Welcome to my blog, a place to explore and learn about the experience of running a psychiatric practice. I post about things that I find useful to know or think about. So, enjoy, and let me know what you think.

Sunday, May 31, 2015

The Blank Screen

The question of the psychiatrist's relative anonymity has come up lately in an interesting way. In a recent twitter conversation, Jeffrey Lieberman made a comment about a piece in the NY Times, to which Dinah from Shrink Rap responded, and things went back and forth, with others chiming in. Dinah noted that one of the "chimers" was driving some of the contention, but does not identify himself, and that to effect real change, perhaps he should.

More recently, Dinah published a post on Shrink Rap about this issue. The bottom line is that she is basically herself with her patients, but not fully so.

Dear readers, you may have noticed that I don't use my real name on this blog. The reasons are complicated. In truth, a strongly determined patient could figure out that her psychiatrist writes this blog. Just as a moderately determined reader could figure out my real name. I haven't tried to make it impossible.

But I do think there's a difference between a patient seeking out a connection, and my shoving my opinions and experiences in her face. The former is the proverbial grist for the mill. The latter is my making my patient's treatment about me.

I like the way a little anonymity frees me up to make snarky, sarcastic, or even kind, generous comments. I like the fact that I'm writing my own blog, not for some other publication, where I would contain, or at least subdue my personal take, in favor of something more evenhanded. In fact, I have done just that writing for Carlat. 

In my work with patients, I rarely offer advice, mostly because how am I supposed to know better than my patient what he should do, or if I can figure it out, so can he, so there's something important to understand about why he hasn't done so. 

Granted, I no longer work with patients who are very sick. Back when I did, I was much freer with advice and suggestions, because I felt that's what they needed. 

Similarly, I rarely share my opinions, or personal information. But sometimes I do. It all depends on whether or not I think it's helpful. And sometimes, it's hard to know.

I don't practice that way, and it's not how psychoanalysis in general is practiced these days, nor  has it been for quite some time, but the stereotype (Freud, S. (1912). The Dynamics of Transference. The Standard Edition of the Complete Psychological Works of Sigmund Freud, Volume XII (1911-1913), 97-108, p.99.) of the silent analyst sitting behind the couch, acting only as a mirror or a blank screen persists.

So let's consider the concept of the blank screen.

The earliest reference I can find in the analytic literature (on pep-web), is in Jelliffe, S.E. (1930). British Journal of Medical Psychology. Psychoanal. Rev., 17:348-359.

The analyst becomes a blank screen upon which are projected pictures of the patient's infantile life. 

In Character Analysis (1933 New York: Orgone Institute Press, 1945 pp. 4ff., 119-140, p. 137) Wilhelm Reich makes the following statement with respect to countertransference:

… it is a mistake to interpret the general analytic rule that one has to approach the patient as a blank screen onto which he projects his transferences in such a manner that one assumes, always and in every case, an unalive, mummy-like attitude. Under such circumstances, few patients can "thaw out, " and this leads to artificial, un-analytic measures. It should be clear that one approaches an aggressive patient unlike a masochistic one, a hyperactive hysteric unlike a depressive one, that one changes one's attitude to one and the same patient according to the situation, that, in brief, one does not behave neurotically oneself, even though one may have to deal with some neurotic difficulties in oneself.

Yes, this is the same Wilhelm Reich that Lieberman writes about in Shrinks. He had his nutty ideas about "orgone", but he also wrote an amazing book on character.

These are some more references:

The concept of the analyst as a blank screen is an abstraction...The countertransference appears today as an inevitable impurity due to the fact that every analyst, in spite of his analysis, remains an individual with his own characteristic interpersonal patterns which he cannot entirely eliminate from the treatment situation, just as he cannot change the timbre of his voice, the expression of his eyes, the height of his body. Alexander, F. (1954). Some Quantitative Aspects of Psychoanalytic Technique. J. Amer. Psychoanal. Assn., 2:685-701.

In the psychoanalysis of adults, the psychoanalyst keeps his personality in the background as much as possible. The better the psychoanalyst succeeds in being like a blank screen, the easier it is for the patient to regress from an object relationship to a transference relationship, to project upon the psychoanalyst infantile fantasies and to re-enact phases and situations of the remote past. It is, in other words, desirable that the analyst avoid becoming a member of the patient's primary group. Sperling, O.E. (1955). A Psychoanalytic Study of Social-Mindedness. Psychoanal Q., 24:256-269.

the old concept of presenting a blank screen to the patient may have been reduced to absurdity by many psychoanalysts, [but] the fact remains that deliberately adopting special attitudes and time restrictions for special cases changes the character of therapy in these cases, converting it into a form of rapport therapy. This may indeed have excellent results. What form of psychotherapy cannot produce its quota of excellent results or, for that matter, condign failures? It may indeed be the only alternative in cases which are inaccessible to the customary technique. The important issue cannot be burked. Do such practices constitute psychoanalytic therapy or are they simply forms of rapport therapy?Glover, E. (1964). Freudian or Neofreudian. Psychoanal Q., 33:97-109.

And more recently:

The assumption, for example, that the blank screen was the aspirational goal for the analyst to maintain can not only be challenged on theoretical grounds, but also on the more relevant observation that there is no such thing as a blank screen, and analysts are always revealing themselves consciously and unconsciously to the patient. MacGillivray, W.A. (2011). Psychoanalysis Never Lets Go Freud and His (Reluctant) Followers: From Classical to Contemporary Psychoanalysis: A Critique and Integration by Morris N. Eagle New York and Hove: Routledge, 321 pp., $36.95, 2011. DIVISION/Rev., 3:10-13.

Freud does not explicitly use the term ‘blank screen' in his work to describe the neutrality of the analyst, but rather gradually develops a non-invasive approach to psychotherapy in which the analyst ‘gives up the attempt to bring a particular moment or problem to light’ (Freud, 1914, p. 147), and refuses to ‘decide [the] fate’ of the patient or to ‘force our own ideas upon him, and with the pride of a Creator to form him in our own image and to see that it is good’. Carpenter, A. (2010). Towards a History of Operatic Psychoanalysis. Psychoanal. Hist., 12:173-194.

In, Observations on Transference Love (Freud, S. (1915). Observations on Transference-Love (Further Recommendations on the Technique of Psycho-Analysis III). The Standard Edition of the Complete Psychological Works of Sigmund Freud, Volume XII (1911-1913), 157-171, p 163.), one of his 5 technique papers, Freud writes about "neutrality".

...we ought not to give up the neutrality towards the patient, which we have acquired through keeping the counter-transference in check.

Freud certainly was not anonymous to his patients. Many were colleagues and friends, not to mention his daughter. He saw them in his home. He took up a collection to help provide income for the Wolf Man. He joked with his patients. Flirted with them. He did a lot of things most therapists would call boundary crossings or violations today. And we now know not to do these things, in part, because he did them.

But he tried his best, based on whatever he knew at any given time, not to get in the way of the analytic process. To let the patient free associate, and to maintain an attitude of observation and inquiry toward the patient's productions. I think that's what he meant by neutrality.

A good exposition is given by Glover (Glover, E. (1928). Lectures on Technique in Psycho-Analysis (Concluded). Int. J. Psycho-Anal., 9:181-218.):

Is it actually the case that in the customary analytic methods we do preserve complete detachment? It is immediately obvious that in certain respects we do not. For example, we are rarely content with the material given to us, but by interpretation imply that material exists which for some reason or another has not been presented to us...
...we have to admit that interpretation is not strictly detached, but, on the other hand, whatever the patient may think, it is not an actual repetition of a parental attitude. Again, when a patient comes late we do not remain detached; if need be we go out of our way to bring this fact into associative connections. Again the patient reacts as if we had said, 'You miserable little procrastinator, what do you mean by not coming when I told you to come?', and again we are able to investigate this repetitive reaction...In fact, whether the analyst is content with a simple suggestion or backs it with authority, he will usually find that his patient takes occasion to react to the situation in some typically infantile way, and he will be able to make some capital out of the analysis of such a reaction. Nevertheless, in a negative way he has on this occasion abandoned neutrality and has taken up a parental rĂ´le, which the patient legitimately identifies with the prohibitive activities of his own super-ego, or, going further back, with the categorical forbiddings issued by his parents...
...It is therefore true to say that, in the usual analysis, there are isolated occasions when the analyst abandons his attitude of neutrality...or, in other words, plays the part of parent or super-ego...

So the idea was that full detachment and neutrality are impossible, but should be pursued by the analyst in order to allow the patient to engage in the analysis and to examine patterns of thinking, feeling, and behavior. If the analyst abandons neutrality and intervenes, she is participating in those patterns rather than facilitating their examination.

Nonetheless, it has become clear in the intervening century since Freud started developing these ideas that not only are full neutrality and detachment impossible, but the attempt at achieving them can create a stilted analysis, and make it impossible for the patient to make use of the treatment. So the blank screen is no longer considered a goal for the analyst. 

In 1995, Owen Renik wrote, The Ideal Of The Anonymous Analyst And The Problem Of SelfDisclosure ( Psychoanalytic Quarterly, 64:466-495).

Renik believes that ANY anonymity is impossible, a myth, a self-idealization. If an analyst states an opinion, Renik sees this as a way to encourage the analysand to explore his own opinions. He advocates a less authoritative stance by the analyst, and references Winnicott's notion that when he discussed his own ideas in a session, these were merely, “subjective objects placed between analyst and patient,” to be examined and tossed around and understood. 

In other words, Renik rejects the blank screen as an authoritative stance by the analyst, and a false one, at that, designed to promote idealization of the analyst in the analysand. He believes that the analyst's thinking should be made available to the patient. My impression is that he believes this should be true at all times.

I think Renik is extreme, and the disclosure he encourages can amount to a narcissistic turning of the treatment's focus on the analyst, rather than the patient. But I agree that a complete absence of disclosure is both impossible and undesirable. The real skill is in discerning when it will and won't be helpful to disclose.

I don't hold by the belief that telling a patient something about myself will necessarily prevent the development of fantasies. Sometimes it facilitates them. 

In, Some Reflections on the Question of Self-Disclosure (Journal of Clinical Psychoanalysis, 1997, 6:161-173) Ted Jacobs writes: 

...certain revelations on the part of the analyst can limit or inhibit aspects of the patient's imagination and the free flow of fantasy. Since we are interested in the patient's creations, and, theoretically, these are stimulated by nondisclosure and analytic anonymity, the use of self-revelation would seem to work against our aims. If a patient knows, for instance, that I was skiing in Vermont a few weekends ago, it is unlikely that she will imagine me tanning myself on the beaches of Oahu. Clearly, this is a limitation. On the other hand, nondisclosure and analytic anonymity, especially if rigidly and automatically applied, can have a far more limiting effect.

In certain patients, those who have had long experience with secretive, nonresponsive parents or whose self-esteem is particularly fragile, the traditional analytic attitude with regard to self-disclosure may have a stultifying, and quite inhibiting, effect. Instead of functioning to free up the mind and to open up communication, it can shut it down.

It is good to remember, too, that if, for a particular reason, I choose to reveal where I've been on my brief vacation, that surely does not put an end to my patient's fantasies. It may, in fact, prove to be a powerful stimulus to them. There remains much room for my patient to fantasize, much in his inner world to explore. The patient, for instance, is quite free to imagine me, as often happens, as a tangle foot novice on the slopes, nearly breaking my neck on the beginners' hill; or, less frequently, but more accurately, as completing the giant slalom in record time.

In this post, I've used the terms, "anonymity", "neutrality", "detachment", and "blank screen" somewhat interchangeably, but they are not identical. I suppose, for me, anonymity means not linking to my blog from my LinkedIn profile. Neutrality means listening openly and without prejudice to what my patients tell me, and not taking sides, either with the patient, or with whoever the patient perceives to be opposing him, or in the way of Anna Freud, remaining equidistant from the patient's Ego, Id, and Superego. Detachment refers to that delicate place of remaining emotionally engaged, allowing my personality, my humor to show through, but with the clear message that the patient's emotional reactions are not mine. And the blank screen? It's not what I do, or try to do. It isn't part of my clinical "vocabulary".