If I omit discussing Anne-Marie Sandler’s “The Past Unconscious
and the Present Unconscious,” an excellent summary of the work she and Joseph Sandler produced, it is not that it should be neglected. I do, though, have to mention my disappointment that this paper and Rizzuto’s are devoid of references. That said, this volume overall will stimulate readers to follow up on further work by the contributors, and not least on the work of Jacqueline Amati-Mehler.
REFERENCES
Amati Mehler, J., Argentieri, S., & Canestri, J. (1990). The Babel of the unconscious. International Journal of Psychoanalysis 71:569–583. Bion, W.R. (1991). A Memoir of the Future. London: Karnac Books. Fonagy, P., Gergely, G., Jurist, E., & Target, M. (2002). Affect Regulation, Mentalization, and the Development of the Self. New York: Other Press. Rand, H. (2000). Who was Rumpelstiltskin? International Journal of Psychoanalysis 81:943–962. Searles, H.F. (1962). The differentiation between concrete and metaphorical thinking in the recovering schizophrenic patient. Journal of the American Psychoanalytic Association 10:22–49. Segal, H. (1950). Some aspects of the analysis of a schizophrenic. International Journal of Psychoanalysis 31:268–278.
Siobhan O’Connor 850 Harrow Road London NW10 5JU, UK E-mail: [email protected]
____________ ____________ Coasting in the Countertransference: Conflicts of Self Interest between Analyst and Patient. By Irwin Hirsch. New York: The Analytic Press, 2008, 240 pp., $34.95. DOI: 10.1177/0003065109336662
Irwin Hirsch’s book explores a group of analytic impasses that are well captured by his title, Coasting in the Countertransference. Coasting takes place when the analyst chooses “comfort or equilibrium over creating useful destabilization . . . at some cost to patients” (p. 2). Hirsch is candid to a fault as he delves into several categories of such analytic pitfalls. His observations will be challenging and thought-provoking for all readers. I
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came away with great respect for his analytic acumen and his capacity for relentless self-scrutiny. In his second chapter he examines “situational factors” that may limit the analyst’s optimal emotional availability to the patient. Illustrating his point with one of his early cases, he shows that the analyst’s personal loneliness may help create “dependent and crisis-oriented patients” (p. 34). He suggests that we can extricate ourselves from clinical impasses once we are willing to “abandon preferred relational states that have cre- ated comfortable mutual equilibrium” (p. 38), and then “introduce a somewhat different mode of relatedness” (p. 192). He wonders “how much sexual transferences to us are stimulated by our efforts to develop these desires” in the patient (p. 42). All too often, I suspect. Another astute insight is Hirsch’s point that an impasse may arise when the analyst’s theory has an all-too-comfortable fit with the analyst’s personality. Ernst Ticho noted, by contrast, that analysts may conversely select a theory to restrain troubling elements in their personalities. For example, Anna Ornstein once quipped, “If anyone needed a theory of empathy, it was Heinz [Kohut].” Hirsch usefully reminds us that “Ferenczi and Rank sharply criticized clinical psychoanalysis for becoming exces- sively dominated by theory” (p. 109). Although he is a respected relational analyst, Hirsch argues that relational theory may lead analysts to discour- age exploration of the patient’s anger. Lest this appear to be an anomalous lapse in his group loyalty, note that Hirsch also tells of a colleague who felt profoundly disappointed in his relational institute and training analysis, but later felt “liberated” (p. 124) by a second, classical personal analysis. Hirsch’s openness won me over, after his summary of a case he felt he handled poorly, with the candid admission “I think this is about the worst I’ve done in an extended treatment” (p. 62). I also value his advice that, when we realize we are “coasting” with a patient, we may get things back on track by addressing the patient’s interactions with us in the here and now. I wish he had connected his insights on coasting with Strachey’s classic work on the therapeutic action of psychoanalysis. Strachey (1934) wrote brilliantly about analysts’ avoidance of making transference interpretations because “the analyst is exposing himself to great danger in doing so” (p. 158), making himself the target of the patient’s now released impulses. Hirsch’s ruthless candor and introspection naturally encourage the reader to speculate about his possible blind spots. A prominent theme in the book is envy and competition. Throughout the book, Hirsch fre- quently draws attention to his enviably full practice. He acknowledges his
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competitive feelings toward patients who surpass him in wealth and life- style. However, the only time I noticed that he admits he envies fellow analysts was when he was abroad and envied German colleagues for their generous insurance coverage for analysis. All this makes me wonder if Hirsch tries to contend with some of his envious feelings by inducing them in us, his readers and colleagues. This might help explain why he keeps reminding the reader how busy his practice is. He discloses that he is an only child. I wonder if his lack of sibling experiences might contrib- ute to his implication that patients must vie with their analytic “siblings” for the analyst’s all-too-limited emotional resources, in a game of musical chairs that dooms some to failure (Waugaman 2003). Hirsch seems idiosyncratic in his condemnation of clinical practices by his colleagues that, according to him, “fall closer to ethical borders” (p. 173). Unless he means closer to being ethical—which I doubt—I am surprised that he is so judgmental about seeing patients less than once a week; seeing patients for ninety-minute sessions; and having telephone sessions with patients. To his credit, he admits that his motives in criticiz- ing such practices might be “to shade my own selfish behaviors” (p. 173)—that is, “coasting in the countertransference.” And I strongly agree with him that phone sessions are best avoided, since they “represent golden invitations for withdrawal” (p. 63). When Hirsch lists analysts whose writings have inspired him, Harold Searles comes first. Searles’s work indeed offers many commonalities with Hirsch. For example, Hirsch notes that “there is always a danger that we [therapists] accent our patient’s problems in order to enhance our own comparative sense of esteem” (p. 147). Searles went still further, arguing that therapists have an unconscious need to keep their patients ill, in order to project their own disavowed psychopathology onto their patients. Hirsch focuses so exclusively on the danger of emotional withdrawal from the patient that the reader will naturally wonder about the opposite risk of overidentification. Hirsch briefly discusses some “pitfalls” (p. 74) of the analyst’s excessive emotional availability—e.g., it may be infan- tilizing and create excessive dependence in the patient; it may increase patients’ guilt about their selfishness and “darker sides”; and it may inter- fere with a patient’s preference to be more remote from the analyst. I would add that, as analysts increasingly recognize and work with post- traumatic psychopathology, overidentification with the patient may also lead to vicarious traumatization in the countertransference.
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Hirsch might have devoted more attention to the possible psycho
dynamics of emotional detachment by the analyst. He deals well with overwork and emotional depletion in one’s personal life as contributing factors. He notes that some patients collude with the analyst to maintain treatment stalemates. But he stops short of a deeper exploration of uncon- scious factors in the patient that elicit such a withdrawal from the analyst. On the one hand, he notes accurately that “analysts often fail to use counter- transference productively” (p. 5). However, he chooses to downplay the patient’s role—“I suggest that . . . the reverie involved in these [counter- transference] withdrawals sometimes reflects exclusively analysts’ nar- cissistic concerns . . . and may not at all be of informational value in understanding patients” (p. 7; emphasis added). I worry that analysts’ blind spots for the patient’s impact on the countertransference will thereby be widened rather than reduced. Hirsch gives an excellent example where he does in fact look more deeply at his withdrawal from one patient. “I came closest to literally falling asleep with Jill more so than with anyone else” (p. 69). Notably, Jill’s childhood included “the most egregious sexual abuse I had ever encountered” (p. 68). He explored with Jill his “sleepiness as a represen- tative facsimile of her dissociation while being sexually assaulted by her father” (p. 69). Unfortunately, Hirsch seems to overlook the likelihood that Jill suffered from high-functioning dissociative identity disorder. The ongoing impasse Hirsch describes in their work may have required treat- ment modifications geared to that diagnosis. I am tempted to recommend that readers skip Hirsch’s first chapter, lest they not get any further in this fine book. This first chapter spells out the problem of the analyst’s colluding with patients to maintain an impasse. But it is only later in the book that Hirsch gives compelling examples of using an understanding of these dynamics to resolve impasses. Chapter 1 unfairly portrays Hirsch as confessing that he knows he misuses his patients but cannot stop himself from continuing to do so. If Hirsch is correct that “in each analyst, multiple self states exist” (p. 56), I suspect a different authorial self state wrote chapter 1. It is there that we learn Hirsch prefers to see eleven patients a day, with many sessions back-to-back (see Greenson 1974). He cynically believes that, given plentiful referrals, “for economic purposes I believe most analysts will see as many patients as possible” (p. 20), even though “a near ideal com- mitment and passion to patients cannot exist under the conditions I describe as my own, and those of virtually every colleague I know who
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has the same opportunity or luxury” (p. 21). I am surely not the only reader who has decided to limit his practice, precisely to avoid the dan- gers of overwork that Hirsch so persuasively describes. I take a five- to fifteen-minute break between sessions. I find that routinely taking notes after each session is an excellent opportunity for self-supervision, and it gives me time to be more emotionally prepared for the next patient. This excellent book suffers from some minor but distracting editorial shortcomings. Several paragraphs run on for more than a page. Sentences are sometimes interrupted by up to six lines of references. In one case, a sentence (on p. 178) is thus interrupted four times, with a total of twenty- one references. Inconsistently, but much more readably, some pages put the voluminous references in a less distracting footnote. In his final paragraph, Hirsch re-creates the dark tone of his first chapter, admitting that “the picture I have painted . . . may appear bleak and cynical” (p. 199). Despite that, his book is full of clinical gems, and all analysts will benefit from reading it—especially if it encourages them to emulate Hirsch’s exemplary self-scrutiny.
REFERENCES
Greenson, R. (1974). The decline and fall of the fifty-minute hour. Journal of the American Psychoanalytic Association 22:785–791. Strachey, J. (1934). The nature of the therapeutic action of psychoanalysis. International Journal of Psychoanalysis 15:127–159. Waugaman, R.M. (2003). The analyst’s caseload as a family: Transferences to fellow patients. Psychoanalytic Quarterly 72:575–614.
Richard M. Waugaman 4701 Willard Avenue #204 Chevy Chase, MD 20815 E-mail: [email protected]
____________ ____________ Hurry Down Sunshine. By Michael Greenberg. New York: Other Press, 2008, 234 pp., $22.00. DOI: 10.1177/0003065109336008
Manic-depressive disorder, or in our present nosological jargon bipolar
disorder (for a review, see Healy 2008), has had a checkered career in psychoanalysis. Recent years have seen this often tragic affliction defined,
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