Casi clinici 3: Dora: Frammento di un’analisi d’isteria (Italian Edition)

Sigmund Freud (1856–1939)

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Why observing and interpreting actualization of the transference in the therapy situation is necessary was admirably stated by Freud , p. The conception of the transference I am proposing is that it cannot be prevented from existing any more than the neurosis can be prevented from existing because it is ubiquitous and continual. It can be inhibited from becoming explicitly identifiable and identified by patient and analyst, but if there is a relationship, there is transference both conscious and unobjectionable transference and preconscious or unconscious suppressed or repressed transference.

In psychoanalysis on the other hand, the general view is that the transference should be fostered, even to the point of bringing about a regressive transference neurosis. Indeed one does those very things which are avoided in psychotherapy allegedly to inhibit the development of the transference. Sessions are frequent, the couch is used, exchange is kept to a minimum to lessen the realistic aspects of the situation, and transference is interpreted actively but only after it has allegedly "spontaneously" developed!

According to the line of argument I am advancing, instead of speaking of fostering the transference one could speak of making its manifestations as explicit as possible in the analytic situation including the inadvertent influences on its manifestations which come from the setting and the analyst's interventions. My changed conceptions of the intrinsic criteria of analysis, some beginning efforts to apply them, and experience in teaching them to therapists of varied experience has led me to believe that the attempt to use analytic technique in this broader range of circumstances is justified.

The shift from a view of transference as a distortion and concomitantly to initial emphasis on the analyst's contribution to the transference, alters both the atmosphere of an analysis and the sequence by which the deeper more regressive aspects of the patient's pathology become explicit. The change in atmosphere is one from the patient being wrong and misguided to one in which his point of view is given initial consideration. In other words his rational capacity is respected rather than belittled. It is in such an atmosphere, after his point of view has been acknowledged, that he is more likely to be willing to look for his own contribution to his experience.

The position is of course contrary to the one which argues that to acknowledge the rationality of the patient's point of view is to confirm his belief that his experience is fully accounted for by the current behaviour of the analyst. As to the sequence in which the deeper aspects of the transference become explicit, initial attention to the here-and-now as an interaction makes it easier to obey the classic analytic injunction to proceed from the surface to the depth Fenichel, The presenting material will not even be as deep as preconscious but rather conscious but withheld ideas.

I note that the current discussion in our literature of the role of construction in the analytic interaction in contrast to the uncovering of fixed schemata raises important and difficult questions about the validity of the concept of the exposure of progressively deeper verbally organized psychic material. A concept of continuing construction in the analytic interaction which at the same time re-evaluates the conceptualization of the relationship between conscious, preconscious, and unconscious may fit the data better. The less time available the less opportunity will there be for the development of the patient's history if priority is given to the transference in the here-and-now.

But only if one begins with a prior conviction that the history must be reconstructed as much as possible will one see this as unfortunate. I believe that less is accomplished if one gives priority to interpretations of transference outside the therapeutic situation and of genetic material at the expense of facets of the transference within the therapeutic situation. At the same time, an expanding and therapeutically useful awareness of pathogenic history is not only not incompatible with the conception of transference and its analysis which I am describing but on the contrary it is more likely to be enhanced by such analysis.

The relevance of this view of the analysis of transference to the possibility of carrying it out in an expanded range of extrinsic criteria is different for two major classes of the extrinsic criterion of the patient's pathology schematically stated, the relatively more healthy allegedly analysable and the relatively sicker unanalysable. The distinction I advanced between transference and regressive transference now becomes crucial. With the healthier patients frequency is often considered necessary to "keep open the wound into the unconscious" as I put it in p.

With a concept of proceeding from the beginning from more obvious surface manifestations, the image of painful probing against strong resistance is no longer appropriate.

To question the necessity for an induced regression is also to question the necessity for going beyond what the patient can acknowledge with relative comfort. Nor is this a programme for remaining superficial. It is rather a recommendation to take progressive steps more in tune with the patient's resistance. The couch is likewise considered essential in terms of the need to induce regression. It too then becomes dispensable if one accepts the reasoning I have just outlined. Whereas in the case of the patient usually considered analysable the objection to the use of psychoanalysis in less than the optimal analytic setting is that a regressive transference will not develop, in the case of the sicker patient it is said that a dangerous regression may develop spontaneously.

The catastrophic regressions that sometimes takes place in analysis make analysts careful not to employ the method if the patient is considered incapable of withstanding the rigours of an enforced regression. My suggestion that regression beyond that which already characterizes the patient's pathology is not only unnecessary but undesirable, as well as my description of an initial focus on the therapist's contribution and on the presenting layer of transference in a changed conception of transference and its analysis, mitigate the potential dangers of analysis of the transference in sicker patients.

With this different way of working, the couch and frequent sessions likewise become less dangerous as promoters of regression. Frequency and the couch must be looked at not only in terms of their potential for inducing regression but for their almost contrary potential for providing support. It is argued that frequent sessions are necessary to gain access to the transference in healthier patients but it is also argued that frequent sessions are necessary to provide the support which sicker patients require to tolerate the analysis of transference.

While it may be true that for some patients frequent sessions imply support, it may be true for others, as I said above, that frequent sessions imply the dangers of no respite. So too while the couch is ordinarily considered to be conducive to regression it may enable an isolation from the relationship which has a contrary effect. No universal meaning of any aspect of the analytic setting may be taken for granted. It follows that no universal prescription can be given for this or that type of case. One may generalize that analytic work goes better with healthier patients lying down and sicker patients sitting up and with frequent sessions for both kinds of patients but a particular patient may not conform to the rule.

The meaning of the setting must be analysed in each instance. Nor is degree of pathology the only variable which determines a patient's response to the analysis of transference. Apart from pathology some take to it like a duck to water and can work despite infrequent sessions, while others never seem to find it congenial. It would seem obvious that one can accomplish more with greater frequency simply because there is more time to work.

But if greater frequency is frightening to a particular patient, frequent sessions may impede the work despite interpretation. One cannot simply assume that more is better. The optimal frequency may differ from patient to patient. We must not confuse optimal frequency with obligatory ritualized frequency.

The analyst's experience in the setting is likewise an important consideration as well as one which varies from analyst to analyst. It is not only the analyst's character structure which determines how he can work best but his training and habits too. Some analysts say they have difficulty in keeping abreast of the transference in a patient who comes less frequently. Some analysts feel themselves isolated from a patient on the couch whereas others are more comfortable with the usual set-up.

I turn to the matter of neutrality. As Lipton has so well described, neutrality is not a matter of any particular behaviour on an analyst's part but of the attitude with which he conducts the analysis. The argument that psychoanalytic technique cannot be used in the face-to-face position because of the reality cues afforded the patient is a variant of the mistaken idea that it is the external stimulus rather than the patient's interpretation of that stimulus which matters.

Discussions of the issue seem to gravitate to quantitative terms as though there are fewer stimuli if the patient cannot see the analyst. It may be that the patient facing the analyst is exposed to a wider range of stimuli but the patient's response is to the quality not the quantity of stimuli. It is rather that the contribution of the analyst is different in the two situations with concomitant different contributions by the patient.

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The technique requires a stance on the therapist's as well as the patient's part which is significantly different from the give and take of most human relationships. The therapist may find it easier to refrain from ordinary human interaction if the patient is on the couch because the physical arrangement is different from ordinary human interaction. I believe the situation is eased for the therapist by experience in conducting himself this way as well as by really becoming convinced not only that the notion that the transference can develop without contamination is an illusion but also that however revealing he thinks his cues may be they may nevertheless be ambiguous to the patient, especially if the analyst generally does not affirm or deny the patient's conjectures.

I shall not attempt to discuss the complex issues of self disclosure. The difficulty of maintaining neutrality is of course greater in sicker patients whose demands for interpersonal interaction rather than talk are often greater and whose relatively slow change in the therapeutic situation frustrates the therapist's hopes. The very obviousness of the therapist's participation in an interpersonal interaction in such cases has made it easier to overlook the subtler but equally important role played by the interpersonal interaction in the less sick patients.

My position on the intrinsic criterion of resolution by techniques of interpretation alone will be obvious from my earlier discussion. While the more opportunity and the more successful the work the less the role which unanalysed interpersonal effects will play in the outcome, it remains true that unresolved transference and new experience play a role in all psychological therapy.

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I do not have much to say about the experience of the therapist. I believe there is an automatic safeguard in that the therapist is likely to see only that which he is capable of dealing with. At the same time I believe it is an error to teach a beginner to stay away from the transference that he sees. I find the technique easier to teach and learn for beginners than the usual psychotherapy since the usual psychotherapy offers no useable guidelines for when transference should be dealt with and when it should be avoided.

Therapists use the technique to whatever degree their skill and comfort in exposing the transferential significance of the patient's experience of the relationship permits. There is another feature which is considered to be an essential of the psychoanalytic setting if psychoanalytic technique is to be used.

Casi clinici 3: Dora

I refer to the fact that the psychoanalytic process is considered to be possible only if it is open-ended in time. A predetermined limited duration of a therapy introduces many additional issues. I do not know the lower limit in duration for the use of the technique I advocate, but I have used it successfully in once-a-week therapy preset to last no longer than nine months. The assumption that a regression is necessary for analysis is related to another, often only implicit, assumption about the psychoanalytic process which I would like to question.

It is that analysis is a kind of all or none proposition, yielding its positive results only if carried through to the end. It is this belief which may sustain patient and analyst through long periods of apparent stagnation and stalemate, but this belief is often a vain illusion. Freud compared interrupting an analysis to the interruption of a surgical operation.

I suggest, on the contrary, that in the changed way of conducting it which I am proposing analysis may be a process with progressively cumulative benefits, interruptable at various points without necessary loss of what has been gained. It might be argued that with certain kinds of pathology and with limitations of time, useful effects could be obtained by psychotherapeutic methods which would be lost if the psychoanalytic method were used. As with all the issues I have discussed this one too requires much more experience and systematic research.

The technique I advocate would make the practice of someone who sees patients in a combined psychoanalytic and psychotherapeutic practice more integrated and consistent. As of now in such practice the gross and witting manipulation he may permit in his psychotherapy makes it more difficult for him to adopt the frame of mind of searching for even unwitting suggestion in his analytic work, while, influenced by prevailing psychoanalytic technique, his psychotherapy suffers through excess restraint on interaction and interpretation, especially of the transference.

I am in a position now to make a suggestion about a change in the prevailing practice of setting a predetermined limited goal for patients who cannot be seen in the usual analytic setting. Not only do I question the desirability of a predetermined limited goal, but I also question the desirability of a predetermined ambitious goal, which latter can also be characterized as one of the extrinsic criteria allegedly necessary for an analysis. In either case the setting of a goal by the therapist whether explicitly or by implication in recommending either psychoanalysis or psychotherapy as the preferred treatment is a major initiative on his part which, to return to a central theme of this paper, can be experienced by a patient in many different ways.

It may well remain a silent unexplored but influential suggestive and directive context of the entire therapy. There is much to be said for flexibility and delay in fixing a goal, and with continuing examination of implicit references to a goal. Lipton has argued that one of the unfortunate consequences of the division between psychoanalysis and psychotherapy is the effort to set a goal at the beginning by way of a relatively prolonged diagnostic period.

He points out that Freud practised only analysis, whatever the circumstances.

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My opinions about type of case and type of therapist to which, and by whom, I consider the analytic technique applicable obviously have major implications for the economics and sociology of the practice of psychological therapies. These considerations will assuredly make it more difficult for the proposals that I have advanced to be considered on their own merits. Should the use of the technique I describe in less than the optimal setting for an analysis still be called psychoanalysis?

There is a difficult terminological problem here. Other things being equal, obviously an analysis conducted at lesser frequency and for a shorter time cannot accomplish what otherwise could be. There ought to be different names for an analysis carried through as fully as it could be and one which is partial and incomplete. The name psychoanalytic psychotherapy should be reserved for a technique which does not deal with the transference in the way I have suggested is the essential criterion of analytic technique. If a therapy which uses analytic technique with less than optimal extrinsic criteria and without the intention of going as far as one could be called neither psychoanalysis nor psychoanalytic psychotherapy, what should it be called?

Perhaps it will be time enough to worry about the name if my overall argument gains some acceptance. For a further discussion of terminology see Gill A history of this paper will help the reader to set it into perspective. Although it was originally hoped that the three presentations and discussions would be published as a unit, that never came to pass.

Rangell's paper was delivered from notes. Stone's paper was not published as such but its essential contents have been published in two papers. Impact on Psychoanalytic Training , edited by E. International Universities Press, My own paper is now being published for the first time in a revised version. The present version has therefore had the benefit of these criticisms, so I do not know whether they would consider that their criticisms still apply.

The difference between the present paper and the one originally read rests upon what I believe is a significant improvement in my presentation of my understanding of transference since the time of the original paper. I consider transference to have two sources of determinants which are separable only conceptually and misleadingly even then: As for the actual situation, one must distinguish between its description by an external observer and how it is experienced by the patient.

The transference is the expression of the simultaneously active pre-existing patterns and the experience of the situation and is thus an indivisible unity. Nevertheless one can assign different weights to the two sources. In the constructively proceeding analytic situation the weight falls on the first source and one can refer to the relationship between the two sources as the way in which the analytic situation influences the specific manifestations of the transference.

If one wishes to emphasize the two sources equally one can formulate the transference as co-determined by the two sources. This latter formulation, however, may imply a greater degree of involvement on the part of the analyst than most analysts would accept as descriptive of a constructive analytic situation. It would be desirable to have a general model which would not make a prior commitment to the relative role of the two sources. In that case one could formulate the transference as the resultant of the two sources.

The original version of this paper was written in the perspective of the formulation of the two sources as co-determinants. The present version is largely written in the perspective of the transference as the specific manifestation of the first source as influenced by the second. The reason for this shift is a recognition on my part that the first version was written in the context of the assumption that the analytic situation usually includes a contribution from the second source which is greater than is usually acknowledged.

I still consider that to be true but because the essential point of the paper does not rest on that conviction and in deference to the usual assumption that transference should be defined in terms of the ideal of a constructive analytic situation, I have written this version in accordance with that latter assumption.

I will elsewhere attempt to explicate further the three possible formulations, namely the two contrasting biases and the formulation which attempts to state a model which avoids either bias. I would like to express special thanks to Stanley Goodman, M. The increasing recognition that all aspects of the analytic situation are contributed to by both parties, in however varying proportions, must be taken into account in conceptualizing crucial psychoanalytic concepts like transference, free association, regression and the role of the experience of the relationship.

This recognition highlights the role of unwitting suggestion in all psychological therapy. It suggests that rather than by criteria of the setting, psychoanalytic technique may be characterized not only by the avoidance of witting suggestion but also by the analysis of both witting and unwitting suggestion and thus distinguished from psychoanalytic psychotherapy. Psychoanalysis and psychoanalytic therapy then become more dichotomous than continuous and the range of applicability of analytic technique, even if in the pursuit of only a partial and incomplete analysis, can be broadened in terms of frequency of sessions, recumbency, pathology, and experience of the therapist.

In consideration of the possibility that analytic technique in such broadened circumstances may fail to include an induced regression, the role of unwitting suggestion in such induced regression is pointed out and the question is raised whether such regression beyond what the patient brings to the therapy is a desirable and necessary part of an analysis. Some quantitative aspects of psychoanalytic technique.

Discussion of paper by M. Transferenece regression and real experience in the psychoanalytic process. Panel on conceptualizing the nature of the therapeutic action of psychoanalytic psychotherapy Nemetz J. Problems of Psychoanalytic Technique. The Psychoanalytic Quarterly Inc. The Gorham Press, , pp. The Development of Psychoanalysis. Nervous and Mental Disease Publishing Co.

Discussion of the widening scope of indications for psychoanalysis. Boringhieri, The interpretation of dreams. Frammento di un'analisi d'isteria Caso clinico di Dora. Boringhieri, Fragment of an analysis of a case of hysteria. Osservazioni su un caso di nevrosi ossessiva Caso clinico dell'Uomo dei topi.

Boringhieri, Notes upon a case of obsessional neurosis. Boringhieri, The dynamics of transference. Nuovi consigli sulla tecnica della psicoanalisi: Boringhieri, On beginning the treatment. Il problema dell'analisi condotta da non medici. Conversazione con un interlocutore imparziale. Boringhieri, The question of lay analysis. Psychoanalysis and exploratory psychotherapy.

The analysis of the transference.

The Analysis of Transference. Teoria e tecnica dell'analisi del transfert. The interpersonal paradigm and the degree of the therapist's involvement. Il paradigma interpersonale e ila misura del coinvolgimento del terapeuta. Psicoterapia e scienze umane , , XXIX, 3: The range of applicability of psychoanalytic technique. Tendenze attuali in psicoanalisi. Analytic Press Italian translation: The Technique of Psychoanalysis.

La tecnica della psicoanalisi. The patient as interpreter of the analyst's experience. Il paziente come interprete dell'esperienza dell'analista. Psicoterapia e scienze umane , , XXIX, 1: Transference problems in the psychoanalytic treatment of severely depressive patients.

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