Sunday, November 25, 2012

The Nature of Determinism - The Reluctant Psychoanalyst Leads a Case Seminar

Presenting our clinical work to others is one of the most terrifying, and sometimes fun things that we analysts do.  There is a nakedness when we do this.  We are showing our work, and, while there will hopefully be moments where others appreciate and understand what we are doing, there will almost inevitably be criticism, which is hopefully presented in the spirit of being constructive, but exposes areas we have not thought of, interventions we did not make, and ways in which we have somehow failed the people, our patients, about whom we deeply care and whom we are invested in  helping.  Presenting our work to our peers can, thus, be terrifying.  I believe that the experience of presenting to our peers is parallel to the terror our patients feel when they are in a psychoanalytic - or, indeed - any exploratory therapy session.  The experience of terror is manifold, and I want to address one layer of it, though there are certainly many others.  When I ended my own analysis, I was flabbergasted at the amount of energy that I had.  On reflection, I surmised that one aspect of the increase in energy was that - though I consciously felt like I had settled into my analysis and had woven it into the context of the rest of my life - in fact, I think that I was girding my loins on a daily basis - preparing to see and be seen in a more naked and raw form, and that this was psychically expensive.

This week I substituted as the facilitator/teacher/supervisor in an ongoing clinical case conference.  The presenter was describing work that she was doing with a man, a man who had considerable difficulties and a man whom she was just beginning to get to know.  I noticed that the therapist and the man were working together to understand the man and how he functioned.  That is, the therapist would offer an interpretation of how the man had engaged in a particular action and she and the man together would evaluate how it is that he had done that.  The group, too, was engaging with the therapist in this way - how can we understand this man.  On the surface, this was a very psychoanalytic process, both between the therapist and the patient, and in the collegial interaction that the seminar participants were having with each other.  What, it can seem, could be more analytic than to be trying to understand what is causing a series of behaviors on the part of a client?  But I found both the clinical material and the discussion to be frustrating.  I felt, somehow, that we were missing something in the consulting room and now in our meeting room by focusing - I think prematurely - on the root causes of the behavior.

As I thought about it, and then talked about it, I realized that my frustration was based in part on the fact that we did not have access, in these interactions, to the man's feelings - to what his direct experience of the moment and of the world was.  I felt that the therapist's focus on the dynamics that were underlying the interactions the man was having felt premature or even defensive to me.  When I presented this position, there was some sense that it made sense and then we worked to try to get an understanding of why the therapist was working in this way (OK, I guess it's just what psychoanalysts do...).  I quickly realized, and pointed out to the group that we were again engaging in the same activity, but now it was taking place between the therapist and me.  That is, we were wondering about what the dynamics were that were leading the therapist to wonder with the patient about what was causing his behavior.

I asked the group and the presenter if we could try to approach the material differently.  I then asked her what she was feeling in the room.  She said that she wasn't sure, but she thought that she was feeling terrified.  This man she was treating was potentially suicidal and was alienating people who were important to him at work.  She wanted to support him so that bad things didn't happen.  She had, very early in the hour, offered a summary statement of some material that the patient had presented, and he experienced her observations, which the group did not see as deep at all, as coming in from left field - specifically he was relating what a person had told him and the content of that included a brush off.  When the therapist noted the brush off, he was surprised by it - he hadn't heard it and further was a little puzzled by how the therapist had heard it in that way - again something that was obvious to all of us in the room as a brush off.

So, as we talked further, it became clearer that the therapist was terrified not just of the circumstances surrounding this particular hour, but perhaps of the patient's demonstrated inability to accurately perceive and make use of information that others provided in emotionally charged interactions (as a therapy hour can be).  To allow him to describe his experience of the world can, then, become scary because we are moving further and further from what moors and tethers us to the world.  It felt like it would be better - meaning safer, and more supportive, to tell him about this world - through interpretations and through working with him to create a shared understanding of how he operates than to simply listen to his distorted understanding of the world, not knowing just how badly distorted it is.

This was a new understanding of what the therapist had been doing with the patient.  It was based not on her articulation of what she intended to be doing, but on discovering what was occurring - at least partly unconsciously - between the two of them.  Moving from the conceptual to the concrete, and simultaneously moving from the intellectual to the emotional, with the therapist trusting that this would be helpful, allowed us to think differently about what was taking place in the consulting room, and allowed something different to happen in the room between the therapist and I.  We had a new, shared understanding of what had happened, and we were more directly engaged with each other.

At this point, one of the participants asked a question that is typical for case conferences.  "So, what would you have done differently."  I was stumped.  I didn't have an answer, and I thought it would be unkind to offer an alternate way of intervening.  But the real reason for my being stumped didn't emerge until after the case conference.  And that was, there was no other way for the therapist to have intervened.  Given who she was, and who the client was, at that moment she did the best that she knew how to do.  She may have thought about other options - don't we often do that when we are engaged in any kind of conversation - but she could not, I don't believe, have said anything other than she did.  That is the nature of psychic determinism.  We do what we are determined to do.

This then, becomes the reason for a consultation or for a supervision session or for reading about the analytic process.  By engaging with other sources, we expand the possible ways of intervening.  The question is not what I would have done differently in that session, but what the analyst has available to do in the upcoming session that she might not have had before.  Will she be able to feel less tied to figuring everything out and be able to float a bit more on the sea of this man's thoughts?  Will that prove useful or it will it unmoor him and her?  Does he need the kind of work that she is doing with him?  Will this become apparent to them if she let's loose of the reins a bit?  Or might he become better able to describe his world when he is less worried about making sense of it?

It might seem that some of the questions in the last paragraph are rhetorical - as if I know what the answer is and am asking to make some kind of point.  In fact, I intend them as actual questions - questions that will, depending on what emerges from the interaction between the analyst and analysand if the analyst does engage differently, inform the analysis as it moves forward in an iterative process.

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