, R. 184
Gedo, J. E. 96, 185
Geerkin, I. 68
Gelb, P. 194
Gerlach, Alf 28
giving advice 99–111
“child guidance” intervention 107
giving mementos and gifts to the
patient 177–202
psychoanalytic literature 179–182
Goldberg, A. I. 96, 149
gratis treatment 15–17
Green, Aaron 66, 70–71, 76–78, 80, 168
objectalizing function 80
Greenson, Ralph 42–44, 69, 74, 115
treatment of Marilyn Monroe in home 42–44
Grinker, Roy 179
group psychotherapy, termination process in 184
group therapy literature 184–185

Hartmann, H. 108
Hippocratic tradition “Primum non nocere” 14
Hoffman, I. Z. 6, 185
Holy Mary complex 41
home-like soothing stability 32
homoerotic transference 23
homosexual implications 122
Hooke, Maria Teresa 28
hypnotic intervention in oncology setting 53–55
hypochondriacal preoccupation 46

intangible gifts 185

intersubjective theory 132
in-vitro fertilization 189
IPA China Committee 28

Jackson, Edith 179

Jacobs, Marc 68, 85, 113, 123, 131, 135, 146–147, 200
Jones, E. 9, 38–41
Josephthal, Dan 83

Katharina treatment in mountain inn 34–37

Kernberg, O. 93, 136
Killingmo, B. 85, 185
Kirsner, D. 42
Klein, M. 85, 87, 193
Kleinian 85, 88, 95
neo- 149–152
Kohut, H. 110
Kris, Anton 42, 99–100, 109–110
Kris, Marianne 32
Krupnick, J. L. 136–137
Kurtz, S. A. 65, 71, 79

Langer 8
Langs, R. 43, 67, 179
Lanzer, Ernst 179
Laufer 67
Lazar, S. G. 19
Levin, S. 182–183
Levine, Susan 196
Lichtenberg and Slap 72
Lipton, S. 26, 131, 135
Loewenberg, Peter 28
Lorenzo 47–50
Lowenstein, R. M. 92

Mahler, Gustav
capacity for psychological understanding 41
death from complications of streptococcal heart disease 39
in Leiden 38
positive response 42
response to Freud’s comments 41
Marcus, D. M. 149–151
clinical description 151
maternal sexuality 87
maternal transference 21, 45
McLaughlin, J. 86, 146, 172–173, 175, 194
Meissner, W. W. 68–69, 72, 76, 78, 145
merger-abandonment anxieties 88
Merleau-Ponty, M. 167
Middle School/Object-Relational theoretical stance 172
Miller, Arthur 42–43
Milner, M. 8
missed appointment dilemma 18–27
Mitchell, S. 5, 131
Monroe, Marilyn 42–44
death 43
treatment 42
Moore, Mark 31
Morrison, A. L. 155–156

Nagy, T. 9
narcissistic injury 9
Nathan, P. 74
NIMH collaborative treatment study of depression 136
“nonexistent sexual identity” 118
nonpsychoanalytic therapists 31
nonresponsiveness 130
Norton’s treatment of dying patient in hospital 44–46

Oedipal strivings 20
oedipal transference 95
omnipotent fantasy 13
one-person psychology 145, 147, 153
optimal disillusionment 96
Orange, D. M. 147

Palvarini, P. 133
Pandora’s box 36
paternal transferences 159
patient’s
“acting out” 100
angry demand 45
anxiety and conflicts 78
dignity 59
dreams 86
ego functioning 86
immediate family members 19
mental functioning 148
mother’s psychic fragmentation 182
object representation 88
pathogenic beliefs 115–116
productions and behaviour 147
psychological weaknesses 101
psychology 145
punitive unconscious self-criticism 110
sadomasochism and narcissism 97
self-representation 88
subsequent communications 199
“unconscious plan” 116
value system and ideals 89
physical touch, gift of 189–190
Pine, F. 87, 185
Pizer, B. 155, 173, 194
placebo pharmacotherapy 137
Poland, Warren 4
posttermination mourning 77
pre-Oedipal
pathology 182
trauma 175
professional hypocrisy 142
projective identification 24, 85, 149, 162, 170, 193
pseudo-helplessness 25
psychic presence 173
psychoanalysis 3–4, 6, 8, 15, 17–18, 25, 32, 36, 38, 42–43, 50, 80, 85, 92, 97, 99, 110, 113–116, 119, 131–132, 134, 136, 142, 149, 170–172, 178, 203
“classic” and “romantic” visions of 85
field of 113
fundamental rule of 171
relational psychoanalysis 131–132
psychoanalytic
achievements 4
exploration 20
field, mental space in 50
patients 20
process 6, 59, 135
psychotherapies, long-term 136
situation 143
taboo 124
technique, theories of 134
theories of technique 134
therapy 32, 137, 155
training 83
tree 124
psychoanalytic treatment 34
via Skype 17
psychological
guilt 25
ramifications 23
significance 20
psychosomatic attack 123
psychostructural organization 85
psychotherapeutic change process 134
psychotherapeutic interventions 50
psychotherapy
task of 134
tedious 10
PTSD symptoms, crystallization of 29
Puget, J. 65, 73

Rachel 186, 193–195

Rachel Rosenblatt 91–92
Rachman, A. W. 144, 149
guidelines about self-disclosure 144
Racker, H. 88
Rebecca 188–189, 197
refusing to listen 83–97
relational psychoanalysis 131–132
relational psychoanalysts 147–149
intersubjective theory of 147
Renik, O. 113, 131, 148, 150, 198
retaliatory attack 122
Roazen, Paul 179
role-responsiveness 136
Rosenfeld, Rachel
taking an adolescent patient to a video arcade 47–50
Rutan and Stone 184
Ruthie 103–105

sadomasochistic scenarios 166

Salo, Frances 65
San Francisco Psychotherapy Research Group (SFPRG) 115
Sandler’s concept of “free floating responsiveness” 97
Sarah’s therapy 191–193
wedding 195
Schachter, J. 77, 141
Schlesinger, H. J. 19–20, 173, 194
Schwaber, E. 68
emphasis upon listening 85
Schwartz, H. J. 154
self-castigation 84
self-destructive enactments 51
self-disclosure 145, 148, 161
gift of 186–188
integral 143
judicious and conspicuous 144
situational 143
technical 143–144
types of 196
self-object relationship 94
self-revelation 143
Settlage, C. F. 181
case description 181, 183
follow-up of a child patient in a hotel room 46–47
sexual boundary violations 162
sexual responsiveness 151
Shapiro and Ginzberg 184
Shill, M. A. 143
Simon’s analysis 26
Skolnikoff, Alan 141
Smolar, Andrew 177
socioeconomic climate 9
Sonnenberg, S. M. 19
Soprano, Olivia 6
Soprano, Tony 6
spiritual superiority 40
Stein, H. 201–202
Stern, D. B. 171
Stern, D. N. 66
Stolorow, R. 131, 147
Strenger 85
stubborn refusal 124
“superego”, analytic 22
Symington 73

talking about oneself 141–163

tangible gifts 178
teleological stance 116
temporal spatial frame 8
termination 75–78
moving towards 127–128
therapeutic
alliance 136
process 52
therapist’s
countertransference 10
desire 196–200
reciprocating for patient’s gift 200–201
response to the patient’s request 193–196
touching the patient 165–174
meanings of touch in clinical context 168–171
phenomenal experience of touch 166–168
touch or not to touch, historically 171–172
transference
and resistance 55
awareness 131
 countertransference enactment (T-CT-E) 71, 131–132
drama of 100
figure 130
frustrating father in 151
idealizing 69
intense 60
material 188
nature of 25
relations 16
resistance 129, 145
transference and countertransference 62
axis 91
difficulties 67, 78–79
effects on relationship 80
stalemate 79
transferential relation 49
transgressions boundary 62
transitional object, gift of 186
treating wealthy patients 10–13
patient’s demands 12
therapist’s willingness 15
treatment by attitudes (TBA) 115
treatment outside the office, conducting 31
encounter with Gustav Mahler in Leiden 38–42
ER setting 61
Greenson’s treatment of Marilyn Monroe in home 42–44
hypnotic intervention in oncology setting 53–55
Katharina’s response 36
Katharina’s revelatory answer 36
Norton’s treatment of dying patient in hospital 44–46
Rosenfeld’s taking an adolescent patient to a video arcade 47–50
Settlage’s follow-up of a child patient in a hotel room 46–47
theoretical and technical reflections 57–62
treatment of katharina in mountain inn 34–37
Turner, C. 43

unconscious fantasies 85
Ursano, R. J. 19

Vanderbilt psychotherapy research group 134

wealthy patients 10
Wegner, P. 175
Weiss, S. 193
Wermer, H. 182–183
westward migration 8
Winnicott, D. W. 32, 66, 71, 75
“ordinary devoted mother” 87
Wolf man’s analysis 76
World War II 75
Wortis, Joseph 179
New Series of Psychoanalytic Lectures 180

Yale University Press 111

Zur, patient’s accomplishments 180