What's a Good Object to Do? - PsyBC

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Commentary on Paper by Neil Skolnick 35 ⎯⎯⎯⎯⎯⎯⎯⎯⎯⎯⎯⎯⎯⎯⎯⎯⎯⎯⎯⎯⎯⎯⎯⎯⎯⎯⎯⎯⎯⎯⎯⎯⎯⎯⎯⎯⎯⎯⎯⎯⎯⎯⎯⎯ transference of conflict is present, the analyst should engage the patient in the more traditional exploratory way. Indeed, Skolnick, relying here on Kleinian concepts, makes a strikingly similar case for technique guided by diagnosis-of-themoment when he describes the particular kind of attunement required by a patient functioning at that particular moment at a paranoid/ schizoid level: “The analyst needs to express empathy for the patient’s experience of their psychic level of organization, and a diminution of attention to interpretation of psychic meaning.” And he is explicit about the diagnostic shifts in the last patient he discusses. Davies (2004), from her relational perspective, has also offered a conceptualization of what can be thought of as multiple shifting diagnoses within the same patient, based on a patient’s particular regressive potentials. “Each self–other organization [is seen] as carrying the cognitive-affective imprimatur of the developmental epoch in which it is organized and set down” (p. 758). Indeed, the relational idea of multiplicity of selves (Mitchell, 1993; Bromberg, 1998) seems to imply some concept of diagnosis-of-the-moment, whether or not it is used to determine technique. Davies’s conceptualization emphasizes, in addition to diagnosis as defined by shifting regressed modes of functioning along various dimensions, the intersubjective aspects of this: the interpersonal context within which each of a patient’s “selves” develops and the aspects of the analyst’s self that play a role in evoking particular regressed selves in the patient. 4 ⎯⎯⎯⎯⎯⎯⎯⎯⎯ 4 A case can be made for questioning any analyst’s standing to diagnose his or her patients. Given the analyst’s inevitable embeddedness in his or her own unexamined biases and unconscious conflicts, subjective misperception can be mistaken for objective assessment. Analysts nevertheless do think diagnostically—as their patients need them to do. I see no simple solution to this problem. Analysts should approach their diagnostic thinking about patients with humility—but not false humility. Limitations on certainty do not mean that a well-trained, experienced, and relatively self-aware analyst’s diagnostic sense of a patient has no validity. The analyst does have expertise in understanding the patient that goes beyond the patient’s understanding of himself, in certain ways, even if this is colored and limited by the analyst’s unavoidable biases; it does the patient a disservice to act as if this were not so. It seems sensible to treat an analyst’s diagnostic thoughts about a patient as at the very least a reasonable working hypothesis, which should, in turn, be open to correction as the analyst attends to and considers explicit or disguised communications from the patient that may constitute commentaries on the “diagnosis” that the patient senses as implicit in the analyst’s approach to him or her.
36 Jay Frankel ⎯⎯⎯⎯⎯⎯⎯⎯⎯⎯⎯⎯⎯⎯⎯⎯⎯⎯⎯⎯⎯⎯⎯⎯⎯⎯⎯⎯⎯⎯⎯⎯⎯⎯⎯⎯⎯⎯⎯⎯ The idea of diagnosis-of-the-moment allows us to value the concept of diagnosis as a meaningful and clinically useful description of a person’s functioning, while not minimizing the contribution of context, not reifying unsubstantiated assumptions about the patient’s personality structure, and thus not constricting the clinical possibilities we entertain for the patient. The term also opens the door to thinking not only about diagnosing the patient in a particular moment, but also about diagnosing the intersubjective moment itself (K. Ebbesen, 2005, personal communication). 5 Diagnosis-of-the-moment, it seems to me, is a concept that most analysts use intuitively, in one form or another, naturally adjusting and responding to the patient’s changing organization of experience. The concept requires us to reframe Skolnick’s essential question,“What’s a good object to do” with greater specificity; the question becomes, “What’s a good object to do for this particular patient at this particular moment, and what is the basis for that conclusion” The particular diagnosis-of-the-moment is what determines analysts’ choices about whether and how to make their own struggles available to the patient. REFERENCES Altman, N., Briggs, R., Frankel, J., Gensler, D. & Pantone, P. (2002), Relational Child Psychotherapy. New York: Other Press. Balint, M. (1968), The Basic Fault: Therapeutic Aspects of Regression. London: Tavistock. Bromberg, P. M. (1998), Standing in the Spaces: Essays on Clinical Process, Trauma, Dissociation. Hillsdale, NJ: The Analytic Press. Davies, J. (2004), Reply to commentaries. Psychoanal. Dial., 14:755–767. Epstein, S. (1979), The stability of behavior: I. On predicting most of the people much of the time. J. Personality & Soc. Psychol., 37:1097–1126. Ferenczi, S. (1932), The Clinical Diary of Sándor Ferenczi, ed. J. Dupont (trans. M. Balint & N. Z. Jackson). Cambridge, MA: Harvard University Press, 1988. ⎯⎯⎯⎯⎯⎯⎯⎯⎯ 5 It might be that some analysts work more effectively when they let themselves be idealized, while others may be more effective when they let their struggles show more openly (A. Frankel, 2005, personal communication); this, in turn, is likely to influence what becomes manifest in a particular patient in treatment with a particular analyst.
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