Prologue: Psychoanalysis Combined with Other Modalities

Complex clinical situations pique all of our interest. Debates that we have all engaged in – such as how to distinguish psychoanalysis from psychoanalytic psychotherapy – fade in the face of clinical urgency, as we struggle to intervene most pointedly and with enduring efficacy. Take the following recent dilemma I wrestled with:

My patient Gail, a forty-year-old school teacher, pages me on a Sunday evening. When I call her back, I can’t hear her voice, only rapid heaving through the phone line, and I can almost feel her cold sweat moistening my ear pressed to the phone. At first, she can’t string together a coherent sentence to explain why she has called. But I know her well by now, and I know how our Friday session has gone: recognition of her mother’s basic limitations; a sense of panic as she recalls her confusion about whether she could go to her mother for refueling when she was a toddler. She could almost remember formulating these questions back then: “Could you soothe me? Could I tell you something about my needs? Are you going to whisk me away? Why did you throw away my favorite soft giraffe that had gotten dirty?” And her then wondering if she could trust me: “How are you different from my mother? Why is it that you seem credible for long stretches of time, but then the trust disappears in an instant when you misunderstand what I am trying to tell you or you leave me for a weekend?”

So, informed with the knowledge of our Friday exchange, and recalling previous similar phone conversations, I begin to talk into the phone. “You sound panicked Gail. I know when you’re like this, you aren’t able to tell me what’s wrong. Maybe hearing my voice will help – sometimes it does. I can only imagine that something has gone wrong over the weekend, maybe together with your confusion on Friday.” Over a few minutes, with some reassurance and tentative suggestions on my part about what may have been confusing about my resembling her mother on Friday, Gail begins to breathe more slowly. Is it my voice that has soothed her, or is it the actual content of what I have said? Gradually, she describes a dream on Friday night in which she was reading safely in a small nook, sensing my protective presence, only for it to disappear, with a sense of her menacing mother hovering around her, unseen and scarily felt, ruining her safe reading space. She goes on to tell me that then on Sunday, her childhood friend abruptly canceled their museum plans without recognizing the impact of it, abandoning her to her husband, who also didn’t understand what was the big deal. Now, she wasn’t sure she could leave her home the coming week, as she felt she needed to hide in the safety of her familiar rooms, uncertain about the risks of attending our three sessions, including the one scheduled for Monday.

We agree to touch base on Monday morning. She calls and leaves a coherent message, saying she will see me at 2:00. When we meet, Gail is impeccably dressed and has a serious expression on her face – as usual – and starts describing the events of a difficult weekend: doubts after Friday’s session, a disturbing dream, an unfortunate rejection by her old friend Judy. I realize over the course of our first minute together, with creeping alarm, that she does not remember our speaking the night before. So I ask what she remembers about Sunday night. A slow look of recognition, then embarrassment, then horror comes over Gail, and she says, “I remember that we spoke. I’m hazy about it, though. What did I tell you? I was scared, I remember that.” I establish that there was no alcohol on Sunday (sometimes there is). Slowly, during that session, with a Gail that is an amalgam of mortified, perplexed, and shaken, I piece together the events of the weekend, now with greater detail and discrimination of her affects.

I have several problems. First, Gail’s panic attacks. The dynamics are pretty clear to me, and they are becoming clearer to her: a disorganized attachment to her mother has been replicated within the transference relationship, and there is a confluence of (a) a difficult session in which Gail wavers about whether I am trustworthy; (b) undifferentiated maternal/new objects in a dream; (c) a rejection by an alleged trusted friend; and (d) a semi-rejection by her unpsychologically-minded husband. Gail has a panic attack triggered by old and new abandonments. These panic attacks have been occurring with increasing frequency, now four years into her three times weekly psychoanalytic psychotherapy conducted with her sitting up, as early developmental memories have become searingly accessible to her. I tried several medications that could be ameliorative at the beginning of the therapy, but side effects aborted those trials. I know Gail is leery of other possible pharmaceuticals. She has been a student of meditation and mindfulness exercises, and these haven’t helped. What else should I consider to buffer her rushes of affect, particularly when they occur outside of sessions, and especially when I cannot return her phone calls immediately? Or should I stick with traditional technique as per the internalized voices of my esteemed supervisors, given that regressive material has been evidently rising to the surface for constructive understanding and integration, the goals of depth treatment?

I have another problem here. Gail doesn’t seem to remember with continuity what happened between Sunday night and Monday afternoon. I cannot attribute the disruption to alcohol. I’ve had a gnawing feeling for the past year or so that there have been other discontinuities of time and sequence, but this is the first clear-cut example that she has confirmed. She has not suffered physical or sexual abuse early in her life – at least not that we’ve discovered thus far. And the disruption to her ego functioning, which had been resilient prior to treatment, has only occurred within the gradual reconstruction of her early relationship with her mother, a woman who suffered her own serious losses and traumas, a woman overwhelmed by raising four young children close in age, a woman with a hot temper, and without natural attunement capacities to serve as a foundation for her caretaking. So, under the pressure of this regressive treatment, which I have been confident would give Gail the best opportunity to heal, she is crumbling.

So what are my therapeutic options? Should I explain that we have uncovered feelings that are too overwhelming too quickly, and recommend that we decelerate this treatment approach? Should I turn to interventions that will solidify her ego functioning, especially for application between sessions when I am not with her? What about focusing on some other way she can conjure me up between sessions as a kind of transitional object that is sufficiently differentiated from her mother and that she can hold onto? Or what about a referral to a different psychiatrist for medication management of her panic? Would this be too scary, or more likely, would this be experienced as a rejection, leading her to say: “so you, like my mother, can’t handle my strong feelings?” And finally, perhaps most important, what about the fact that we’ve entered the territory of a traumatic transference experience (see Vivian Dent, this Inquiry issue), in which intense overlap between me and her cold, erratically available mother has resulted in her questioning how safe she is with me? What alterations, if any, should I initiate to my therapeutic stance if this therapy is to continue beneficially for Gail?

From the perspective of hoping to illuminate the efficacy and limitations of the analytic approach, and from the perspective of hoping to address some of these limitations (Akhtar, 2000, 2012), I am struck by the advantage of having a greater diversity of tools for use in these situations. I have the sense, from informal conversation with colleagues, from hearing cases presented, and from review of the literature, that I am not alone. No single approach, especially when we treat patients over a long period of time, and especially when we treat patients who fall within the “widening scope” (Stone, 1954), is likely to be sufficient for a successful outcome. I have the sense that surrounding the subject of emotional trauma – as described beautifully by Vivian Dent in this issue – we are at great risk of replicating an early traumatic object relation if we adhere too closely to somewhat traditional approaches. As Vivian writes, it may be necessary technically to concentrate on conflicting “parts” within the patient before new relational learning can become the focus of the treatment.

The contributions in this issue address a range of clinical situations that can be divided into several categories: patients too acutely symptomatic to begin in-depth psychotherapy; patients whose defenses do not permit exploration; patients whose exploratory trajectories have been derailed or stalled, for a variety of reasons; and patients with early developmental trauma, who might fit into the above categories, and may require additional special technical management. On one hand, the traditional psychoanalyst could think about “parameters” (Eissler, 1950), or “supportive interventions” (Killingmo, 1989), which describe non-interpretive approaches to patients. On the other hand, novel approaches (Akhtar, 2011) – including techniques borrowed from other disciplines – may be indicated. For example, Jill Bresler takes us through several forms of mindfulness with her obsessional patient Sara, who is initially unable to use the standard relational analytic approach because of her rigid defenses; Lisa Lyons introduces dialectical behavioral therapy to Barry, who is too acutely self-destructive to embark on exploratory introspection; Vivian Dent plays “pillow catch” with a patient to help her patient modulate feelings that are too overwhelming for discussion early in treatment; Marie Hoffman adds prayer to buttress her tempering of Rachel’s bad internalized objects; and I add group therapy to Robert’s analysis when our work on the sibling transference is unable to deepen. One way to synthesize these efforts is to say that the authors are thinking outside the box: some patients need engagement at the level of their acute psychological symptoms as preparation for in-depth work, some need to speak through their bodies before speaking with words, some need a new plane of entry when the discourse has led to a stalemate, and some need the analyst to move out of the way – for a while – if an early traumatic attachment has been replicated.

I hope, through our authors’ sharing their clinical dilemmas with our readership, to continue the dialogue of how best to help our patients. I think such a dialogue requires that we flesh out modalities unfamiliar to most psychoanalysts, and pinpoint when and in what circumstances they might be indicated. Although such a protocol could be conceived through research, I think the complexities of such a program make it more likely that we will begin to stitch together such an approach through clinical reporting, and has been our recent legacy, through correlation with child developmental observation. I am indebted to our authors and their patients for inviting us into their consulting rooms for such important collaboration.

Andrew I. Smolar, M.D.

Issue Editor