Psychoanalysis and Psychotherapy by Bach
Psychoanalysis and Psychotherapy by Bach
Psychoanalysis and Psychotherapy by Bach
STUDENTS OF PSYCHOANALYSIS
AND PSYCHOTHERAPY
THE HOW-TO BOOK
FOR STUDENTS
OF PSYCHOANALYSIS
AND PSYCHOTHERAPY
Sheldon Bach
First published in 2011 by
Karnac Books Ltd
118 Finchley Road
London NW3 5HT
ISBN-13: 978-1-85575-887-2
www.karnacbooks.com
For Rebecca, Matthew, and Julia,
who continue to learn and to teach me
CONTENTS
ACKNOWLEDGEMENTS xi
INTRODUCTION xv
CHAPTER ONE
How to choose a psychoanalytic theory 1
CHAPTER TWO
How to do an initial interview 3
CHAPTER THREE
How to choose your personal psychoanalyst 8
CHAPTER FOUR
How to listen to a patient 13
CHAPTER FIVE
How to frame and change perspectives 17
vii
viii CONTENTS
CHAPTER SIX
How to recognize and understand self-states,
alternate states, true and false selves, multiple
identities, etc. 21
CHAPTER SEVEN
How to manage the telephone 26
CHAPTER EIGHT
How to get paid for your work 28
CHAPTER NINE
How to understand and manage the transference 32
CHAPTER TEN
How to tell what the transference is 39
CHAPTER ELEVEN
How to deal with the sadomasochistic transference 45
CHAPTER TWELVE
How to manage narcissistic disequilibrium 51
CHAPTER THIRTEEN
How to understand the need for recognition 55
CHAPTER FOURTEEN
How to make a careful referral 60
CHAPTER FIFTEEN
How to refer a patient for medication 62
CHAPTER SIXTEEN
How to manage vacations, weekends, illnesses,
no-shows, and other disturbances of continuity 67
CONTENTS ix
CHAPTER SEVENTEEN
How to think about analytic process 71
CHAPTER EIGHTEEN
How to maintain your physical health
and mental equilibrium 74
CHAPTER NINETEEN
How to practise holistic healing 78
REFERENCES 81
ACKNOWLEDGEMENTS
xi
xii ACKNOWLEDGEMENTS
xiii
INTRODUCTION
xv
xvi INTRODUCTION
How to choose
a psychoanalytic theory
W
hen I began in this field we all studied Freudian
theory because at that time anything else was
considered “not psychoanalytic”. It was a dif-
ficult theory and I studied it assiduously with, among
others, David Rapaport, who seemed to believe that
you couldn’t be a Freudian unless you learned chapter
seven of The Interpretation of Dreams by heart.
Nowadays there is a smorgasbord of theories avail-
able and beginners often are inducted into one or the
other almost by chance, depending on whom they hap-
pen upon as a supervisor or analyst. Fortunately, more
and more institutes are offering courses in orientations
other than their own, so that students are often faced
with a panoply of rich and varied viewpoints that can at
times seem quite confusing.
It took me a while to realize that major psychoana-
lytic theories have generally been constituted around
the personal character structure, culture, and world-
view of their originators, an unsurprising conclusion.
If that is the case, it would seem reasonable that you
might choose a theory as you choose a friend, that is,
1
2 T H E H O W -T O B O O K F O R S T U D E N T S
How to do an initial
interview
I
n an initial interview the patient is seeking relief
from some kind of suffering. He wants to find out
what the matter is and what can be done about it.
He is hoping to find that you are the person who can
help him.
In an initial interview you are trying to figure out
whether you can help this person, whether you want
him as a patient and, if the answer to the first two
questions is positive, how you can get him to come
back.
You should always have in mind a bottom fee below
which you cannot afford to work. If the patient cannot
reasonably meet this fee or if you do not want to work
with him, then you should make a careful referral (see
14, How to Make a Careful Referral). Although every-
one reacts poorly to being rejected, you should make
a real effort to help the patient allow you to make the
referral, because it will generally be to his own great
advantage as well as to yours.
Try to be totally natural with the patient as if he
were your friend, which he might eventually become.
3
4 T H E H O W -T O B O O K F O R S T U D E N T S
I
t was more than 50 years ago that as a candidate in
a doctoral psychology programme I heard a student
ask the director how to choose a personal analyst.
I remember his reply: “Take the analyst to a stable and
see how the horses react to him.” This was impractical
advice even at that time, and more so now that there
are no longer any stables in Manhattan. But the import
was clear: training qualifications, reputation, and the
number of books written were less important than
some affective personal quality to which horses were
more sensitive because their minds were presumably
not distracted by cognitive considerations.
You should of course consider length of training and
other qualifications, books and articles written, courses
taught, etc. since these may sometimes indicate a
depth of commitment, but do not be overly impressed
by the accoutrements of reputation, since some highly
reputed analysts, just as some highly acclaimed physi-
cians, may be total duds.
Other things being equal, you should prefer an ana-
lyst who has practised a substantial number of hours
8
H O W T O C H O O S E Y O U R P E R S O N A L P S Y C H O A N A LY S T 9
Clinical Illustration
W
hen I was in training in the Fifties and early
Sixties, we were taught to listen primarily
for the unconscious meaning of what the
patient was saying. Our ultimate goal was to convert
the unconscious or primary process meanings back
into conscious or rational thought. It was as if we were
translating a foreign language, the language of dreams,
back into everyday English. Some of us got to be quite
good at this simultaneous translation, but it was never
entirely clear whether it was the lifting of repressions
that helped the patient, the fact that we were paying
such close attention to them, or something else.
Of course this was a distortion of the kind of listen-
ing that Freud had sometimes recommended, which
was listening without a defined goal, with free floating
attention. That is still quite difficult to do, as getting paid
to be purposeless requires an uncommon faith in the
analytic process. It is still a lot easier for us to assume
the role of translator, advisor, benign adversary, older
13
14 T H E H O W -T O B O O K F O R S T U D E N T S
Clinical Illustrations
R
ecently I was walking in High Line Park, newly
built on an elevated rail track that runs over
a part of the meat packing district in lower
Manhattan. Suddenly I came upon a little amphithea-
tre in the air, two stories above the ground, with a
huge picture window where the stage should be, look-
ing down on Tenth Avenue. Now Tenth Avenue is a non-
descript street, with few stores, few pedestrians, and
uninteresting vehicular traffic. But framed in this huge
window and from this aerial perspective, it took on an
interest and meaning such that several dozen people
were crammed into the amphitheatre, just staring out
of the window at something that ordinarily would never
have drawn their attention. My first thought was how
wonderful it must be to be a creative architect!
But then I realized that analysts are in fact archi-
tects of the mind and that we are constantly engaged
in framing, re-framing, and changing perspectives on
our own and our patients’ vision of things. For the way
we see things, frame them, and give them perspective
17
18 T H E H O W -T O B O O K F O R S T U D E N T S
How to recognize
and understand self-states,
alternate states, true
and false selves, multiple
identities, etc.
I
think that the term self-state was popularized by
Kohut (1971, 1977) and later used by the relational
analysts, most prominently Bromberg (2009), as a
way of organizing, speaking about, and structuralizing
experiences concerning the self. From the Freudian per-
spective, “state of consciousness” is a related but more
experience-distant concept, elucidated by Rapaport
(1951) in his encyclopedic Organization and Pathology
of Thought.
There seem to be multiple parameters to a state of
consciousness, including certain patterns of affect, dif-
ferent kinds of body schemata, different organizations
of time and of thought, and different degrees of aware-
ness of self and other. Thus it involves self-feelings that
include both mind and body; a total sense of one’s self
21
22 T H E H O W -T O B O O K F O R S T U D E N T S
How to manage
the telephone
O
f my own three analysts, one never answered
the telephone while he was with a patient
(I was not even sure if there was a telephone in
his office), and the two others always did. One of the
answerers explained that he wanted to always be avail-
able for patients, but that he would get off the phone
as quickly as possible and limit the number of calls to
two per session.
Although the best analyst turned out to be one of the
answerers, as a patient I was always at least slightly
disturbed by this practice and have resolutely refused
to answer the phone while with a patient except for
emergency situations. Most of the time I even turn
off the ringer, especially with certain people who are
extremely sensitive to impingements, but sometimes
I forget. This is part of my general policy of arranging
the office, the lighting, the temperature, the pillows,
etc. to suit each person’s preferences whenever possi-
ble. I look back with horror at my early years of practice
when, for example, I smoked without asking permis-
sion, although that was common practice at the time.
26
HOW TO MANAGE THE TELEPHONE 27
W
hen supervisees have complained about diffi-
culty in getting paid, or when I have had such
problems myself, it has almost always been a
question of the therapist’s ambivalence about charging
for services or lack thereof. Thus many people have
difficulty charging when the patient does not show up,
for whatever reason, or when the patient complains
that they are not helping, or when they themselves feel
that they are not helping.
One problem seems to be that it may not feel fair
or appropriate to get paid for merely talking to some-
one, whereas it clearly feels appropriate to get paid
for administering a psychotropic chemical to someone,
even though it might be useless or even toxic. Now
that brain studies have shown that talking therapy acti-
vates brain areas similar to psychotropic medication,
we may yet come to accept that talking therapy can be
as powerful a force as drug therapy for both help and
harm.
It has taken me a long time to realize and then
fully believe that the treatment begins when the
28
HOW TO GET PAID FOR YOUR WORK 29
M
ost analysts agree that understanding, man-
aging, and interpreting the transference and
countertransference is the most important but
difficult part of any psychotherapy. This note cannot
pretend to even introduce the subject, so a number of
additional readings will be appended to it.
Although Freud “discovered” transference and at
times realized its importance, it is strange how little
he wrote about it, and how confusing or ambivalent
some of these writings are. This trend continues to the
present day, suggesting that the transference is not
only very important, but also broader than originally
conceived and somewhat mysterious in its workings.
Initially it was viewed as simply the displacement
of feelings that pertained to an earlier object, such
as the father, onto a later object, such as the ana-
lyst. It is still viewed by many in this simple, restric-
tive sense. But in 1914 Freud expanded this to include
the notion of a transference neurosis that encom-
passes the entire treatment and complicates matters
somewhat. In the full-blown transference neurosis
32
H O W T O U N D E R S TA N D A N D M A N A G E T H E T R A N S F E R E N C E 33
Clinical Illustrations
O
ne way of thinking about this extremely complex
subject is to imagine that all analyses have at
least two transferences running at the same
time: one in the foreground and one in the background
(Treurniet, 1993). The one transference, sometimes
called primordial, basic, narcissistic, or background
transference, is a transference to the analyst as the
environmental mother, that is, to the analyst as prima-
rily a function for holding and containing rather than as
a person to be related to. This is the transference that
keeps the analysis ongoing, as it provides some vary-
ing degree of basic or analytic trust that allows your
patient to fulfil the minimal requirements of an anal-
ysis, namely, appearing from time to time, speaking
occasionally and paying his bills. This basic transfer-
ence is largely preconscious or unconscious and han-
dled through management, although it may become
an object for analytic examination early on if trust is
lacking, or later on as the analysis proceeds.
The other type of transference, sometimes called
classic, neurotic, object-related, Oedipal, or iconic
39
40 T H E H O W -T O B O O K F O R S T U D E N T S
Clinical Illustrations
I
include sadomasochistic relationships in defining
perversions because in my experience they always
go together, and although you may not see many
actual sexual perversions in your practice, I am certain
that you see sadomasochistic relationships all the time.
Now Freud and many early analysts did not seem to
think that perversions were necessarily coupled with
other pathology like disturbed object relations, but
I have never seen an instance where they were not,
although I am probably defining disturbed object rela-
tions much more widely than Freud did.
What Freud did get brilliantly right was the link
between sadomasochism and the beating fantasy,
which many people believe to be universal. The
Novicks’ (1987) data suggests that beating fantasies
are a developmental fact for most people, but that in
certain children the beating fantasy becomes a fixed
fantasy or a pathological obsession and that these are
the more challenging cases.
Following Freud (1919), the conscious fantasy is:
a child is being beaten, which covers the unconscious
45
46 T H E H O W -T O B O O K F O R S T U D E N T S
I
t was said of Rabbi Bunim, the Chassidic sage, that
he always carried two notes, one in each pocket of
his trousers. One note read: “The world was made
entirely for you”, while the other note said: “You are
nothing but dust and ashes”. Depending on whether his
self-esteem was too high or too low, he would reach into
one pocket or the other and read the appropriate note
to help rebalance his narcissistic equilibrium. Whether
consciously or unconsciously, we are all continuously
engaged in rebalancing our narcissistic equilibrium and
in helping our patients rebalance theirs, even if only by
our steady presence.
For those lucky enough to have internalized a steady
presence in childhood, this self-esteem regulatory
process is automatic and usually requires no thought.
For those who have not adequately internalized this
regulatory process, and that includes psychotic, bi-
polar, borderline, and many narcissistic patients, the
treatment itself becomes the major regulating mecha-
nism; and the frequency of sessions, their continuity,
and the analyst’s homeostatic responses all contribute
51
52 T H E H O W -T O B O O K F O R S T U D E N T S
How to understand
the need for recognition
A
recognition scene depicts that moment at which
long lost or even presumably dead characters
are suddenly recognized for who they are and
found to be very much present and alive. Recognition
scenes abound in The Odyssey, where the old nurse
Eurycleia recognizes the disguised Ulysses by his scar,
in the New Testament after the Resurrection of Jesus,
and in Shakespeare where, for example, Pericles rec-
ognizes his daughter who was lost as an infant. Rec-
ognition scenes can also encompass the discovery of
one’s own identity or true self, or of someone else’s
identity or true nature. The moment of recognition
always places the event in a new and larger context,
so that what formerly seemed insignificant or mean-
ingless suddenly becomes drenched and suffused with
meaning and emotion.
I recently came across a beautiful description of the
awakening of a young girl who, for the first time in her
life feels recognized by an adult:
There was very little conversation in my family.
The children shrieked and the adults went about
55
56 T H E H O W -T O B O O K F O R S T U D E N T S
T
here are many reasons you may not be able to
work with a patient whom you have seen in an
initial interview. You may feel unable to work at
a fee that the patient can realistically afford, you may
not have the hours or the time that the patient needs,
or you may simply not feel able to work well with this
particular kind of patient. As realistic as the reason
may be and as carefully as you may explain it, most
people feel hurt and rejected, even though they may
have been ambivalent about coming. I have found that
it often helps to make a careful referral.
I begin by explaining why I feel that this is not the
best situation for them, and then offering to help them
find something that will feel just right. I say that I will
think about what they’ve told me and then call them
within a week with the name of another therapist.
It will take that long because I want to give this some
thought and because I have to phone people and find
someone who is right for them and who has the appro-
priate fee and hours available. I do not want to give
them just any old name.
60
HOW TO MAKE A CAREFUL REFERRAL 61
I
t is very difficult to know when to refer a patient
for psychoactive medication because a good part of
the data base for psycho-pharmacological research
has been so distorted by the medico-pharmacological-
advertising complex that reliable data is difficult to
come by (see for example Marcia Angell, 2009). The
best non-partisan data I have found suggests that
most anti-depressants may perhaps be slightly more
efficacious than placebo, but not significantly so, and
that the frequent side effects, including depersonaliza-
tion, render them of dubious clinical efficacy for many
patients. Nevertheless, I have seen occasional patients
who seem to have been helped by anti-depressants
and others who feel that they have been helped, and
I support this without hesitation if the patient desires
them.
It should be mentioned that for many depressed
patients, vigorous exercise, relaxation techniques, and
supplements such as SAMe, St John’s Wort and fish oil
have been shown to be as effective or more effective
than many psychotropic medications (Kirsch, 2010;
62
H O W T O R E F E R A P AT I E N T F O R M E D I C AT I O N 63
I
n the old days when analysts saw patients six days
a week, they often referred to the “Monday crust”,
that is, the “resistances” and other disturbances
that arose during the break and that “interfered” with
the treatment. Although we may understand the mean-
ing of these phenomena somewhat differently, in these
days of once or twice a week therapy we are often
much less sensitive to the phenomenon itself.
Thus I recently saw in consultation an analyst who
had arrived a minute or two late for a session and apol-
ogized to the patient who graciously said it was nothing,
but at the end of the week the patient announced that
he was forced to cut back his hours for financial rea-
sons. The analyst never made the connection between
his “insignificant” tardiness and the patient’s reaction,
nor did the patient.
67
68 T H E H O W -T O B O O K F O R S T U D E N T S
M
any decades ago when I was teaching a course
in psychology, I asked the students to pair up
and then to gaze uninterruptedly into each oth-
er’s eyes for several minutes. This proved to be enor-
mously intriguing for some students and impossibly
difficult for others, and all of us were surprised at the
extremes of emotion that it provoked.
I am reminded of this every time I begin seeing a
new patient, for it seems that we are inherently pro-
grammed to connect to each other or to struggle
against that connection, just as we have learned that
an infant is programmed in many modalities to connect
to its primary caretaker.
In a similar way, I feel that whenever a patient
walks into our office an analytic process is potentially
engaged, and that this process takes on a life and a
shape of its own. And that is why whenever I do an
initial interview (see 2, How to Do an Initial Inter-
view) I am concerned to evaluate the patient’s poten-
tial for engaging this process, and also concerned that
I do nothing traumatic, e.g., a quiz type “psychiatric”
71
72 T H E H O W -T O B O O K F O R S T U D E N T S
A
n informal survey of a few dozen colleagues, each
of whom has been practising psychoanalysis from
30 to 60 hours a week for decades, has provided
me with the following information. One of them exer-
cises by walking up the stairs of his apartment building
while talking on his cell phone; another does 90 second
wall-sits while reciting Shakespeare; several walk each
day or play occasional games of tennis, while most of
the rest engage in some more directed physical activ-
ity like going to the gym, running, or working out at
home. The women analysts seem to be more gregari-
ous and more sensible about exercise than the men,
some of whom are either maniacal or else totally
neglectful. One or two do nothing that could be even
faintly construed as exercise. This seems surprising in
a profession where remaining seated for long hours at
a stretch, often under severe emotional tension, is the
rule.
The professional hazards are well known: lower back
trouble and burnout are common. For the former, many
analysts try to move between sessions, do exercises,
74
H O W T O M A I N TA I N Y O U R P H Y S I C A L H E A LT H 75
I
t was interesting to watch the reactions of col-
leagues when research first began to demonstrate
that talking to people produced brain changes anal-
ogous to those produced by psychotropic medications.
Even analysts who strongly believed in the power of
talking therapy and the unity of the mind and body
behaved with astonishment, as if some fairy tale had
turned out to be literally true! Such is the difficulty we
labour under in healing the split Cartesian world-view
we have inherited.
But there may be more to this than mere cultural
sluggishness or difficulty with metabolizing new ideas.
Recent brain research suggests that minds and bod-
ies, or the mental and the physical, are represented in
different neural circuits, so that the phenomenological
experience of body and mind is of separate categories,
like numbers and colours. This might make it more
understandable that we seem to cling to a Cartesian
view even when we believe it to be incorrect, because
it conforms more easily to the way the brain processes
the world (Lieberman, 2009).
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HOW TO PRACTISE HOLISTIC HEALING 79
81
82 REFERENCES