The Process of Case Writing: A Fourth Pillar of Analytic Training.

The educational and clinical effects of the process of case writing during analytic training have not been extensively studied, even though the case report, as a product, has prompted attempts to make it a more revealing and accurate document. Countertransference experiences during an analysis can constrain both the candidate's writing and the analytic work, while examining them during the writing process can deepen the candidate's analytic work. Three overlapping resistances to the writing, and their underlying anxieties, are described. These are publication resistances: concerns about the anticipated reception of the candidate's work by potentially critical readers; transference resistances: feelings toward the analytic institute that requires the writing; and countertransference or reimmersion resistances: fears of reawakening reactions from the analysis. These can interfere with finding a safe internal space in which to write. Examples are given of writing through of these resistances during case supervision, resulting in more open writing and in a deepening of the analytic work. As the case writing process can have direct and potentially profound effects on the candidate's current and future analytic work, it is proposed that the process of case writing is a fourth pillar of analytic training, in addition to the candidate's personal analysis, case supervision, and didactic seminars.

When the Analytic Patient has Attention Deficit Hyperactivity Disorder.

Most analysts are now treating or can expect to treat adult patients with cognitive deficits such as attention deficit hyperactivity disorder (ADHD), based on the prevalence of this syndrome in children and its continuation into adulthood. ADHD is a cognitive disorder considered by nonanalytic and analytic writers to be a dysfunction of affect regulation and behavioral inhibition. Analysis deals with these issues, and most analytic theories address affect regulation. Manifestations of ADHD can mimic the clinical expression of intrapsychic conflict, in which the cognitive deficits are embedded. If these symptoms are interpreted primarily as transference resistances without acknowledging the cognitive contribution, the patient may experience a resurgence of feeling misunderstood and shamed, helpless and defective. Confusion in the countertransference is a hallmark of analyses in which cognitive deficits are intertwined with psychic conflict, sometimes leading the analyst to compartmentalize the cognitive and the conflictual and to miss aspects of the patient and the process. Appropriate action within the analytic frame may be needed to help the patient seek information, specialists, or coaches to deal with limitations in executive functioning. A variety of technical considerations and confusions in the countertransference are illustrated.

Treatment preparatory to psychoanalysis: a reconsideration after twenty-five years.

The author's initial article on treatment preparatory to psychoanalysis (1983) challenged the long-held belief that a therapy with the same analyst would contaminate a subsequent analytic transference. The current article reconsiders the original process of transition from therapy to analysis and describes methods that can further its effectiveness. Although specific noninterpretive interventions to enhance preparation for analysis are rarely written about, they are discussed among colleagues and in supervision. Levy (1987) has described a bias against the description of strategic or tactical choices in analysis. It is increasingly clear that some patients' fear of exposing shameful defectiveness underlies their resistance to entering analysis, as does the originally described fear of an uncontrolled regression. It is useful to delay interpretation until shame sensitivity can be assessed and modulated. In the past there was pressure to keep the preparatory therapy brief so that the analyst would not become too well known to the patient. Less concern about strict anonymity allows more time for the patient's resistances to abate before the recommendation is made. Methods are described and clinical illustrations show how a deepening process can be fostered, how indications of readiness for the transition can be assessed, and when and how the recommendation can be made.