Psychoanalytic Psychology 2010, Vol. 27, No.

4, 513535

2010 American Psychological Association 0736-9735/10/$12.00 DOI: 10.1037/a0020454

THE AMBIGUITY OF THE PSYCHOANALYTIC SITUATION AND ITS RELATION TO THE ANALYSTS REVERIE
Eystein Victor Vpenstad, PsyD
Oslo, Norway

This article is about ambiguity in psychoanalysis, an ambiguity that is particularly striking in the psychoanalytic relationship between patient and analyst. The analyst is a professional in his consulting room, in his chair behind the patient, but he is at the same time a gure in the patients realization of his inner world of objects. The analyst is a transference gure, but he is also a real person with his own inner private reverie and a subjective contribution to the analytic process. For some patients, the ambiguous analyst is an enormous challenge or threat. This article describes parts of the analytic process with one such patient, a man with an early history of severe trauma who at the start of his treatment completely denied this ambiguity and felt every reminder of his analyst being anything else but professional as a threat to his sanity. The author tries to show how the improvement of the patients tolerance for ambiguity depended on the work done in the analysts private reverie, a quite demanding process for the analyst. Keywords: ambiguity, early trauma, reverie, authentic analyst, analyst exposure

But you are a professional

In his book Phe nome nologie de la Perception (Phenomenology of Perception), written originally in 1945, the French psychologist and philosopher Maurice Merleau-Ponty stated that ambiguity is of the essence of human existence, and everything we live or think has always several meanings (Merleau-Ponty, 1962, p. 196). Merleau-Ponty suggested that Freud was on the way to discovering this essential ambiguity through his theories of the unconscious (Merleau-Ponty, 1969). Sass (1998), describing the relevance of hermeneutics to psychoanalysis, emphasizes that ambiguity is the essence of psychoanalysis. But what is ambiguity? And can we say that this is a relevant concept for psychoanalysis? I will try to answer the rst question with a small vignette from the psychoanalysis of a man of about 35 years of age:

Eystein Victor Vpenstad, PsyD, private practice, Oslo, Norway. Correspondence concerning this article should be addressed to Eystein Victor Vpenstad, P.O. Box 7217 Majorstua, 0307 Oslo, Norway. E-mail: vaapenst@online.no

513

514

VPENSTAD

The patient tells me that last night he was really scared in a shop. He was about to buy some new headphones, but he is not easy to satisfy, and the purchase took some time. Patient (P): I became increasingly scared that the salesman would be angry. Analyst (A): Sometimes you are not completely satised here either. Maybe you are scared that Im going to be angry with you when you say so. P: No, no, no! You are a professional, and its me that Im not satised with. That I dont manage to say everything like you said I should do, and that I cant keep up my attention all the time.

Every time we touch on our relationship, every time the transference is mentioned, the patient exclaims: But you are a professional! When I acknowledged this but also put forward that he also met me here as a person, the patient showed no sign of trying to understand this duplicity or ambiguity, and he just said again and again: But I see you as a professional, and you are just doing your job. Sometimes I tried to say something like this: Its important for you that I am professional so that I can take all the bad and difcult stuff that can come into our sessions. He took this as a conrmation of my professionalism and did not hear the rest of the message in the interpretation. The ambiguity is obvious in the transference: The analyst is a concrete (professional) person in his consulting room, in his chair behind the patient, but he is at the same time a gure in the patients realization of his inner world of objects. In the transference, the patient can attribute to, and imagine the analyst as, almost anything. Working through the transference can give the patient a more realistic picture of the analyst as analyst and as a person, but it will not eradicate the ambiguity of the psychoanalytic relationship, only move it from an omnipotent wish to dene the analyst in one particular way to an ability to live with the fact that it is impossible to know everything about the other. Ambiguity is that something or someone has several meanings and cannot be understood or described in only one denite way. For instance, in the diagnostic process we can discover that the patient can t into a diagnosis, but that she is so much more than this particular diagnosis. Then let us move to the second question: Can we say that ambiguity is a relevant concept for psychoanalysis? I think that we can, and in much the same way as Freud used everyday concepts to illustrate what is happening in psychoanalysis. Ambiguity is also a central part in some of the most important psychoanalytic theories: Consider Winnicotts (1971) description of potential space and transitional phenomena (and objects), where the most important thing seems to be the double meaning an object or a fantasy can have as a representative for the space between play and reality. Bion (1962) produced a theory about K. This is, among other things, the awareness of the fact that our increasing knowledge also means that there is much we still do not understand or know anything about. This is what Bion (after Keats) called negative capability, a capacity that Bion according to Symington and Symington (1996) regarded as not an immediate mental discipline to be engaged in just prior to the session, but rather a way of life (p. 169). The paradigm of mentalization, described by, for instance, Fonagy, Gergely, Jurist, and Target (2004), is just this capability to see the manifold and ambiguous in others, in ourselves, and in the relationship. A good capacity to mentalize is characterized by an appreciation of how our own contribution and the reaction of the other can have several meanings. And mentalization is about our capacity to tolerate the fact that the mind of others (and our own) is complex and intricate. A central contribution is that of Melanie Klein (1946/ 1997). Her descriptions of the development from a paranoid/schizoid position, character-

AMBIGUITY OF THE PSYCHOANALYTIC SITUATION

515

ized by a one-dimensional preoccupation with part-objects, to a depressive position where there is an increasing capability to endure the doubleness of relationships to whole persons, must be central to the psychoanalytic understanding of ambiguity in the human existence. Meltzer and Williams (1988) describe in The Apprehension of Beauty how the childs encounter with the beauty of the mother-object triggers an ambiguity about the interior of the object because this interior is basically unknown and unobservable, and this also contains the recognition of the fundamental difference between self and other. The authors describe how the epistemological instinct, the urge to know about the interior of the containing object, which later on develops into a more general motivation for knowing and learning, starts at this point. But it can take different directions: One is the curious exploration of the ambiguous world; another is the attempt to destroy the interior of the object and deny the paradoxical and double qualities of the world. We should also consider Freuds (1918/1955) concept of Nachtra glichkeit. Ku nstlicher (1994) describes in his illustration of Nachtra glichkeit how Freud made this concept have at least two meanings: how earlier experiences get their meaning in retrospect through actual fantasies in the psychoanalytic situation, and how the original traumas are transferred into the future as a pathological process, what Freud called repetition compulsion. Karlsson (2000), in discussing the existential and hermeneutical meaning of Nachtra glichkeit, points out that the existence of nachtra glichkeit illustrates this unnished character of experiences (p. 20). I would like to say that this unnished character of experiences is the same as the ambiguity of life that Merleau-Ponty is talking about when he says that everything we live or do always has several meanings and will never be nally understood. Another Freudian concept that touches upon the fundamental ambiguity of life is overdetermination. A basically hermeneutic approach to psychoanalytic epistemology makes it difcult to think that the concepts of ambiguity and overdetermination cover the same phenomenon. I agree with Sass (1998) when he says that:
The hermeneutic assumption of fundamental ambiguity should not be confused with the Freudian notion of overdetermination, which also acknowledges a multiplicity of meanings. Overdetermination presupposes not ambiguity but what I would prefer to call complicatedness. It views a given psychological event as the end point of a number of different trains of association or other causal chains, perhaps more than one is ever likely to uncover, yet each of which links a discrete and determinate set of events. Hence, on principle at least, the causal chains could all be discovered, thereby providing a complete explanation of the phenomenon in question. (p. 279)

Ambiguity is central to the hermeneutic way of understanding psychoanalysis (Mitchell, 1993; Orange, 1995; Sass, 1998; Sass & Woolfolk, 1988; Stern, 1997). Mitchell (1993) says that the basic data of psychoanalysis, that which is to be understood or analyzed is fundamentally ambiguous (p. 56). Mitchell (1993) and Sass and Woolfolk (1988) warn against conating ambiguity and overdetermination. Mitchell (1993) writes the following: To say that human experience is fundamentally ambiguous is not the same thing as saying it is complex (p. 57). Sass and Woolfolk (1988), criticizing the work of Donald Spence (1982), say that it seems that Spence, like all positivists, accepts what one might call the complicatedness of the world, but not its fundamental ambiguity (p. 447). According to Orange (1995), ambiguity and confusion differ (p. 53). The concept of overdetermination promises a nal solution to the confused patient or analyst. The hermeneutic notion of fundamental ambiguity cannot give such a promise, only a new set of questions. We must simply live with ambiguity, as opposed to complicatedness, which can be sorted out through the understanding of overdetermination.

516

VPENSTAD

The Threatening Ambiguity and the Boullion-Heat

The purpose of this article is to try to describe how threatening the ambiguity of the analytic situation can be for a traumatized patient, and how an increase in the patients tolerance for the ambiguous in the psychoanalytic situation depends on the analysts own inner work, not only in the countertransference, but also in his own private thoughts and fantasies, what Bion (1962) and later Milner (1987) and Ogden (1997, 2004a, 2004b) have called reverie. Being the analyst of this patient became a great challenge. The patients extreme anxiety for real human contact and his continuous struggle to cross me out induced in me a feeling of increased distance to him. The psychoanalysis was for a long time marked by the patient insisting on a one-dimensional picture of the analyst as only a professional. This made me experience the relationship to the patient as meaningless and repulsive. His suffering gave no resonance in me. His denial of my subjectivity and personal presence was sometimes felt like an insult, and it could make me dislike him and look forward to the end of the sessions. The patient became the one that I thought the least about, and he soon became my buljongpasient (an idiom derived from the phrase buljongpar (bouillonheat), used of long-distance skating where some competitors are so dull that the spectators pass the time with a hot drink). The sessions became for me a break from the monotonous round of everyday life, a time out when I could lose myself in daydreams and fantasies of every kind. After a while I became shamefully aware of the fact that the patients traumatic life and history did not touch me to any extent. Fortunately, I did understand that in this, my own private reverie (Ogden, 1997, 2004a), lies the road to the patient. What is happening in the analysts reverie, in his own subjective thought, dream, and emotional world, is decisive for the patients development, even when the analysts inner thoughts do not have direct relevance for the patient (Ferro, 2002, 2009; Ferro & Basile, 2008; Ogden, 2004a, 2004b; Spezzano, 2001; Symington, 1986).

Notes on Ambiguity in Contemporary Psychoanalysis

Several authors use the concept of ambiguity to describe the psychoanalytic situation. Sass (1998) argues that ambiguity is the essence of psychoanalysis. De Bernardi (2000) quotes Baranger and Baranger (19611962)1 in her description of what she denes as the radical ambiguity of the psychoanalytic situation: Every event within the analytic eld is experienced in the category of as if [. . .] it is essential to the analytic procedure that everything and every event in the eld is at the same time something else. The analysis disappears, if this essential ambiguity is lost (p. 336). She claims that it is only in this way that the patients unconscious fantasies can be brought into the present in the analytic relationship. Modell (1988) and Adler (1989) emphasize the same fundamental ambiguity in the psychoanalytic situation. Model describes how the patients creative use of the transference depends on the patients ability to tolerate the ambiguity between reality and illusion and time as a paradoxical variable: that the past is in the present and that the present can
This paper was originally in Spanish, but has recently been translated into English (Baranger & Baranger, 2008). Baranger & Baranger speaks about the essential ambiguity of the analytic situation.
1

AMBIGUITY OF THE PSYCHOANALYTIC SITUATION

517

bring forward the past. Adler discusses the concepts of projective identication and transitional phenomena in the light of what he calls the essential ambiguity (p. 81) in the psychoanalytic situation. Adler says that the analytic process creates an ambiguity that prepares for a creative development, especially in the transference. The ambiguity in the analytic situation arises from the fact that it is unclear to both participants how much of the actual difculties in the therapy come from the transference, and how much comes from the real relationship between patient and analyst. Hoffman (1998) describes how the analyst appears in a fundamentally ambiguous way and how the patient tries to interpret the analysts experience of the patient, himself and the relationship. This is not made any easier by the fact that the analyst might have an ambiguous relationship with himself, and what comes from the analyst can also be a compromise between conscious and unconscious forces. Hoffman claims that what the patients transference accounts for is not a distortion of reality but a selective attention and sensitivity to certain facets of the analysts highly ambiguous response to the patient in the analysis (1998, p. 119). He points out the ambiguity in the relationship between psychoanalysis as a ritual with a clearly dened asymmetry and the mutuality and spontaneity in the concrete exchange between patient and analyst. The analyst is both an authority and a coworker. In this landscape, the analyst has a superior responsibility to act as wisely as possible, says Hoffman. Skolnikoff (1996) says that psychoanalytic education should help analysts to endure this ambiguity rather than create an illusion of authoritative knowledge.

The Concept of Enactment

The concept of enactment has become central in contemporary psychoanalysis underlining the development of more relational and intersubjective views on the psychoanalytic process (cf. Aron, 1996, 2006; Bateman, 1998; Benjamin, 2004; Hoffman, 2006; Jacobs, 2001; Mitchell, 1997). Through enactments, the analysts subjectivity comes into the analytic relationship, often as a spontaneous reaction to the material presented by the patient, for instance through projective identication. Enactments made by the analyst are more and more understood as useful ingredients of the psychoanalytic process. Mitchell states that enactments and reenactments are not understood as detracting from interpretations, but rather as providing powerful, ongoing examples on which interpretations can be based (1997, p. 182). But such a view of enactments can be in conict with an ideal of neutrality:
In general, countertransference enactments delay analysis of the patients transference distortions and may even make them unanalyzable. Although they may be the only means by which an appreciation of some aspect of the patients psychic reality is reached, they are mistakes nonetheless. (Chused & Raphling, 1992, p. 112)

In this view, there is an ambiguity: Enactments are viewed as the only route to some aspect of the patients psychic reality, but at the same time as a mistake. Aron (1992), being a little bit more reluctant to view enactments as a mistake, points to another ambiguity inherent in the phenomenon of enactments:
The analysts goal, however, is to understand these patterns with the patient, and while recognizing the inevitability of participating and enacting and even welcoming this development as the necessary next step in the progress of the analysis, the analyst should not be

518

VPENSTAD

participating, that is, taking on any particular role, purposefully or deliberately. Participating should be done inadvertently, as much as possible as a response to the patient, rather than as a deliberate provocation or suggestive interpersonal inuence. Viewing the analysts participation as inevitable is a description, rather than a prescription of analytic activity. (p. 493)

We cannot decide to enact, it is not a deliberate gesture, and we even consciously try to avoid it, but according to Aron, we sometimes welcome it as the necessary next step in the analytic process. This is a demonstrative example of the essential ambiguity in contemporary psychoanalysis. Hoffman (2006), in discussing enactments in psychoanalysis, has shown how the analyst, when working with a severely traumatized patient, can move from an objectivist framework, where the analyst always knows exactly what the patient needs and how to provide it, to a constructivist framework in which what the patient needs and what the analyst is doing are both characterized by ambiguity and uncertainty (p. 724). This recognition of the fundamental ambiguity of the analytic situation will not take away the potential for enactment of pathogenic experiences of the past, but this potential for enactments is always present along with the potential for new experience (p. 724, italics in original). And Hoffman continues: Excessive zeal about being the good object can blind the analyst to the multiple conscious and unconscious meanings that his or her participation could have for the patient, as well as for himself or herself (p. 724).

The Patient
The patient is a single man in his mid-thirties. He comes from a medium-sized town in the very south of Norway. In infancy he was diagnosed with a severe form of cancer. He was in treatment for almost 4 years. The treatment was extremely painful and traumatic, both for him and for his parents. His childhood was difcult and marked by several different psychological and emotional problems. At present he lives alone and supports himself with part-time jobs and social welfare. His daily life is all about obsessive control and developing systems to deal with everything, especially relationships. His anxiety is ever-present, and he has a lot of psychosomatic pain. Early in his analysis, he told me about his earliest memories and the time of the cancer treatment. He was very afraid of dying, but also angry with the adults who forced him to have very painful injections and undergo surgery. He thought they were about to kill him several times. He remembers very intense pain. They had to tie him to the bed to prevent him from pulling out the medical apparatus. His parents took part in the treatment and were among those who had to restrain him by force to carry it out. More than once they thought he was cured, but there was another relapse. His parents were exhausted.

Trauma Derails Normal Psychological Development Toward Tolerance of Ambiguity

It seems obvious that the patient has been inicted with what Freud (1920/1959) describes as an extensive rupture in the mental shield against external stimuli. Kahn (1986) describes how strains and injuries coming from the mothers absent ability to protect the child against overwhelming stimuli will damage the childs development of body-ego functionality. The patients ability to digest and process sensations is severely damaged. The development of alpha-function (Bion, 1962) is also damaged, and he struggles to

AMBIGUITY OF THE PSYCHOANALYTIC SITUATION

519

create coherence between inner and outer reality. Anzieu (1989) describes the impact of intense pain on the young infant: Pain bursts through the network of contact-barriers, destroys the facilitations which channel the circulation of excitation, short-circuits the relays which transform quantity into quality and cancels out differentiation [emphasis added], reduces the differences in level among the psychical subsystems and tends to spread in every direction (p. 200). It seems difcult for the patient just to be in the world. He experiences himself as being in constant danger and has an ever-present alertness against every sort of impression. Winnicott (1949) describes how a mental apparatus is created as a consequence of a (bodily) trauma. When the psychosomatic being is disrupted, there must be a thought instead. Thinking has to take care of and make up for the lack of safety, the absent continuity of being. It becomes what Phillips (1995) observes: Whenever the world is not good enough one has a mind instead (p. 235). The result of this, says Winnicott (1949), is an intense memorizing or cataloguing (p. 248) as an effort to deal with the overwhelming emotional experiences resulting from the environmental impingements. Phillips (1995) says that in the absence of relatively reliable environmental provision the mind becomes a kind of enraged bureaucrat (p. 235). He proceeds to describe this process as a military coup where a dictator or terrorist exterminates the unconscious (the ambiguous) because, since they are extremely efcient bureaucrats, everything has already been accounted for (p. 236). Kohon (2007) describes the same phenomena:
The subjects state of mind cannot tolerate uncertainty, inconsistency, ambiguity [emphasis added], or contradiction. It is a mind that cannot play; there is only a frantic search for reassurance that is never fullled. Something in them turns into an internal tyrant, a terrorist, a Maoso, who is idealized and to whom they gladly submit. (p. 214)

The ambitious bureaucrat in the patients mind cannot accept any form of ambiguity. If he should use the service of a psychoanalyst, this analyst must be professional and nothing else. When I failed to be a good environment for him, he mobilized his bureaucrat-mind and became aware of his body. This could happen, for instance, when I tried to introduce my own version of reality or interpreted the transference too directly.

Denial of the Ambiguous: Insisting on the Analyst Being Professional

Patient (P): I just want you to speak out if I go beyond the psychoanalytic setting here. Analyst (A): You want me to tell you if you go past the limits? P: Yes, so I dont have to be uncertain about it, and so I can avoid using our time on something that is not . . . or do not lead anywhere. A: You want me to decide what you can say and not say so you dont have to be afraid of me not being able to stand what you are telling me. P: I know that I am supposed to say everything, and I try to do so, but its so difcult. A: You have noticed how difcult it can be to speak freely.

520

VPENSTAD

The patient goes on to tell me about a psychiatrist whom he had seen on an American TV program, and that the psychiatrist was so active and direct.
A: You wanted to speak to him; this psychiatrist could tell you what was right and wrong. P: Yes, he was very loud and clear . . . but now I start to think that I am too critical about you . . . that makes me scared . . . I just want to say that I think you are a professional and that you probably have heard much worse than I bring here.

In this session, as in many sessions with this patient, I discovered that I was thinking about many other things, everyday problems and different daydreams. Sometimes I thought about an old skating rink not far away from my ofce. For many years this stadium was the main arena for major long-distance skating championships. There is an expression from the old championships, buljongpar (bouillon-heat), whose meaning I have explained above. It became obvious to me how the sessions with this patient had become the bouillon-session of the day. In his Sessions I could leave the arena and go to my inner cafeteria to get myself something hot to drink in the form of a daydream or a trivial set of thoughts. Many times I tried to analyze my own thoughts, dreams and fantasies to see if there was anything I could use in my understanding of the patient. During one period my thoughts were about a small chink in the windscreen of my car. This could of course have something to do with the patient, but I was not able to use this for anything concrete. I think that my travel into this private thought and dream world was a result of the patients wishes to keep me away from the relationship and make me into a professional robot that should not think or feel too much about him. But I also think that it was a result of my reduced capability at that time to contain and be moved by the patients situation; his suffering found no resonance in me. It seems as though the patient prevented every sort of emotional contact. Such a contact became too ambiguous and dangerous for the patient and maybe for the analyst as well.

On the Patients Use of Strong Methods and How His Defense Almost Collapsed
After approximately 2 years in analysis, the patients defense against the relational ambiguity came to a critical point. The patient was increasingly occupied with the idea that he could use very strong methods to nd out exactly what others might think about him, and if he did not nd out, he could use his imagination to decide for himself what the other person was thinking. He did not have any doubt about his fantasy being a correct measurement of other peoples minds, and he did not agree with my suggestion that this had something to do with magic. He practiced to become even more certain about the inner life of others, and he was in apprenticeship with a clairvoyant woman in his hometown. In this period he was constantly dreaming about violence, but he was reluctant to speak to me about his dreams in any detail. On the other hand, he told me a daydream in which he surprised a rapist and took a cruel revenge on this violent criminal. At the same time his mind was occupied with reasoning about how the Nazis could have been even more effective in their extermination of annoying individuals. He emphasized again and again that he was not a Nazi, and he dissociated himself from everything that the Nazis did or said, but he could feel the same urge to annihilate all the things that perturbed and tormented him in an effective and systematic way. He wanted to kill every doubt and ambiguity.

AMBIGUITY OF THE PSYCHOANALYTIC SITUATION

521

I thought that it was me or my private inner sanctuary that he wanted to erase. He wanted to eradicate my effort to bring forward the ambiguous and frightening idea that I could have something in my mind regarding him, something that he could not grasp or control. Maybe that is why he did not want to tell me any details from his dreams. He said that everything that was said in our sessions came back to him in his daydreams and troubled him. He said: I just want to clean out all those thoughts from my brain. I suggested that he wanted to clean my brain too, but this interpretation only made him anxious, gave him an urgent need to visit the toilet, and made him say: No, no, no, I cant get in there! The next day, he started the session by describing how his entire body ached. He did not sleep at all the previous night, and he was worried and afraid, and he was certain that he was suffering from CFS (chronic fatigue syndrome). This morning in the shower he thought that he would pour out.
A: Your skin could not hold you together? P: Exactly. I am so ugly, disconnected and incoherent, Im not able to say anything in a proper way, I cant express myself here, not show any emotionality, only all those things I want to get rid of, Im so exhausted. A: You dont expect me to understand you either; Im just a professional, only doing my job. And you cant reach me. P: Oh no, I dont want to say that about you. You are completely awless; the problem is my ever-present lack of an ability to express myself in a proper way. A: Can you see how you take the blame, the whole responsibility again, and how you let me off? Its always you who do something wrong. Its you who dont say or express yourself well enough. P: But if you should take to your heart everything I say, you would be exhausted too. A: So thats what you think about being a professional, its avoiding exhaustion and defending myself from being affected by all the things you bring to our sessions. P: I cant stop it, its my responsibility, and it must be! A: Its impossible for you to let me be responsible, to let me take care of you. P: (crying) I should have been in an institution, and you should have been there too. Then I could have been cared for 24 hours a day. A: I think that you are telling me that you feel that I dont quite understand in what an awful state you are between the sessions. You need the analysis 24 hours a day and not just four times a week. P: But thats impossible . . . or maybe . . . in a way . . . yes . . .

This session was followed by some weeks when I did not think the sessions were as boring as they used to be. On the contrary, it was increasingly uncomfortable to be with the patient, and when he emerged in my thoughts outside the sessions, it was as if he came closer, and it was more annoying to meet him, but it was not possible for me to say what this was all about. For instance, he started to complain about my ofce not being fully

522

VPENSTAD

soundproof, and suddenly I was not sure myself after many years at the same ofce. There was something that could pour out, that could not be held together, something which neither he nor I could keep inside any longer.

The Break Is Like a Deep Cut

About 4 weeks after this session came the Christmas holiday. This Christmas, I extended my vacation by 4 weeks so that the whole break was 6 weeks. After this break, he came back and said that he thought he would die during the holidays. And when he started to talk about death, I came to life. His miserable life during Christmas made a great impression on me, and I thought that my own 4 weeks on paternity leave had been quite a challenge, but miles away from his struggle to keep himself alive (both physical and psychical). He told me that he had cut himself by accident with scissors just 1 week before we were scheduled to start again. The wound was not deep, but it bled a lot, and he was afraid that he could just pour away. He said that the pain from this wound was twofold. The rst part was the damage to his body, a wound that would not go away. The second part was the fact that this wound would take a long time to heal, but this second part also meant that his body was working on the case, that there was something inside him that could work on things even when he did not take an active part in it or was not in charge all the time. He sank into the couch and felt calm during most of the session; he said it was good to be back. All this made a great impact on me. I felt that we were together in a new way. His situation affected and worried me, but this seemed to help him, as he became more relaxed, and it looked like we had found each other again after the break. Without thinking I said: It seems like the both of us have survived. I had survived 4 weeks of paternity leave, he had survived 6 weeks in a matter of life and death, but he came through and was now able to establish the relationship again. Maybe he found a relational core that could calm him because the same core put me in a more uneasy state, but also made me more alive. And I also think that my unease came from realizing that during the break I had been together with a small child the same age as the patient when he became seriously ill. I had been in contact with the vulnerability of a small child. What if my little child should have been put through painful treatment and hovered between life and death? Would I have been able to survive that? I could only just start to think about this, but mostly it felt like a sickening sense of distaste and an urge to visit the toilet and get rid of the contents of both mind and body. Toward the end of the session, he said that the couch was hard. He probably noticed that we were approaching another break and that he had to wait until tomorrow for our next session. At that moment it felt like an ocean of time. I had to go to the lavatory.

The Analysts Dream

One weekend almost 3 years into the analysis, I had the following dream: I am working at a hospital. We are going to perform an operation on an old man, he is in narcosis, and I put on my facemask. It is comfortable that I am anonymous and covered up (only a professional) and that the patient is asleep. Suddenly, a nurse arrives with a newborn child; she tells me that it is the old mans child and that I have to look after it. We put the infant in a small bed beside another small bed, which turns out to contain my own sleeping infant. The operation is about to start when I realize that I am alone in the room, and I am

AMBIGUITY OF THE PSYCHOANALYTIC SITUATION

523

not a surgeon. It is a bit uncomfortable, but I am not really worried about the old man on the operating table, as he is sleeping. I decide to wait for the surgeons to arrive. But then the newborn infant wakes up and start to scream; it is covered with excrements and urine. I try to nd the alarm button, as the infant falls out of the bed. I realize that I have to sort out this mess on my own. It is an intense feeling of helplessness and incompetence, but not hopelessness. My own child is still asleep.

Working Through in the Countertransference

In her renowned paper Working through in the countertransference, Irma Brenman Pick (1985)2 describes the ambiguity in the analysts balance between feeling disturbed, exposed and pulled into the relationship with the patient on one side and being able to interpret the material without too much anxiety on the other. Joseph (1983) explains the delicate balance between acting-out (enact) and suffering in silence, and points out that both extremes can be equally nontherapeutic. Smith (1993) has the opinion that every analyst is constantly dragged between confronting and not confronting their own resistance against the analytic work. The work of the analysts own private mind is decisive in helping the patient reach the depressive position. Pick (1985) say that [the analyst] need not only to move into the paranoid-schizoid internal world of the patient; [he] also require some exibility in tolerating and working through the tensions between [his] own conscious and unconscious impulses and feelings toward the patient (p. 352). Pick describes how the analysts superego can react strongly when parts of himself, parts he does not want to know about, are pulled into the relationship with the patient. If this analyst-super-ego is too rigid and strict, the analyst is in danger of becoming as one-dimensional and primitive as the patient in his relationship to himself and the patient (Vpenstad, 2008). But if the analyst is able to work through his ambiguous experience of both wanting and not wanting to know, including the ambiguous relationship the patient has to the analyst, he can develop a deeper and more empathetic contact with the patient. If we repress our own inner conicts and deny the possibility of a primitive response, we are in danger of acting out something that we should have digested, worked through and communicated as an interpretation. Pick (1985) species that a more free and spontaneous patient often comes from the working through of the analysts own struggles, resulting in a more spontaneous analyst and a more emotionally free interaction with the patients projections. If we can tolerate this process without being too dominated by impeccable neutrality (Pick, 1985, p. 361), our involvement can help us to understand the patients material in a better way, and in a way that can have a greater chance of reaching the patient. I think that my dream was an important contribution to this sort of working through. Perhaps it primarily concerned my own personal struggles, involving an encounter with a newborn child, touching upon the depths of parenthood and containing nameless dread (Bion, 1962), but I think that this analysis also illustrates the process described by Pick: We have a newly educated analyst who wants to do everything by the book, dominated by impeccable neutrality and a strict analyst superego; and we have a patient who does not make it easy for the analyst. I am, in a signicant amount of time, left to my own inner ambiguity between the desire for a time-out in my private reverie and the guilt and shame

Revised version (1997).

524

VPENSTAD

of not being more alert and in contact with the patient and his suffering. The patients improvement must go through my own gradual realization and processing of my private reverie. In the analysts private reverie we will nd the key to both the patients and the analysts recovery. The inner work of the analyst in this subjective and ambiguous way is not always connected directly to the patients material, but will in any case have a signicant effect on the analyst, the relationship, and the whole treatment because the analyst is developing his analytic attitude and liberates attention to his work as an analyst. This liberation of attention is, I think, similar to Freuds (1912/1958) recommendation of an evenly suspended attention, which puts the analyst in the position of being sensitized to her or his own unconscious impulses or fantasies (Ellman, 2002, p. 155). This evenly suspended attention when visiting the analysts private and personal life does not have to leave immediately, but can, on the contrary, prolong the stay. A mother who can contain her childs pain and help the child to tolerate it, is not a saintly mother, but a esh and blood mother who knows about her own wishes to be rid of troublesome problems (Pick, 1985, p. 358).

Memories of Childhood and Development of a Stronger Transference

After almost 4 years of analysis, the patient said that he wanted to cry more in the sessions, but he felt he was not able to. I tried to say that he did not know how I would react if he should start crying, and that he expected that I would not like it. He said that if he should ask for my help, he would not know what I could do for him. This obviously made him sad, and I felt the same. He held back his tears and told me that as a 10-year-old he had a fracture in his leg and was admitted to hospital again. His father came to the hospital with him and stayed during the night. He was in great pain that night, but he was not able to call for his father, as he did not know what his father could do for him. In the session the next day, he was unable to use the couch, and he sat himself in an armchair. He agreed to my interpretation that he had to hold himself together. He also conrmed my allusion to yesterdays session and the correspondence to our relationship. He told me that his father instructed him to go to sleep that night at the hospital rather than listening to him and caring for him, and he did not know what to say to his father. I told him that he had not known how to use me either, and that I had not known how to reach him.

Fantasies About the Analyst

Shortly afterward he started a session by saying that his head was full of gments. But now it was possible, without the bureaucrat taking over, to suggest that there was something that both disturbed and interested him, maybe a thought about our relationship or some notion about his analyst. At once he presented a story about something that had happened a few minutes ago when he was sitting in the waiting room; three women had come by, and he was certain that at least one of them could have been my wife, and that she had visited me just before his session. Those women could all have been your wife, he said. I was tempted to ask him what my wife looked like, but he continued by saying that he could sense that the couch was still warm and that this meant that my wife and I must have stretched out on it. I told him that he was imagining that we had slept together on the couch. But this was too much, and he said that the couch was too narrow for that sort of activity. We could then talk about how he had to repress everything sexual, and he said that for him the most important thing was to understand what it is like to have a wife.

AMBIGUITY OF THE PSYCHOANALYTIC SITUATION

525

I got a sudden idea about him sleeping in his parents bed and that it is both exciting and safe. Not long after this session, it was Easter and a 10-day break. In the rst session after Easter, he started by saying that he had considered talking about the analytic relationship. He had noticed that I had talked about our relationship many times. He said that he too was now interested in this topic. But it was so difcult because he was so good at being careful and hiding, he explained. During the Easter holiday, he had gone through his papers, and he had come across a feature article written by me some years back. He had read it again and got especially interested in what I had written about how the helper can be affected by what the sufferer brings to treatment. During Easter he had also been dreaming about a clairvoyant woman (Miss B) with whom he was still in contact in his hometown. In the dream, Miss B came to visit him in his childhood home, arriving in a Mercedes with a chauffeur. Miss B invited him to join her, but his parents asked her how she could do this without testing him. He answered them by saying that she knew him so well and was condent in his special abilities. They drove away to a strange place, where he had to ght alone against an intense blue light which could make him forget everything, and that was something he did not want to happen. He got away from the blue light and awoke. There are several interesting topics in this dream, but I will only give an account of an exchange we had about the Mercedes:
A: You may have noticed that I drive a Mercedes? P: As a matter of factyes I have. Mercedes . . . thats like those government cars, with a big bonnet, its a here-I-come-car, so different from Miss B. A: You think it suits me better? P: Aaaaoooo (stuttering) . . . I dont know about that, but I think it is a car that ts those who want to endure everything.

I remembered my previous private reverie concerning the need to change the windscreen after the spray of gravel. I said: Yes, you have experienced me as one who wants to take everything, and maybe thats been important to you too, but now I think that you are starting to acknowledge that it may not be like this, that I cant endure everything, and that you have to ght on your own, as in the dream. He was quiet for a while, and after some hesitation he said that he didnt mean to say anything bad about Mercedes, and he wondered if my Mercedes was rather old. In the session following this one about the Mercedes, he constantly had the impression that there had been a woman in my ofce just before he entered. He always sensed a mild ladies perfume in the room. He wondered whether he had said something about Mercedes that had offended me when I omitted to conrm his idea about a recent female visitor in my ofce. I tried to say something about his fear of offending me with his utterances about my Mercedes, and that he became afraid when he sensed that he could have been right. In one of those sessions after Easter, he said that he knew that I was also a clinical child psychologist, and he said that he should probably have started his analysis with me when he was 6 or 7 years old. He thought that at that age he had fewer psychological defenses and his sadness and despair were more at the surface. If I had started at a later age, it would have been too late, and I was not ready to start earlier, he said. But in my hometown, there was no psychoanalyst or child psychologist who could help me, only my parents . . . they got some help. Besides, I would have wanted

526

VPENSTAD

my analyst to be in independent practice, I dont like the quality of those in the public sector. I said that he told me that he would have wanted to start his analysis much earlier, and that he now wanted me to talk to the little boy in him. He said that it was obviously many years since he was six, and that you may have been just out of university and pretty green. I said: You want me to help the little boy too. He looked down and started to cry.

Toward Greater Tolerance for Ambiguity and Increased Ability to Express Distress
Two months later, the patient started a session by saying that he now thought that his treatment was marked by cooperation.
P: I am also more condent in your capacity, I think its sufcient, but I also think that anyway I cant use it. Lately I have noticed that I have tried to destroy your capacity, and this makes me really sad. Are all those years in analysis a waste of time? A: Maybe we have to cooperate to understand this. P: But you will disappear, sooner or later you too will be gone.

I felt sick and lled with thoughts of my own difculties and my own anxiety regarding fatal loss.
A: You can feel how grave it is that one day we will not be together any more. P: But this couch is actually rather good, hard but good. I feel sad in my mind, but my body is calm, only a little stiffness in my neck. A: You can feel that the couch can hold you together, that we can be together when you are lying down and Im sitting up, even when there is something sad here as well.

He was quiet for a while. I could feel an urge for a new bouillon-break, but fortunately the inner sickness was too strong. I had some thoughts about a strong windscreen without fractures.
P: oh dear, my chest has started to ache. A: Maybe something came to your mind? P: Oh no, its the chest, can I stay on the couch . . . I have to get up!

He got up and approached the chair. This was a great disappointment for me, and I wondered if he had noticed.
P: Am I just to give up, it turns around so quickly, whats good cant last, I need so much more. A: You need more than 45 minutes here. P: Yes, thats correct, but now I just have to wait for my breakdown, thats how it feels right now.

AMBIGUITY OF THE PSYCHOANALYTIC SITUATION

527

I could feel that something was collapsing in me too when he stood up. It was unpleasant, but it also felt as if something had opened up, that I was less professional and more human.
A: You can feel it and speak about it; maybe thats because you can stand it a little bit more too. P: It doesnt feel like that at the moment, but my GP always says to me, when I want her to take another sample or test, that we can measure almost anything, but we dont always know what the results really mean. Shes probably right.

After a weekend break a few weeks later, the patient came to a session in a happy and enthusiastic mood. My weekend had been rather noisy, with fussing and nagging from kids. The patient described his relationship to his 2-year-old nephew; he was so fun to play with. I said something about the difference between husband and friend, and father and uncle, how good it is to be an uncle who can enjoy the happy moments with a child and then leave when the trouble starts. He probably sensed that my own experience was seeping out and forming my response (enactment). I thought that the next coming from him would be a litany of bodily complaints, but his reaction was a good laugh, a laughter I did not know he had. He said: Yes I know, you must be right, you are the one to know. He was silent for a while, then he remembered a dream from his childhood, a dream he had several times just after he was cured from his cancer. In the dream he wakes up at night and starts to move in the direction of his parents bedroom, but outside the door he is blinded by an intense light and lifted up in the air. My association to the dream was the fact that his brother must have been conceived just before his nal recovery at the age of almost four; the brother was born about ve months after he had ended his oncological treatment. I told him this, and he replied: Yes, thats true; they had to nd comfort in something, and then they made my brother. In my own reverie I was living through my own ambiguous family life and the creation of my own child, which must have taken place approximately a year into his analysis. After 5 years, we had a session containing a discussion on the unconscious and the fact that many things in life are ambiguous and not always easy to understand. The concept of ambiguity had entered our common vocabulary. He was concerned with the fact that, after all, he wanted to achieve as much clarity and understanding as possible.
P: I will try to focus even more on . . . (he checked himself and said with a groan): that was indeed an ambiguous way to defend oneself against ambiguity. A: An ambiguous way to defend against ambiguity? P: Yes, because in the word try we have a double meaning and an emergency exit. Your intention can be to do it, but you could also say that you tried, but that it didnt go. A robot would not understand the word try. You might say that the unconscious needs loud and clear orders. A: But maybe even thats not enough. The unconscious is not a robot. P: No, thats true; its always something more, always! Ooh, this is difcult!

528

VPENSTAD

The Analysts Reverie

I believe that this psychoanalytic process can show how the patients development (including a greater tolerance of ambiguity) has to go through a maturation of the analysts reverie, through the analysts own inner world. To borrow from the skating world again, this analysis illustrates how the analyst can move from being forced into more or less voluntary exile on the stand to a closer relationship with the patient on the rink. The patients improvement depended on my encounter with myself in my own internal skating rink. From there I could gradually open up my mind to receive greater amounts of the patients existence and history. This could not happen without the patient daring to visit my inner rink to see if he could nd some relational meaning there. Thomas Ogden (1997, 2004a, 2004b) is among those who have developed Bions theories about reverie. Bion (1962) used the concept reverie to describe how an infants mother is holding the child in her mind by actively working on her thoughts and experiences with the child. Ogden (2004a) expands the reverie concept to include more than just a description of how the analyst makes himself receptive to the patients projections. He argues that the analysts reverie also includes a motley collection of psychological states that seem to reect the analysts narcissistic self-absorption, obsessional rumination, day-dreaming, sexual fantasizing, bodily sensations, and so on. (p. 177), and he continues:
The workings of the analysts mind during analytic hours in these un-self-conscious natural ways are highly personal, private and embarrassingly mundane aspects of life. [. . .] I believe that a major dimension of the analysts psychological life in the consulting room with the patient takes the form of reverie concerning the ordinary, everyday details of his own life (that are often of great narcissistic importance to him). [. . .] It requires great psychological effort to enter into a discourse with oneself, because to increase the consciousness about our private reverie is to touch on an essential inner sanctuary of privacy, and therefore with one of the cornerstones of our sanity. (pp. 184 185)

The use of our self-knowledge in this way, Ogden argues, is meant primarily to increase our understanding of the patient. Michael Feldman is concerned with how the analysts inner work is demanding but decisive for the patients ability to improve and grow. It is important that the analyst should not just shove aside his reverie, but preserve and retain the belief that inside his reverie there might be something useful, even if it does not seem so at the moment.
If the analyst can retain the belief that the outcome of this intercourse will, on balance, be a constructive one, this offers him some freedom from the tyranny of the demand for exclusive attachments to particular internal objects, as a means of avoiding anxiety and guilt (Feldman, 1993, p. 282). The paradox that we encounter in analytic work is that it is painful and threatening for the patient that the analyst should be able to think for himself, engage in an intercourse within his own mind from which the patient is excluded, [but] the patient relies on the analysts capacity to do this (Feldman, 1993, p. 284).

If the analyst is able to contain himself and his own material, his own private dreamlike states of mind, then this might make him more supportive of the development of a similar state in the patient. Gradually I was able to accept being an ambiguous analyst. To be professional does not mean to be distant or to try to hide everything that happens inside you. This realization came as a gradual and reective process (when the patient, and

AMBIGUITY OF THE PSYCHOANALYTIC SITUATION

529

consequently I myself, became aware of the poor sound insulation of my consulting room, and in the analysts paternity leave and the subsequent dream). But it also happened in a more spontaneous cooperation with the patients increasing openness to, and communication of, his experience of the relationship (as when I said that both of us had survived and I became painfully aware of my own fear of losing a child, or when I said that he might be right in his idea about my relationship with Mercedes cars). We can see a change in the patient in the session where he remembers being at the hospital with his father when he was 10 years old. With the discovery of what was inside this memory, and our ability to connect it to the relational situation (the transference) in the analysis, it was possible for the patient to open up and tolerate a more ambiguous relationship to me. This is also illustrated in the session shortly afterward, when he arrived with his head full of gments. I think gments are his word for the fact that more of what is ambiguous in the relationship can enter his mind. From then on he produced many fantasies about his analyst and our relationship, and simultaneously I became more touched by the patient and the sessions was no longer as boring as they used to be.

The Analyst Makes the Exposure of Himself More Feasible

When the patient insisted that I was only professional and therefore did not have my own personal contribution to make, it was also comfortable for me. It is tempting, in cooperation with the patient, to hide behind a denial of the essential ambiguity of the psychoanalytic situation. An augmented tolerance for the ambiguous could also bring about an increase in the exposure of several parts of the analyst in addition to his professionalism (e.g., when the patient got up from the couch after stating that he thought it was good, and my relationship with Mercedes cars). It is the analyst who must experience and try to understand what the patient cannot relate to without being a cataloging bureaucrat. And it is the analyst who for a long time must work through what has aroused in him and try to give back to the patient in small pieces his understanding of the patient. But a recovery in the patient can also be a product of his discovery of something about ourselves which surprises us, and it can be unpleasant for the analyst when he is exposed in this way. Nevertheless, it is an important sign of development in the patient when he can have courage to come forward with his discovery (Mitrani, 2001). According to Ferro (2002) the patient is all the time listening to and talking about his experience of the analyst. Ferro thinks that these observations can be quite accurate, and he describes how the patient in this way guides the analyst in opening his mind for the patients projections. At the beginning the patient said that he had decided that I had an open mind, there was no need for any guidance because the analyst was a professional who could take anything. Gradually he was able to admit and talk about what I could have in my private mind, and we approached a situation where he could start to guide me and try to examine what I was able to contain in my mind. Joseph (1983) argues that the analyst must explore thoroughly and for a long time what in the patients ideas can be linked to actual observations of him or herself. This is what containing is all about, says Joseph. Hoffman (1983) is expressing the same view:
Every patient brings to bear his own particular perspective in interpreting the meaning of the analysts manifest behavior as it communicates, conveys, or inadvertently betrays something in the analysts personal experience. The fact that a particular perspective may be charged with tremendous signicance and importance for the patient does not nullify its plausibility. If anything, the opposite may be the case (p. 408).

530

VPENSTAD

Joseph (1983) accentuates how this can be a painful process for the analyst. She says that psychoanalysis must be an experience to both patient and analyst if it is to have any effect. The analyst must learn to appreciate his own inabilities, inadequacy and incompetence. It becomes important for the analyst to nd a new way of regulating himself, a way that take into account the inevitability of loss, mistakes and our own vulnerability (Benjamin, 2004; Slochower, 1996). If the patient can manage to regard the analyst as less omnipotent, and not only as a professional, then he can nd a more realistic and endurable strength in the analyst. The patient can identify with this durability and introject it as a more realistic (ambiguous) relational experience and a more endurable inner object (Feldman, 1993). Feldman (1993) puts forward that it is important that the patient can experience that his attempts to destroy the analysts reverie has not succeeded. This brings the patient in contact with an analyst who is capable of caring for his ability to think for himself and to have a private mind. Ambiguity does not necessarily mean that something is hidden while something else is visible. Merleau-Ponty said that our existence always has several different meanings and that this existence can never be denitely registered or nally understood. If we think that we have discovered something about ourselves or someone else, there will always be something else that is yet to be discovered and that could expand or change our apprehension (this equates to Fonagy et al.s (2004) and Bions (1962, 1965) fundamental principle of never-ending learning from experience). This patient wished that his (and my) existence should be accounted for once and for all; he wanted an unambiguous settlement. When the patient started to open his mind to the ambiguous, it happened through his courage in discovering me, and at the same Time I let myself be discovered (exposed). This does not mean that I have self-disclosed who I really am or that the patient has revealed the actual person of the analyst. What it means is that he has conrmed that there is something more about me that he can discover, but I will never be nally accounted for. Through the discovery of parts of the analysts reverie, the patients belief in the possibility of enduring different mental states and their ambiguity increased. It is not only the contents of the analysts reverie that are important for the patient, but also the discovery of its function. One example was when the patient gave more than one meaning to cutting his nger, one concrete and one symbolic. He understood that there is a place where his wound can be healed without his being active or having to look after it all the time. Another example occurred in the session when he could see through my reaction to the story about his nephew. I may have invited the patient to say something about his experience of my person too soon, and this was very scary for him. At the beginning he consistently reacted by denying that he had seen or captured anything about me. If I had encouraged him to say something about, for instance, my Mercedes in the rst years of the analysis, this would have resulted in a litany of bodily discomfort, pain and agony, and he would have had to leave the session to visit the toilet. Simultaneously he probably noticed that I was not ready to receive him and his experience of our relationship and me. Courage works both ways. When the analyst increases his courage to stand an enhanced exposure of his own person, the patient can dare to come forward with his perception of the relationship.

Toward a More Alive and Authentic Analyst

My opportunity to talk to the patient about the Mercedes in this way, and to appreciate that he could be right in his conception of the fact that I own a car that is supposed to stand

AMBIGUITY OF THE PSYCHOANALYTIC SITUATION

531

everything, increased my ability to be more open and alive and less occupied with being so clever and always available with all my knowledge. In one session the patient said that he thought his analyst had become something other than what the rst impression had suggested, and it was now possible for the patient to come forward with his wish to start analysis with me as a 6-year-old. It seems as though he started to understand the ambiguity of his being here both as a grown-up and as a child. He probably tried to make this concrete by asking if I was newly educated at that time. I perceived his question as an attempt to keep the fantasy alive, more than as a ight away from the ambiguity in his presence and in the age difference between us. The patient apprehended that the analyst had changed from a newly educated need to be clever type of analyst to a more experienced analyst after 5 years. A fresh analyst probably needs to cling to a one-dimensional and unambiguous professionalism. Experience is marked by a more exible and authentic attitude and an increased negative capability and an ability to encounter ambiguity. My analytic attitude was gradually marked by a decreasing need to follow the patient all the time and never disappear into my own thoughts and daydreams. When I could tolerate the fact that private thoughts had a place in my mind, I could also tolerate the patients strong attempts to keep me away. One of the consequences of this was the patients growing interest in several parts of my person (for instance, the women in my ofce and what could have happened there) and his growing ability to establish a stronger transference through the memory of his father not being able to help him at the hospital when he broke his leg as a 10-year-old.

The Concept of Living Through

Elsewhere (Vpenstad, 2008) I have tried to describe a phenomenon I have called living through in the psychotherapeutic work with a severely disturbed child patient. I think this can be equally important in the work with adult patients. By this I mean that the therapeutic work with borderline children (and maybe with other children and adults to) must be done jointly by the therapist and the patient. They must both carry out the work of development and change. It is not always possible to nd out whom the actual feeling belongs to or where it originally came from, and it is not always possible to distinguish between, or nd out, when the feeling left the therapist (in a transformed way) and entered the child. This process goes back and forth, and I think it can be helpful to think about this as a joint venture where the therapeutic development lies in the experience of doing it live or together living it through. The child and therapist are doing it, rather than talking about it, and this means that the therapist also must be willing to change in some way. (Vpenstad, 2008, p. 223) I think that my paternity leave and the dream I had about 3 years into the analysis are examples of living through. The paternity leave and the dream made me understand that I had to choose between funeral boredom (Green, 1986, p. 163) and the analysts act of freedom (Symington, 1986). The rst choice is connected to a correct or classical technique, marked by an analyst who is quiet, unavailable and just professional. The second choice is an analyst who through his inner life moves, develops and changes (Slavin & Kriegman, 1998) in a way that the patient can join. So what made it possible for me to choose the second alternative? I think that my private experiences at the time of this analysis both consciously and unconsciously made me more tolerant of the ambiguity in life and in psychoanalysis. The feeling in my dream

532

VPENSTAD

was helplessness, but not hopelessness. This gave me a greater tolerance for my own ambiguous position including a decreased need to be clever all the time. The analysis became more important for me personally. It changed from being a boullion-pair to becoming a treatment process that I wanted to write about. As Klauber (1986) has put it, being this patients psychoanalyst started to give me some satisfaction:
The most neglected feature of the psychoanalytic relationship still seems to me to be that it is a relationship. [. . .] Patient and analyst need one another, [. . .] the analyst also needs the patient in order to crystallize and communicate his own thoughts, including some of his inmost thoughts on intimate human problems which can only grow organically in the context of the relationship. They cannot be shared and experienced in the same immediate way with a colleague, or even with a husband or wife. It is also in his relationship with his patients that the analyst refreshes his own analysis. It is from this mutual participation in analytic understanding that the patient derives the substantial part of his cure and the analyst his deepest condence and satisfaction. (p. 46)

The analyst must acknowledge and contain his need to take care of both his professional and his private life. And the analyst must understand that there is no way that he can make a soundproof wall between his private and professional life. My dream concerned both my personal life and the patients treatment. The patient was gradually able to take advantage of my increased ability to endure the exposure of my subjectivity in the analysis. This process developed from an almost exclusive meeting with myself in my own private reverie to an intersubjective and experiential dimension (Wachtel, 2008) in living through a meeting of minds (Aron, 1996).

The Aliveness in Ourselves

The patient has come to life and can show more emotion, even if this does not mean that his life is easier. Joseph (1983) says that improvement in some patients is marked not only by an increased emotionality, but also by the patient engaging in the analytic work in a new and more comprehensive way. In that context the fear of breakdown (Winnicott, 1974) is also a sign of improvement (Abram, 1996; Ghent, 1990). The patient became able to experience more of the original trauma in the analysis and in the transference, for instance when he had to leave the couch and acknowledged that he needed more than 45 minutes. The analysts interventions are not adjusted to an objectively accounted and thoroughly measured receiver, but nevertheless have an effect because I believe more and more in what I say. I can concentrate on description rather than on change, and my level of activity seems not to overwhelm the patient; he displays aroused emotionality and pain but also an increased vitality. The patient can feel that I am trying to describe him, think about him and want to take part in the construction of his history. It is important not only to uncover something inside the patient, something that was there from the start, but also to describe him and create him from what is alive, and ambiguous, in ourselves.

References
Abram, J. (1996). The language of Winnicott. London: Karnac Books. Adler, G. (1989). Transitional phenomena, projective identication, and the essential ambiguity of the psychoanalytic situation. Psychoanalytic Quarterly, 58, 81104.

AMBIGUITY OF THE PSYCHOANALYTIC SITUATION

533

Anzieu, D. (1989). The skin ego. New Haven, CT: Yale University Press. Aron, L. (1992). Interpretation as expression of the analysts subjectivity. Psychoanalytic Dialogues, 2, 475508. Aron, L. (1996). A meeting of minds: Mutuality in psychoanalysis. Hillsdale, NJ: Analytic Press. Aron, L. (2006). Analytic impasse and the third: Clinical implications of intersubjectivity theory. International Journal of Psychoanalysis, 87, 349 368. Baranger, M., & Baranger, W. (2008). The analytic situation as a dynamic eld. International Journal of Psychoanalysis, 89, 795 826. (Originally published in 19611962) Bateman, A. W. (1998). Thick- and thin-skinned organisations and enactment in borderline and narcissistic disorders. International Journal of Psychoanalysis, 79, 1325. Benjamin, J. (2004). Beyond doer and done to: An intersubjective view of thirdness. Psychoanalytic Quarterly, 73, 5 46. Bion, W. R. (1962). Learning from experience. London: Karnac Books. Bion, W. R. (1965). Transformations. In W. R. Bion (Ed.), Seven servants (pp. 111183). New York: Jason Aronson. Chused, J. F., & Raphling, D. L. (1992). The analysts mistakes. Journal of the American Psychoanalytic Association, 40, 89 116. De Bernardi, B. D. (2000). The countertransference: A Latin American view. International Journal of Psychoanalysis, 81, 331351. Ellman, S. J. (2002). Freuds technique papers. New York: Other Press. Feldman, M. (1993). The dynamics of reassurance. International Journal of Psychoanalysis, 74, 275285. Ferro, A. (2002). In the analysts consulting room. London: Routledge. Ferro, A. (2009). Mind works: Technique and creativity in psychoanalysis. The New Library of Psychoanalysis. London: Routledge. Ferro, A., & Basile, R. (2008). Countertransference and the characters of the psychoanalytic session. Scandinavian Psychoanalytic Review, 31, 310. Fonagy, P., Gergely, G., Jurist, E. L., & Target, M. (2004). Affect regulation, mentalization, and the development of the self. London: Karnac Books. Freud, S. (1955). From the history of an infantile neurosis. In J. Strachey (Ed. and Trans.), The standard edition of the complete psychological works of Sigmund Freud (Vol. 17, pp. 1124). London: Hogarth Press. (Original work published 1918) Freud, S. (1958). Recommendations to physicians practising psycho-analysis. In J. Strachey (Ed. and Trans.), The standard edition of the complete psychological works of Sigmund Freud (Vol. 12, pp. 109 120). London: Hogarth Press. (Original work published 1912) Freud, S. (1959). Beyond the pleasure principle. In J. Strachey (Ed. and Trans.), The standard edition of the complete psychological works of Sigmund Freud (Vol. 18, pp. 1 64). London: Hogarth Press. (Original work published 1920) Ghent, E. (1990). Masochism, submission, surrender: Masochism as a perversion of surrender. Contemporary Psychoanalysis, 26, 108 135. Green, A. (1986). On private madness. London: Karnac Books. Hoffman, I. Z. (1983). The patient as interpreter of the analysts experience. Contemporary Psychoanalysis, 19, 389 422. Hoffman, I. Z. (1998). Ritual and spontaneity in the psychoanalytic process. Hillsdale, NJ: Analytic Press. Hoffman, I. Z. (2006). Forging difference out of similarity: The multiplicity of corrective experience. Psychoanalytic Quarterly, 75, 715751. Jacobs, T. (2001). On misreading and misleading patients: Some reections on communications, miscommunications and countertransference enactments. International Journal of Psychoanalysis, 82, 653 669. Joseph, B. (1983). On understanding and not understanding: Some technical issues. In M. Feldman & E. B. Spillius (Eds.), Psychic equilibrium and psychic change. Selected papers of Betty Joseph (pp. 139 150). London: Routledge.

534

VPENSTAD

Kahn, M. M. R. (1986). The concept of cumulative trauma. In G. Kohon (Ed.), The British school of psychoanalysis: The Independent tradition (pp. 117135). London: Free Association Books. Karlsson, G. (2000). The question of truth claims in psychoanalysis. Scandinavian Psychoanalytic Review, 23, 324. Klauber, J. (1986). Difculties in the analytic encounter. London: Karnac Books. Klein, M. (1997). Notes on some schizoid mechanisms. In M. Klein (Ed.), Envy and gratitude. The writings of Melanie Klein. (Vol. 3, pp. 124). London: Vintage. (Original work published 1946) Kohon, G. (2007). Borderline traces and the question of diagnosis. In A. Green (Ed.), Resonance of suffering: Countertransference in non-neurotic structures (pp. 203215). London: International Psychoanalytical Association. Ku nstlicher, R. (1994). Nachtra glichkeit. The intermediary of an unassimilated impression and experience. Scandinavian Psychoanalytic Review, 17, 101118. Meltzer, D., & Williams, M. H. (1988). The apprehension of beauty. Perth: Clunie Press. Merleau-Ponty, M. (1962). Phenomenology of perception. London: Routledge. Merleau-Ponty, M. (1969). Phenomenology and psychoanalysis, preface to Hesnards LOeuvre de Freud. In A. L. Fisher (Ed.), The essential writings of Merleau-Ponty (pp. 81 87). New York: Harcourt, Brace & World. Milner, M. (1987). The suppressed madness of sane men. The New Library of Psychoanalysis. London: Routledge. Mitchell, S. A. (1993). Hope and dread in psychoanalysis. New York: Basic Books. Mitchell, S. A. (1997). Inuence and autonomy in psychoanalysis. Hillsdale NJ: Analytic Press. Mitrani, J. L. (2001). Ordinary people and extra-ordinary protections. A post-Kleinian approach to the treatment of primitive mental states. London: Routledge. Modell, A. H. (1988). Changing psychic structure through treatment: Preconditions for the resolution of the transference. Journal of the American Psychoanalytic Association, 36S, 225239. Ogden, T. (1997). Reverie and interpretation. London: Karnac Books. Ogden, T. (2004a). The analytic third: Implications for psychoanalytic theory and technique. Psychoanalytic Quarterly, 73, 167195. Ogden, T. H. (2004b). On holding and containing, being and dreaming. International Journal of Psychoanalysis, 86, 1349 1364. Orange, D. M. (1995). Emotional understanding. Studies in psychoanalytic epistemology. New York: The Guilford Press. Phillips, A. (1995). The story of the mind. In E. G. Corrigan & P.-E. Gordon (Eds.), The mind object (pp. 229 240). London: Karnac. Pick, I. B. (1985). Working through in the countertransference. In R. Schafer (Ed.), The contemporary Kleinians of London (pp. 348 367). Madison, CT: International Universities Press. Sass, L. A. (1998). Ambiguity is of the essence: The relevance of hermeneutics for psychoanalysis. In P. Marcus & A. Rosenberg (Eds.), Psychoanalytic versions of the human condition (pp. 257305). New York: New York University Press. Sass, L. A., & Woolfolk, R. L. (1988). Psychoanalysis and the hermeneutic turn: A critique of narrative truth and historical truth. Journal of the American Psychoanalytic Association, 36, 429 454. Skolnikoff, A. Z. (1996). Paradox and ambiguity in the reactions of the analyst at work. Psychoanalytic Inquiry, 16, 340 361. Slavin, M. O., & Kriegman, D. (1998). Why the analyst needs to change: Toward a theory of conict, negotiation, and mutual inuence in the therapeutic process. Psychoanalytic Dialogues, 8, 247284. Slochower, J. A. (1996). Holding and psychoanalysis. Hillsdale, NJ: Analytic Press. Smith, H. F. (1993). Engagements in the analytic work. Psychoanalytic Inquiry, 13, 425 454. Spence, D. (1982). Narrative truth and historical truth: Meaning and interpretation in psychoanalysis. New York: Norton. Spezzano, C. (2001). How is the analyst supposed to know? Gathering evidence for interpretations. Contemporary Psychoanalysis, 37, 551570.

AMBIGUITY OF THE PSYCHOANALYTIC SITUATION

535

Stern, D. B. (1997). Unformulated experience. Hillsdale, NJ: Analytic Press. Symington, J., & Symington, N. (1996). The clinical thinking of Wilfred Bion. London: Routledge. Symington, N. (1986). The analysts act of freedom as agent of therapeutic change. In G. Kohon (Ed.), The British school of psychoanalysis: The independent tradition (pp. 253270). London: Free Association Books. Vpenstad, E. V. (2008). Can you whistle?: The grammar of living through in psychoanalytic child psychotherapy. International Forum of Psychoanalysis, 17, 221231. Wachtel, P. L. (2008). Relational theory and the practice of psychotherapy. New York: The Guilford Press. Winnicott, D. W. (1949). Mind and its relation to the psyche-soma. In D. W. Winnicott (Ed.), Through paediatrics to psycho-analysis (pp. 243254). London: Karnac Books (1984). Winnicott, D. W. (1971). Playing and reality. London: Routledge. Winnicott, D. W. (1974). Fear of breakdown. In G. Kohon (Ed.), The British school of psychoanalysis: The Independent tradition (pp. 173182). London: Free Association Books (1986).

Showcase your work in APAs newest database.

Make your tests available to other researchers and students; get wider recognition for your work. PsycTESTS is going to be an outstanding resource for psychology, said Ronald F. Levant, PhD. I was among the rst to provide some of my tests and was happy to do so. They will be available for others to useand will relieve me of the administrative tasks of providing them to individuals.

Visit http://www.apa.org/pubs/databases/psyctests/call-for-tests.aspx to learn more about PsycTESTS and how you can participate.

Not since PsycARTICLES has a database been so eagerly anticipated!

Questions? Call 1-800-374-2722 or write to tests@apa.org.