Psychoanalysis from the Inside Out: Developing and Sustaining an Analytic Identity and Practice
Author: Lena Theodorou Ehrlich
Editor: Routledge, London & New York, 2020
A spirit of conviction, optimism, and psychoanalytic discipline flows through the pages of this book. Offering a studied counterpoint to certain defeatist currents that undermine psychoanalysts' confidence that they can practise analysis, L.T. Ehrlich challenges the defensive externalisations that attribute our difficulties to external factors, and shows us how the possibility of practising analysis depends, in large part, on ourselves and how we work.
Previous work on the subject
Numerous authors have addressed the issue of how to create the conditions that facilitate the patient's desire for analysis, see: Bassen, C. 1989; Lichtenberg, J. & Auchincloss, E. 1989; Bachrach, H. 1990; Bernstein, S. 1990; Brenner, C. 1990; Jacobs, T.J. & Rothstein, A. 1990; Rothstein, A. 1994; Busch, F. 1995; Rothstein, A. 1995; Rothstein, A. 1998; Grusky, Z. 1999; Bernstein, S.B. 2000; Gann, M.F. 2000; Glover, W.C. 2000; Poland, W. 2001; Jordan, L. 2002; Frank, K.A. 2004; Levine, H.B. 2010; Reith, B. 2010; Vermote, R. 2012; Wille, R. 2012; Kravis, N. 2013, among others.
They are joined by the members of the Working Party on Initiating Psychoanalysis of the European Federation of Psychoanalysis, whose is precisely that, and they have published two excellent books on their findings over more than ten years of research (Reith, B. Lagerlöf, S. Crick, P. Møller, M. Skale, E. 2012; Reith, B. Møller, M. Boots, J. Crick, P. Gibeault, A. Jaffè, R. J. Lagerlöf, S. Vermote, R. 2018).
However, few individual analysts have devoted such comprehensive and methodical attention to the subject as the author of Psychoanalysis from the Inside Out, who has been publishing articles on it since 2004, progressively refining and deepening her thinking (Ehrlich, L.T. 2004, 2010, 2013, 2013, 2016, 2017, 2019).
In the introduction she says: "I felt compelled to write this book for two main reasons. First, as a psychoanalyst, because I am determined to identify the obstacles that prevent analysts from practising more and better analysis. Second, as someone who has benefited from psychoanalysis as a patient, I want analysis to remain available to those who need it. I am therefore interested in countering the tendency I see in myself, and in other analysts, to attribute reluctance to indicate analysis to patients' lack of interest in intensive treatment."
The author sets out her thinking in clear, jargon-free language, delving into the many facets of the problem, and demonstrating the courageous reflection of an analyst in constant flux, always ready to question herself and ask difficult questions. To illustrate her thesis, she provides nine clinical examples of her own cases, as well as supervisory cases, which give an account of the complexity of the factors she takes into account, and of the obstacles she has encountered in her practice. Written with a level of honest detail that does not abound, the cases allow us to see the author's doubts, fears and countertransferential vicissitudes, step by step, and their elaboration. This honesty in talking about her own internal difficulties in creating an analytic identity is one of the most attractive features of the book, and offers a model of self-analysis that should inspire all clinicians and especially young analysts.
L.T. Ehlrich takes a close look at the protean and inevitable internal resistances against analysis, more or less preconscious, of all psychoanalysts. Resistances that manifest themselves in every analysis that might begin, or that is in progress, regardless of the analyst's degree of experience, or of his or her apparent conscious desire to do analysis. The essence of the book is to show us how, if we anticipate, identify and analyse these resistences systematically, paying close attention to them, it opens up the possibility of transforming what might appear to be seemingly insurmountable obstacles into valuable analytic material.
Psychoanalysis from the Inside Out does not deny external reality; it frankly acknowledges the difficulties psychoanalysts may face: (a), a public opinion that perceives analysis as a never-ending, ineffective, self-indulgent, and exploitative treatment; (b), a multitude of competing theories about the mind and therapeutic action; (c), a lack of consensus about which analytic instruments lead to the best results; (d), the tensions of belonging to fractured psychoanalytic institutions; and (e), how demoralising it can be to frequent colleagues who have had traumatic personal analytic experiences, becoming cynical or hopeless.
Having acknowledged external reality, and the difference between practising analysis now and practising it in the 1960s, the author proposes to focus our attention resolutely inwards.
Finding ourselves as analysts
In the first section of the book, the author explores how one variable, the analyst's reluctance to begin a new analysis, affects analytic practice. She does not pretend to deny the adverse role of external realities, but suggests that analysts can use external realities to obscure this reluctance.
She asserts that one cannot think about the doubts we may have about the value of analysis, nor our ability to practice it, without considering the overriding influence of our own analyses: the idealisations and disappointments we have gone through, and the rivalries with our analyst(s). From the outset the indication of analysis is infiltrated by desires and fears, both realistic and infantile, on the part of the patient and the analyst, and can create a collusion between the analyst's ambivalence and the patient's apparent unwillingness to commit to an analysis. It is incumbent upon us to consider that not making an indication for analysis may be an enactment, a co-created resistance between patient and analyst.
This reluctance of the analyst can be thought of from several different points of view: as a response to the intense countertransferential affects mobilised during the encounter with the patient, as a co-created enactment, or as a manifestation of the analyst's unconscious conflicts. If these factors are not taken into account, it is easy to fall back on the reality of an environment that is adverse to long-term treatment to rationalise our reluctance to bond strongly with patients in analysis. The author argues that the analyst's counter-resistance is ubiquitous in all treatments; whether it becomes an interference, or an aid to beginning the analysis, depends on our ability to anticipate it and recognise how it manifests itself in relation to a specific patient.
In her own work, and in observing the work of others, the author concludes that the analyst must do a lot of inner work at each step of the interviews for an analysis to begin. Ultimately, the analysis begins in the analyst's mind. In the first interviews she is particularly attentive to everything she thinks or feels in relation to the patient, and especially alert to any discomfort she may feel in herself, or in the patient, however minor.
With characteristic rigour, she lists five aspects of the analyst's inner workings in facilitating an analysis - I will leave it to the reader to discover them for themselves - and reminds us that almost all patients enter treatment defending themselves by minimising their need for help; the analyst must create a space in his mind that allows him to appreciate the deep need, and the (strongly counter-invested) desire, for intensive help.
One might wonder why the author places so much emphasis on one therapeutic modality, analysis at a high weekly frequency. She replies: "I recognise that although analysis is less practised, has more modest results than was intended when it was idealised, and is an expensive, difficult and impractical treatment, it remains, at least for the time being, the best chance for those who desperately need it".
Developing the capacity for deepening an analysis
In this section, the book addresses the question of institutional transmissions, of how to help candidates transform difficult challenges into opportunities.
It considers that in training candidates it is essential to help them understand that their desires to help patients, and themselves, with analysis are accompanied by equally strong fears of entering into such an intense relationship with a patient. It is essential to face the uncomfortable paradox that candidates, while consciously determined to help their patients, are also afraid of the degree of emotional closeness necessary to develop and maintain an analytic identity. She warns us that, if we avoid this paradox, and do not approach the difficulties of our analytic functioning as symptoms with meanings that need to be understood, we will not be able to find a place in our minds to think analytically and practice analysis.
Some analytical educators suggest that given the widespread difficulties candidates have in finding cases, the demands on the frequency of weekly sessions could be reduced. The author disagrees. She suggests that an understanding of the challenges of initiating an analysis, and the importance of transference-countertransference as an avenue for understanding the analyst's difficulties, should be reinforced in both teaching and supervision. The author proposes that those training analysts who recognise their anxieties about becoming intensely attached to patients, and know how these anxieties manifest themselves in their reservations before indicating an analysis, may be able to offer more help to candidates.
Having observed how often there is discouragement and pessimism about the possibility of starting new analyses among members of analytic societies, the author argues that they need to be addressed directly. She suggests that a process of peer support be undertaken among the Institute's faculty, offering seminars, study groups, and peer supervision groups, in which, using detailed clinical material, members help each other to be in affective contact with the terrors and storms experienced at the beginning of each treatment. L.T. Ehrlich believes that only teachers who are sensitised to their own anxieties about indicating analysis can help candidates to be connected to their own.
With an elegant counter-intuitive twist, the author argues that now is, in fact, the best time to become an analyst. In an era of uncertainty about the structure of our organisations, and of widespread doubts about the usefulness and efficacy of analytic training and practice, L.T. Ehrlich invites us to see this uncertainty and self-questioning as fertile ground for the development of creative, independent-minded analysts. Today's analysts cannot rest on the laurels of the golden age of analysis, where analysts' ambivalence about practising analysis was easily placated by the popularity of analysis, and the many patients who asked for it. Today we have to work and re-work our own fears and reluctance to connect with our inner lives and those of patients, so that we can find the courage, hope and determination to use our minds analytically, perceive patients' needs and help them intensively.
This chapter, originally published as an article in the Journal of the American Psychoanalytic Association in 2019, has taken on a remarkable relevance since the advent of SARS-CoV-2.
In the author's view, the assertion that distance analysis is a priori defensive fails to account for the fact that patients seek teleanalysis for a wide range of reasons, not just defensive ones, and defensive reasons, if indeed present, can be analysed. Although some patients may seek teleanalysis primarily for defensive reasons, such as a need to maintain a fierce distance, only teleanalysis offers a sufficiently flexible framework to contain it and, in time, to be able to analyse it.
The author considers that the question to be asked is whether the analyst and the patient are able to create a good enough frame, and work analytically during teleanalytic encounters. She argues that if teleanalysis is practised with an analytic mindset and an analytic frame it can offer rich opportunities for patients to receive analytic help. Teleanalysis will not destroy analysis if analysts practice analysis within an analytic frame. Recognising how analyst and patient use physical distance to create emotional distance offers valuable analytic information. When considered analytically, the affects and thoughts that distance evokes are not insurmountable obstacles.
However, the author does not believe that every analytic couple should engage in teleanalysis. When both patient and analyst propose teleanalysis for reasons of convenience, it is a departure from uncomfortable unconscious truths that need to be identified and understood.
It takes three to know one
L.T. Ehrlich has observed in herself, as well as in experienced and committed colleagues, the need for regular help in dealing with the onslaught of conflicting and traumatic affects that are inherent in intensive analytic work.
She evokes the issue of the more or less acknowledged stigma of consulting with a colleague. In her experience, many analysts still find it difficult to integrate into their ego ideal the inevitability of their affective involvement, and unconscious participation, in every analysis, with the resulting complications for that analysis. She notes that there seems to be a fantasy that once we have completed our training we no longer need help. The author observes, after more than thirty years of practice, that blind spots and chronic enactments, as well as denial of their existence, have been part of every analysis she has heard, regardless of the experience and skill of the analyst. This has led her to conclude that analysts need to present their work frequently in order to be alert to, and make use of, pervasive interferences to analytic work on the part of the analyst.
Consulting with a colleague serves multiple functions: to make better use of our countertransference in order to have greater access to the patient's suffering; to identify alternative meanings, and not to fall in love with our own ideas or interpretations; to sustain our optimism about the usefulness of analysis; to be alert to our narcissistic vulnerability, and to the regressive calls inherent in any analytic dyad; and, finally, to improve our capacity for supervision.
In the author's opinion, although we may call analysis the impossible profession, many of us have not fully accepted the enormity of the emotional demands to which our work subjects us. In her experience she sees that she was little helped by presentations, private talks and publications where experienced analysts did not talk about their difficulties or failures, but rather presented highly edited and sanitised versions of their work, which had little to do with what she knew of real psychoanalytic practice.
She acknowledges that consulting regularly involves sharing flaws and vulnerabilities, which generates resistance, and comments on how some colleagues have expressed concern about adding even more commitments and work to their lives if they also consult with colleagues. L.T. Ehrlich states that her experience is the opposite: analysts are excessively burdened with their countertransference, and with the guilt of their unconscious collusions in analysis. Consulting with a colleague relieves this burden, and frees them to do more analytic work.
By way of example, the author generously shares her own experience: she currently consults individually with two colleagues in other cities twice a month, participates in two clinical study groups, a local one that meets monthly, and a national one that meets two full weekends a year.
After reading this book, some readers may wonder why, given resources such as this book and its author, decisions are made that reduce the demands of training instead of taking advantage of our good fortune to have the expertise of colleagues whose specific knowledge could help us to solve our difficulties with psychoanalytic tools.
Psychoanalysis from the Inside Out is valuable reading for any psychoanalyst who wishes to practice high-frequency analytic treatments (and is encountering difficulties in doing so). Furthermore, in the opinion of this reviewer, the analytic confidence and depth of knowledge that this book harbours is an invaluable contribution to the training of candidates. Psychoanalysis from the Inside Out is destined to become a little classic.
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