Writing about Psychotherapy
Writing and psychotherapy dwell on the same plane for me - both pursue the same goal, which is to make life richer and more creative.
I have been writing creatively since I was 9 years old. I distinctly remember lying on my bed and watching the sun rays play through the half-open shutters. I thought of the sun as a playful being that is entering my room, seeking company. I got up and scribbled a few lines, in Hebrew, about that experience. Thus my journey as a writer began.
And psychotherapy? That of course started much later. I completed my first Counselling course at Nottingham Counselling Service in 1990. I began seeing clients back then as part of my training. I then completed my MSW (CCTSW) at The University of Nottingham in England in 1992 (for my motives read this Guardian interview). Upon returning to Israel, I continued my training in a three-year Post-Graduate Psychoanalytic Psychotherapy programme at Bar-Ilan University which I completed in 1997 (I am the Deputy Director of that programme).
Relying upon language as the key element bridging between literature and psychoanalysis, Thomas Ogden and his son Benjamin Ogden write that: "Language is not simply a medium for the expression of the self; it is integral to the creation of the self (which is a continuing, moment-to-moment process). In the analytic setting, with its focus on talking as the principal means of communication, voice and language usage are among the principal ways in which individuals bring themselves into being, 'come to life '”. This is particular relevant to listening with the utmost attention to the complexities of the human voice of the patient and the therapist. The onus of this attention is placed upon the therapist who has to master a very complex attention span which stretches like a web almost infinitely. The main source is of course the voice of the patient. But the voice is never one dimensional. Another possible dimension is the particular cultural and national accent which the therapist has to recognize and become familiar with. This may be true to every culture, but working in Israel, the therapist has to differentiate between not only several nationalities, but also widely differing ethnic backgrounds, place of residence and varying degrees of religiosity (including the professed absence of any). Another dimension would be the subtleties of the patient's voice as they alter from one session to another and within each session in relation to his affective state and transference position. Interlinked with this last dimension is the therapist own multi-layered voice. The links between the two voices create yet another dimension which extends the web of attention deep into the unconscious realm where both voices form a new and yet-undiscovered territory. The exploration of this unknown territory is conducted, according to Ogden and Ogden, with the same minute and careful approaches that one adopts when reading a literary text which contains unfamiliar vocabulary and syntax. "The therapist treats the literary work as a creation, in the medium of writing, of a state of mind that the author has experienced in the past or is experiencing (perhaps for the first time) in the very act of writing” Thus, the therapist listens to the patient's words, and his own, as to a text being written during the session. This text is a live event, linked to past occurrence. Furthermore, this live event is in fact a performance of souls where the patient's whole being interacts, consciously and unconsciously, with the therapist's. The text analyzed, therefore, is not only what the therapist or the patient say, but the whole web, or matrix that evolves during their time together. And in this web are caught words, images, memories, objects and introjects.
I was faced with the dilemma a psychotherapist-who-writes encounters when wishing to explore and share, through writing and publishing, clinical materials. The first difficulty which arises in this respect is the question of confidentiality. How can one write about one’s patients without breaking the ground rule of confidentiality? I had an article published on this matter in the Israeli Annual of Psychoanalysis Maárg (Prof Moshe halevi Spero was the Editor) in 2016.
This dilemma has been dealt with throughout the history of psychoanalysis. It was first mentioned by Freud (1856-1939) in his 1915 article concerning love-transference where he wrote:
"We are constantly coming up against the obligation to professional discretion – a discretion which cannot be dispensed with in real life, but which is of no service in our science. In so far as psycho-analytic publications are a part of real life, too, we have here an insoluble contradiction. I have recently disregarded this matter of discretion at one point, and shown how this same transference situation held back the development of psycho-analytic therapy during its first decade."
Freud’s reference to the issue of transference clearly indicates that any divergence from the confidentiality rule will have significant consequence, most likely detrimental ones, upon the therapeutic process. Since then, the issue has been widely explored in the psychoanalytic literature. Several models and solutions have been offered to deal and resolve this dilemma. Most writers emphasized Freud’s righteous claim for scientific progress as the positive motivation for continuing the tradition he has established whereby confidentiality is in fact breached to some extent. Several writers have recommended techniques such as disguising, displacing and distorting clinical and personal issues to try and reduce the harm done by such a breach. Others have offered an alternative whereby details from several patients will be put together deliberately, this enabling to writer to maintain some confidentiality and at the same time also enabling him to explore common clinical themes arising in different setting. Yet another alternative has been offered which is focusing upon the clinician’s process with divulging any revealing details.
Another aspect of the issue has to do with the question of the impact of writing, or wishing to write, clinical case studies upon the clinicians’ attentive and listening position in regard to the patient. It is argues that the clinician who is also a fiction and poetry writer, as is the author of this essay, deals with another difficulty. Who does such a clinician contain his creative desire and keeps separate his inspiration for prose and poetry from drawing upon and intermingling with clinical details derived from therapeutic work? Is it indeed possible to maintain a strict and impenetrable boundary in such a case, considering the prevalence of underlying unconscious process which motivate and nourish all creative impulses?
Bearing in mind the close relationship between psychoanalysis and literature, it is argues that any clinical study is in fact also a fictions study. Drawing upon the study of Hermeneutics, it is argued that fiction and fact are often so closely tied up together in the process of writing, that it is perhaps advisable, or at least feasible, to abandon the attempt to clearly delineate between the two, when dealing with the retelling of clinical material.
I offer a new alternative, based upon an existing tradition brought to perfection by the like of Irving Yalom (1931- ). Yalom emphasizes that the writing of his clinical stories and vignettes touch upon universal existential realities that can be described in such a manner so they do not reveal the particulars of these patients and yet remain true to the processes encountered in the room. Yalom does not claim to maintain his patients’ privacy. He tells their story, the patient’s and his, as an ongoing dialogue, never distinguishing between what is “real” and what is not.
I suggest that one could write a “clinical tale” whereby no particular clinical details of real patients are disclosed. Therefore, the need for distortion of disguise becomes obsolete. What the tale draws upon is the myriad clinical hours available to the writer’s imagination. Thus, confidentiality is strictly kept. Writing such a clinical tale involves a certain detachment from any empirical scientific claim that such work might hold. It is a work of fiction. But bearing in mind the thin and slippery line between fiction and fact in the telling of a story, it is my claim that such a tale holds clinical validity.
My first publication of such material appeared on the Hebrew Psychology website and dealt with the appearance of those very issues of Writing and Psychotherapy (Hebrew) in 2004. In 2014 I had my first publication in English "An Exile in the Room: A Clinical Illustration and a Literary Footnote" which appeared in Vol 22(1) of Psychoanalytic Social Work. The paper described the case of Dan, an Israeli citizen in his late thirties, born and bred in Argentine. I focused upon some psychological effects of exile as played out and repeated in the transference, leading to an instance of an articulation of Bollas' idea of the human idiom. During the course of his therapy, through the working of elements in the transference paradigm, it became possible that Dan's existential gloom and despair, accompanied by various physical symptoms, were the traces of the imprints of his exile from Argentine. Those traces were linked to the articulation of deeply buried sensations and once recognized allowed him to explore instances of unresolved mourning. The mourning process thus resumed allowed him to regain his positive. In conjunction to this, I referred to the impact that Julio Cortázar's (1914-1984) posthumously published book Diary of Andrés Fava (2005) had upon him. The reading of that book served Dan and me as an unconscious object. This object could be represented by Ogden's (2004) term The Analytical Third, and was a part of the therapeutic relationship where he was able to discover, express and elaborate upon his unique idiomatic sense of self.
In 2015, "An Instance of Emotional Absence of a Father Traumatized by War–Clinical Material and Musical Illustration" was published in The American Journal of Psychotherapy Vol 69(1). The paper was based upon Freud's essay from 1914, Some Reflections on Schoolboy Psychology, where he placed immense significance upon the father-son relationship as enabling or inhibiting the individual quest towards a mature, separate, and healthy development. I explored Freud's observations to illuminate the journey taken by Assaff, a 34-year old man who, during the early stages of his adolescence, had a father who was emotionally absent due a traumatic experience during his military service in the Israeli Defense Forces. Through transference work, the impact of the emotional absence will be shown. I demonstrated how the boy was able unconsciously to use the music of Tommy, a rock opera by the British band The Who, as a transitional object. I showed how that piece of music provided Assaff with the sense of hope that helped during the darker times of his adolescent.
In 2016, "Transference-Love and Institutional Involvement in a Case of Psychotherapy Supervision" was published in Psychoanalytic Social Work Vol 23(1). Transference-love in supervision remains a relatively unexplored subject in psychotherapy. The article described and analyzes an incident of the supervision of a student whose dress code raised a question regarding the existence of transference-love. The role of the institution in maintaining a protective envelope is shown to be significant in the satisfactory resolution of what appeared to have been an impasse. In addition, multicultural and gender issues were examined to illustrate the complexity of the subject.
In 2020, "A Remembrance of War – Past and Present Traumatic Fragments in a case of an IDF soldier suffering from Anxiety Disorder" was published at the European Federation of Psychoanalytic Psychotherapy on-line Review.