Paul Ornstein: I strenuously object to prescriptions for treatment that require the puncturing of the optimism of the patient. When I began my analysis, many years ago, I recall one of the things I told my analyst on the first day is that I would not let him tamper with my incurable optimism. He understood this and it led to very interesting developments. From a self-psychological point of view, the analysis is supposed to lead to belated structure building, to the strengthening of the fragmentation-prone self. Once the self is revitalized and made more stable and cohesive, the fantasies that otherwise are maladaptive become unnecessary. There is no need to puncture that fantasy; instead we must accompany the patient, as you said, in the initial phase. But I don’t think there is ever any need to take out the knife. The psychoanalyst should leave the knife at home, or he should not have one. What he needs is a constant effort at understanding, and at articulating this understanding, with a hope that at times—I agree—will never be fulfilled. I also agree that not everybody is analyzable and not every structure can be belatedly strengthened.
Michel Feher: Dr. Akhtar, you presented a nice symmetry between the “someday” fantasy, in which the future prevents the present from taking on substance, and the “if only” fantasy, where the past prevents the present from doing so. But the “someday” may also have another symmetry, an inverse one in which an unending present prevents the future from emerging. This would be the “as soon as” fantasy; for example, “as soon as I finish classifying the books in my library, I’ll be able to get to work.” It is my belief that such procrastination is commonly linked with neurosis, especially obsessional neurosis, but I wonder whether you find any heuristic value in this strictly inverse symmetry.
Janine Chasseguet-Smirgel: Paul Ornstein’s remarks about technique bring up a general point relating to criteria for analyzability. Freud says that we can never give up a satisfaction we once enjoyed, that we can only exchange one satisfaction for another. When it comes to leading the patient from a state of illusion to disillusionment I cannot agree with Paul Ornstein, because this is what analysis is about, though of course it has to be done without leaving the patient feeling abandoned and possibly suicidal. And when we’re dealing with patients who are not neurotic but borderline or perverse, we should keep in mind this criterion for analyzability, namely whether we are able to help them exchange the satisfaction they derive from their illnesses, from the solutions they’ve found for their conflicts and their suffering, for something else that is closer to the reality principle.
One last point: I wonder whether the state of being in love temporarily resolves the “someday” and “if only” fantasies.
Jacques Hassoun: Whenever two boatmen meet each other on the Nile they greet one another and say, “Come and have coffee.” Clearly they will never, but never, stop to have coffee, but it is also the case that never will their paths cross without their saying, “Come and have coffee,” and in Arabic this is called a boatman’s invitation. To pick up on what Paul Ornstein said, is it possible, as an analyst, to say, “Let’s disembark now and have some coffee,” or “I’m going to stop being a boatman,” or “Coffee has become so expensive that I’m not going to invite you any more”?
As far as being in love is concerned, I like to quote something Marina Tsvetayeva said. She was deeply in love with a man, but then she lost all interest in him and barely recognized him when their paths crossed. When he asked what had happened, she replied that when a woman loves a man she sees him as God created him, when she doesn’t love him she sees him as his parents created him, and when she no longer loves him she sees a table or a chair instead of him. Now what we need to know is what kind of table or chair we have the right to reveal in the transference.
(French analyst): With regard to analyzability, it’s a funny thing, but in my experience, after trying and trying, the minute you say that you have to give up and abandon the fantasy of thinking “someday” about a potential analysand, he suddenly becomes analyzable.
Radmila Zygouris: I wouldn’t want this conference to end without a single mention of Harold Searles. Many of us here in France owe a great deal to his book on the treatment of borderline patients. And in connection with the “someday” fantasy I recall how in one of his earlier books he related that, in the course of an analysis with a woman patient who was not analyzable according to traditional criteria, she kept asking him to go with her on a romantic trip to Miami. Of course he resisted this “someday” fantasy of hers, but then one day he understood and told her, “Ah, but it’s just in imagination—well, if it’s just imaginary we can go wherever you want.” And the patient replied, “It’s taken you a long time to make progress.”
Salman Akhtar: I have the greatest respect for Dr. Searles, and his name is in my paper in the bibliography. He also has written about turning pathological hope into mature hope. The experience of giving up hope and then finding that the patient has become analyzable is very common. You know the Kris Study Group monograph on borderline patients—almost all patients began to get better when the analyst gave up. It is not that the patient becomes analyzable because the analyst was waiting, but that the act of the analyst’s giving up constitutes the rupture of pathological hope. What I was saying is that the analyst cannot just sit back and optimistically hope for the patient to become analyzable. This is a definitive intervention; the analyst’s giving up hope is a surgical intervention and in that sense you and I are in agreement.
Dr. Ornstein, I was not at all surprised that you would be vehemently opposed to what I have to say in this regard. I disagree with your statement that the analyst should not have a knife. If we compare the conduct of psychoanalysis to a surgical operation, I think that the psychoanalyst has three kinds of instruments. One is a retractor for removing the tissues, the second is an artery forceps—that is, when we cut an artery we have to clamp it to stop the bleeding—and the third is the scalpel. The retractor is like affirmative intervention and inexact interpretation: “Mmm, I know it hurts,” “Tell me more,” “What happened then?,” “Mmm, so you thought that.” The artery forceps is what in self psychology is called the mending of the disruption.
But if a surgeon performs only with the retractor and the artery forceps, than how is he going to cut? I think psychoanalysis must have surprises. Something new must take place, and for that unmasking, that unveiling, cutting through a layer is essential. You must understand what I am saying about the rupture of pathological hope. If the interpretative technique does not work, then the analyst has to do this, but it is an unusual dimension and I am also aware that it is traumatizing for the patient. But, after all, we raise children and we sometimes traumatize them. We do so for a good purpose, and I don’t think that the fact that the analyst hurts the patient makes this an inappropriate intervention. That is getting too afraid of aggression.
Michel Feher’s comment about the “as soon as” fantasy makes a very good point. In the various character organizations that I mentioned—schizoid, narcissistic, antisocial, schizotypal, transsexual, borderline—I forgot to mention one, and that is the hypomanic organization. In the hypomanic organization the “one day maybe” is supposed to have arrived, and as a result the person is constantly bubbling with confidence. Sometimes we need to induce a dimension of futurity in the patient.
Psychoanalysis began with an interest in the past, with the archeological metaphor of Freud, and then it got interested in the present with the here and now and transference. One thing psychoanalysis has been weak about is the dimension of the future, and this is something I am working to correct. The element of the future enters in from the moment the patient comes for treatment—in the assessment of analyzability, in the hope, the dream, the vision that the analyst has about how the patient would be if he lost the perversion, the neurosis, and so forth. Now I know it may rub some people the wrong way when I say that the analyst can have a vision about the patient. But I think this would be like saying that a mother should not have a vision about her child, and we can disagree over this. But your point is well taken that in some patients we will need to induce the future. I think the point about obsessional neurosis is also very well taken.
In connection with the issue of analyzability, I recall hearing of an anecdote in which someone said to Freud,
A friend of mine has some problems, and he asked me whether he should be in analysis. I told him, “Why not? If it doesn’t help, at least it won’t hurt.” Freud got very upset and said, “Did you tell him it won’t hurt, that it is a harmless procedure?” And then in his characteristic triumphant way he said, “I predict that a day will come when psychoanalysis will be considered as a legitimate cause of death.”
The point I am trying to make is that it is naive, and also disrespectful of psychoanalysis, to believe that it can do everything. It cannot help everybody. There are people who have very defective egos, who for instinctual reasons have very tenacious fixations, people who, because of their experiences, have large stakes in staying sick. There are people who are not capable of this kind of metaphorical dialogue because for cultural reasons they don’t have a sufficient degree of self-observing ego. And so forth. I believe that not everybody can be analyzed.