Steven T. Levy

The use of transarterial microembolization in the management of hemangiomas of the perioral region

The management of oral and perioral hemangiomas depends on several clinical factors. Surgery of these benign lesions can at times be disfiguring, especially when the lips, muscles, or the maxilla and mandible are involved. In addition, by the very nature of these lesions, surgical treatment may be associated with excessive intra- and perioperative blood loss. A series of five patients who had hemangiomas in the perioral region and who were initially treated with transarterial microembolization, preoperatively in two cases and as the only treatment in three cases, is presented. The technique of microembolization is described and recommendations for its use are given.

The Analytic Surface and the Theory of Technique

This paper examines the concept of the analytic surface as a starting point for the interpretive process in relation to the theory of psychoanalytic technique. The history of the concept of the analytic surface within psychoanalysis is reviewed. Four different conceptualizations of analytic surfaces are described (M. M. Gill, P. Gray, A. Kris, E. A. Schwaber). The advantages of a “surface” approach are explored in relation to clinical work, the teaching of psychoanalytic technique, and opportunities for research. Some criticisms of the concept are explored. “Nothing is rich but the inexhaustible wealth of nature. She shows us only surfaces, but she is a million fathoms deep.” Ralph Waldo Emerson

Empathy and Psychoanalytic

: I have attempted to review the major psychoanalytic contributions to our understanding of empathy within the psychoanalytic situation. In doing so, I have discussed the relation between empathy and identification, reviewed aspects of the metapsychology of analytic comprehension, and have described the role of the analysts evenly hovering attention in empathic responsiveness, as noted by several analytic investigators of empathy. The interrelations between empathy and countertransference have been described, and neutrality issues as they relate to empathy have been noted. Certain themes around the development of empathy have been grouped together and critically examined. The work of Kohut with regard to empathy has been discussed in relation to earlier psychoanalytic contributions of which it is an outgrowth and expansion. The changes in meaning and emphasis of empathic processes in Kohuts works have been described and critically reviewed. Empathy in its popular usage refers to the capacity of one person to communicatively partake, in a limited way, in the experience of another. In its differentiation from sympathy and pity, its noncritical or value-neutral character is emphasized. This description of empathy indicates its relevance to psychoanalytic technique, which shares many similar characteristics. Empathy is a general or superordinate term for many more specific aspects of the sensitive interpersonal interactions in the intimacy of relationships like the psychoanalytic one. Attempts to assign a particular psychoanalytic technical meaning to empathy or build clinical and developmental theory around empathy are limited by the multiple referents and generality of the concept. Empathy as a term has its place as descriptive of the analysts emotional relatedness to the patient. It does not refer to any specific psychoanalytic technical intervention or theoretical construct; rather, it describes in a general way the sensitive, tactful, and experience-near way in which the analyst approaches the inner life of his patients.

Repetition compulsion revisited: implications for technique.

Freuds repetition compulsion concept is reviewed and examined critically. It has been used as an explanatory concept to cover a wide variety of clinical phenomena similar only in their manifest repetitive quality, and it appears frequently in psychoanalytic and psychiatric literature. Its relationship to trauma and posttraumatic stress disorder is explored. Emphasis is on the detrimental technical legacy of the concept, which has cast a pessimistic aura of unanalyzability over a wide variety of repetitive phenomena, especially analyzable resistances related to aggressive conflicts. We conclude that the repetition compulsion is an anachronistic concept with detrimental technical implications and that it should be retired.

Neutrality, interpretation, and therapeutic intent

Neutrality is a central concept within the theory of psychoanalytic technique. We spell out the major controversies in which the concept has become embroiled, and provide a definition that we believe coincides with actual psychoanalytic practice. We discuss its merits and weaknesses, noting also the negative consequences of relying on older definitions. We relate neutrality to the interpretive process, indicating ways interpretation protects neutrality and is made more effective by it. We discuss the complex and controversial relation between neutrality and the analysts therapeutic intent.

Unconscious Fantasy: A Reconsideration of the Concept:

Despite general agreement about the clinical importance of unconscious fantasy, the concept itself has remained unclear. After reviewing Freuds work on the subject, the conceptual dilemma is specified: where in current psychoanalytic theory do we place this important, dynamically repressed, structuralized mental content? Three conceptual paths have been followed in attempting to deal with this problem. The first emphasizes the structural, tripartite model, discarding topographic concepts. The second replaces the structural model with a schema model borrowed from academic psychology. The third combines the structural and topographic models. None of these approaches is entirely satisfactory and without problems. Because of their central role in mental life, unconscious fantasies deserve careful definition. They should be distinguished from conscious fantasies and daydreams as well as from the process of fantasizing. They are differentiated from other varieties of unconscious content by their enduring quality and their organized, storylike quality reflecting the distortions typical of the primary process. As dynamically unconscious templates from the childhood past, they shape subsequent compromise formations and are relatively impervious to new experience. The development of psychoanalytic theory from a macrostructural to a microstructural emphasis is discussed in relation to the unconscious fantasy concept.

Suggestion and Psychoanalytic Technique

The role of the analysts suggestive influence on the course and outcome of psychoanalytic treatment is explored, and traditional and newer perspectives on analytic technique are contrasted. The intersubjective critique of the neutral, objective analyst in relation to suggestion is examined. The inevitable presence and need for suggestive factors in analysis, and the relationship of suggestion to transference susceptibility, are emphasized. The manner in which the analysis of suggestive factors is subsumed in transference analysis as part of traditional technique is highlighted.

Therapeutic strategy and psychoanalytic technique.

The role of therapeutic strategy within psychoanalytic technique is described. An antistrategic bias inherent in certain aspects of the “classical” technique is explored in relation to the historical development of psychoanalysis. Clinical expertise, which includes the making of strategic or tactical choices, is relegated to the “unofficial,” due in part to this negative bias impeding the study of technical differences in favor of general agreement about a theory of technique that may differ considerably from actual clinical work. A case is presented that illustrates strategic choices in the management of a severe character resistance in a supervised analysis. Some consequences of a negative bias against therapeutic strategy as it relates to psychoanalytic training is described.

Fantasy and psychoanalytic discourse

Psychoanalytic discourse across theoretica l, geographic and cultural boundaries has become increasingly difficult as psychoanalysis has grown internationally from its central European origins. Psychoanalytic terms have been used inconsistently, often with litt le regard for the problems in communication and scientific and intellectu al progress such inconsistency creates. Likewise, what are usually considered alternative or competing psychoanalytic theories, often connected to geographic regions or cultures, create artificial divisions among analysts that further interfere with scientific progress. It is our view that the majority of such theories are partial theories, or shifts in emphasis, wherein all the necessary ingredients of a comprehensive psychoanalytic theory, of which we are strong advocates, are included at the periphery, as secondary themes, so-called ‘givens’ or ‘goings without sayings’, or smuggled in clinically as artfulness, tact or common sense. The term phantasy or fantasy acquires different meanings and more or less importance or centrality, depending on where in the melange of psychoanalytic discourse one encounters it. In what follows, we will try to summarise an American ego-psychological point of view about fantasy, emphasising what we consider the major issues that underlie controversies about fantasy as conceptualised from this and other theoretical perspectives. We emphasise summarise to indicate that even within the perspective of contemporary egopsychology, of which our work is representative, there is considerable variability, contradiction and lack of clarity about what the term fantasy refers to. In an earlier exploration of fantasy (Inderbitzin & Levy, 1990), we attempted to reconcile or at least delineate several trends in thinking about fantasy within contemporary ego-psychology structural theory, and some of our conclusions from that work will be elaborated here. We will argue that fantasy is central to all psychoanalytic work and that inferences about the consequences of different meanings or usages of the term distort and exaggerate differences in clinical work. These distortions regularly centre on whether or to what extent analysts of different theoretical persuasions focus on the unconscious or on unconscious processes, whether on the past or the present, and whether the clinical work is deep or superficial. It is our belief that all the phenomena described by various groups as fantasy are central to a psychoanalytic view of mental life, inform all clinical work in essential ways and find their way into technical precepts more alike than different. We will return to this later.

Book Review: IMPASSE AND INNOVATION IN PSYCHOANALYSIS: CLINICAL CASE SEMINARS. Edited by John E. Gedo and Mark J. Gehrie. Hillsdale, NJ: The Analytic Press, 1993, 320 pp.,

Impasse and Innovation in Psychoanalysis provides an opportunity to examine major alterations in technique in the psychoanalytic treatment of difficult patients. The reader can observe the clinical application of John Gedo’s ideas about technical flexibility by studying four relatively detailed case presentations. The material, drawn from a seminar given by the authors at the Chicago Institute for Psychoanalysis, allows the reader to listen in on a lightly edited transcript of the proceedings. As a result, the text comes alive clinically; it is varied, imprecise, selfcontradictory, and full of the enthusiasm of the participants. More than anything else, Impasse and Innovation in Psychoanalysis looks at the integration of theory and clinical technique from the perspective of the hierarchy of models of the mind developed by Gedo (Gedo and Goldberg 1973). Four cases are presented in detail, and different technical challenges and their management are discussed. The format includes an introductory comment by Gehrie, then the clinical presentation and seminar discussion, followed by a lengthier commentary by Gehrie highlighting the main issues and problems addressed in the discussion of each case. This is followed by a sequence of notes in which Gedo elaborates on relevant matters brought up in the seminars, and by Gedo’s consideration of issues pertinent to the clinical material but not discussed sufficiently by the seminar participants. This format allows the reader vicarious participation in a clinical seminar led by a distinguished and opinionated clinical innovator. The book has as its guiding principles many of Gedo’s ideas regarding flexibility and technique. A basic premise underlying all of the discussions is Gedo’s insistence that a detailed diagnosis of level of B o o k R e v i e w s