The Therapeutic Setting in Psychoanalysis and Psychotherapy

The Therapeutic Setting in Psychoanalysis and Psychotherapy Gary N. Goldsmith The role of the therapeutic setting in the history of psychoanalysis and psychotherapy was for a long time taken for granted. It is not hard to see why this was so. Since the setting describes the basic arrangement necessary for treatment to occur, it was seen as merely a structural or physical prerequisite, plus a contract for treatment and a code of behavior for patient and therapist, without much further meaning in and of itself. That is, it seemed to need no further discussion - settings exist everywhere, in all different fields and situations. Freud was the first to describe the role of the psychoanalytic setting as a basic platform for treatment - in the series of Papers on Technique he focused on it in some detail. But its function and psychodynamic meanings were not explored until much later, when other thinkers could turn their attention towards it. They were aided by years of accumulated clinical experience which showed that it could not be denied that the setting had dynamic significance in its own right - experience with patients that challenged or breached the arrangements of the setting required it to become an object of increasing clinical attention and concern. A deeper sense of its dynamic function became understood when advances in psychoanalytic theory (especially object relations) helped to shed light on different aspects of psychological development in childhood, and when our experience with different diagnostic entities had expanded. For the purposes of this presentation, I will refer to the therapeutic setting as something that is similar in psychoanalysis and psychotherapy, and in all of the various approaches to psychodynamic treatment that they comprise. This is because the setting, even if it differs in certain important particulars (such as the use of the couch, frequency of visits, relative activity of the analyst), is nonetheless a fundamental feature in every treatment, and plays a similar role. It is not the difference among the therapies that interests me most here, but the role that the setting plays in the treatment. Nonetheless, thinking about the setting is not “beyond theory.” Though common to every form of treatment, it may still be understood in ways that differ according to one’s theoretical approach. Some of those approaches are certain to be discussed in the different presentations this week. It has been said that “the foundation of psychoanalytic treatment, upon which everything else rests, is the psychoanalytic setting.”1 From this it follows that the concept of the therapeutic setting may be Freud’s greatest contribution to technique. 2 Without the special criteria of the setting, free association is not possible - indeed, treatment itself is not possible. Yet Freud devoted far more attention to other aspects of technique such as free association, abstinence and analysis of the transference, because they are unusual and unique to the psychodynamic therapies. His recommendations for the setting are in some measure borrowed from the nature of the setting of hypnosis, from which psychoanalysis departed when he discovered the value of free association. In hypnosis (and in the relationships with one’s physicians in general) the patient’s compliance with the treatment setting is assumed, and not explored. A positive attitude toward the physician is expected as a matter of course. But in “The Dynamics of Transference” (1912) Freud suggested that a smooth treatment is not inevitable, rather it flows from the unobjectionable positive transference.” Remember that in that paper Freud divides the transference into three different types: the erotic transference, the unobjectionable transference, and the negative transference. The second type, the unobjectionable transference, was considered by him to have sublimated erotic origins, and was more conscious than the other kinds, which he considered as problematic forms of transference. 3 Freud felt that the unobjectionable

transference was necessary for a successful result of the analysis, since it was the basis for a cooperative relationship with the analyst (later we would call this the therapeutic alliance.) However, although he described the optimal conditions of the setting required for treatment to occur, he did not elaborate them as he did

3 with the transference, or show the relationship between the establishment of the setting and the unobjectionable transference. He went no further in describing their intrapsychic and interpersonal functions from a theoretical point of view - and thus from a potentially technical point of view as well. He was more interested in describing the theory and technical handling of the negative transference which arose in the course of treatment. And this has been our experience generally in the history of psychoanalysis, as Modell reminds us: “It is easier to identify the forces that interfere with the progress of an analysis than to understand what contributes to its therapeutic success.”4 The reason that Freud could exempt the setting from further theorizing was that he was thinking only of those patients (now called “classical” patients) for whom, in his mind, the setting itself did not need to become a focus of the treatment. In general, neurotic patients accept the arrangements for treatment without much conflict, as a quiet background enabling other, more overtly conflict-based aspects of the treatment to become manifest. You will recall that in cases such as the Rat Man, he saw no violation or even contradiction in departing from the usual setting, when he gave his patient a meal. For him, the setting did not extend beyond the office in such a situation. In other words, he saw the setting as a kind of silent presence, limited to the confines of the office, and not drawing special attention to itself.5 So not only has our understanding of the setting changed, but the setting itself has developed into a more broad-based concept than it was for Freud. Why do we now say that the setting is not just a passive scaffold for the treatment, but something that has dynamic significance in its own right? For one, it is because it inevitably becomes invested with meaning, becoming part of the interpersonal relationship between therapist and patient. To give a brief example: [CASE MATERIAL DELETED FOR WEB VERSION] ……This is a fairly typical way in which problems are revealed in therapy - I use it here not to review the entire treatment, but rather to illustrate the combining of the patient’s attitude towards me and towards the setting, which she thought she was violating. It demonstrates how difficult it is to separate the setting from the perception of the analyst - for the patient they are fused, especially since the patient sees the analyst as the explainer and enforcer of the setting. And indeed, there is some truth to this, because it is the analyst who sets the rules at the beginning, even if we later on take the position of being non-judgmental and abstinent. For some patients this ambiguity is a source of doubt about our neutrality. (If this were a later stage of the treatment I might have looked with the patient for the possible motives for “forgetting” the payment, and also wondered if she were acting out something involved with my earlier, perhaps too strenuous, efforts to pursue her affect about childhood events. However, at the present stage of the treatment it seemed to me that it would have been excessive and inappropriate. I also made the assumption from the patient’s associations that this was a maternal transference reaction, but I would have wondered about the paternal aspects of the transference as well.) Here I needed to do little to maintain the setting. For this

4 patient the opposite was true - she already perceived the setting as controlling and punishing, and proper “role responsiveness” required a different reaction on my part. (I am using the term in Sandler’s original sense: “In the analyst's overt reactions to the patient as well as in his thoughts and feelings what can be called his 'role-responsiveness' shows itself, not only in his feelings but also in his attitudes and behaviour, as a crucial element in his 'useful' countertransference.”6) I wish to make a second point here, that follows logically from the above. The manner in which the analyst manages the setting is a significant part of his analytic function. It is not just the patient who may perceive the setting and the analyst as a single entity. The analyst, on his part, also sees the patient’s attitude towards the setting as part of his or her character, and he works to a significant degree by his use and management of the setting, knowing that this is a response to manifestations of character and transference. This is not only because of the “rules” of treatment that he has learned and internalized, but also because it serves important psychological functions for him as well, helping him to maintain his own perspective and balance in the treatment. It is a source of constraint for his behavior, and helps him to guide the treatment along a useful path and to note diversions from that path. My point here is that the manner of his doing this demonstrates his understanding of the analytic task, as well as aspects of his character, and includes the countertransference issues that are active in him. The meeting ground between the patient’s reaction to the setting and the analyst’s working within the setting, is the field where the analysis takes place. It follows then, that movement in the treatment is marked by periodic perturbations of the setting. Such events inevitably point to areas of resistance and conflict, therefore they become issues for exploration, and eventually, for interpretation. In ego analysis we seek to analyze the resistance at the point of optimal usefulness, and the setting provides the stage for this analytic drama to unfold over the course of the treatment. Just as there are periods of relative quiet in the transference that are interrupted by crises, enactments, or moments of lack of empathy, so too the stresses upon the setting will provide evident signals of this movement. By this time you may have already asked yourself the question of where the setting ends and the transference begins, because at certain moments I am using the term “setting,” or “attitude toward the setting,” when it may seem that “transference” is implied. In general, the setting refers to the ground rules, the rules of the “game” that allow the treatment to occur, to provide the optimal circumstances for the expression of transference. Some would say that it “concentrates” the factors that permit transference to blossom. However, there is admittedly something incomplete or ambiguous in this description, since as I suggested before, everything that occurs between the patient and the analyst is potential material for the transference, including the setting itself. Thus, while we may be able to descriptively separate these aspects of treatment, in the active work of the therapy there may be an inherent confusion in trying to differentiate them. Their interaction is central to the treatment itself, and gives rise to tensions and questions that are productive for analytic reflection; the ambiguity enriches the analytic dialogue. This occurs in part because of the overlap between the verbal and non-verbal aspects of the treatment, which are occurring simultaneously. Setting is basically non-verbal, but provides a template for the recovery of verbal memory and affective response. That is, it promotes the emergence of transference. And the transference in its turn acts again upon the conditions of the setting. In general, however, the analyst would not be thinking of making distinctions between setting and transference while he is treating the patient. If he finds himself asking this question, then there is already significant acting out that requires his attention.

5 ”In “Remembering, Repeating and Working Through” Freud made it clear that the patient “acts” before he “remembers.” His character and conflicts express themselves in one form or another before the recovery of textual memory occurs. Much of that “acting” occurs by way of “testing” the setting, as a sign of resistance or as an effort to learn whether the analyst can be trusted. This may occur in such ways as silence, avoidance of free association, confusion over appointment times, fees, etc. It is the analyst’s empathy which helps him to decide what the meaning of the behavior is, or at least, to point him in the direction of where to look for that meaning. In this effort his manner should be inquisitive and not authoritarian, since the analyst must have respect for all that he doesn’t yet know, and always be attentive to the quality of the therapeutic alliance. This brings me to my next point. I believe that the setting is not only a physical arrangement, a contract for treatment and set of rules for behavior. The setting is also something that lives in the mind of the analyst. Even when it is disrupted by psychological forces in the patient, the analyst’s internalized model of the ideal setting serves as a kind of gyroscope to help keep him in control of the treatment, in control of his understanding of what is happening. Another way to say this is that it is part of the analyst’s work ego, contributing to the climate in the analytic environment - and it becomes part of what the patient eventually internalizes. In a wild treatment situation, for example with an actingout borderline patient who tests the analyst’s patience by gross disruptions of the setting, it may be only the analyst’s internalized conception of the setting that helps him to manage the turmoil, and to measure how far from the ideal situation the treatment has gone. Imagine a patient (and I’m sure you have all had similar experiences) who misses an appointment, requests a new appointment, and then misses that one too. On the phone the patient blames you for not being sympathetic to the difficult circumstances of his life, especially after he had already trusted you so much to understand. Now you have disappointed him like everyone else in his life has done. Now he doesn’t know if he will return to your office. If you make an effort to remind the patient of the contract for treatment, you will be accused of putting that ahead of the patient’s needs, of being even more insensitive than he had thought, and probably of being more interested in earning money than in helping him. If you suggest to the patient that discussing these matters together might prove useful to understanding the crisis you have gotten into, he will say, “well it obviously hasn’t helped so far, why will it now? Maybe it’s useful to you, but I don’t think it’s useful to me.” Here is a situation testing any therapist’s skill. The setting has become the stage for acting out, the relationship has deteriorated into one of blame and anger, and the patient deprives the therapist of any opportunity to find a resolution that will shed light on the source of the problems. The patient, in addition, by means of projective identification, has guessed the therapist’s anger, and in retaliation accuses him of the worst possible crime, selfishness and lack of empathy. I suggest that here the therapist needs to evoke his internalized memory of the setting to weather the storm which may help him ultimately to find his way. And he must remember that he is not the one imposing the setting, rather it is imposed on both members of the dyad - it is imposed on the treatment situation. We cannot describe this situation without referring to the conditions of the setting, so it becomes the reference point for working through the problem that this patient presents. It is just this kind of situation, in work with patients unable to differentiate the treatment setting from external reality, that required an expansion of our understanding of setting, after Freud’s initial work. Since it may sound as if the setting is a rigidly fixed arrangement, the question arises as to whether or not it can be modified. How flexible is it? The answer, of course, depends in part upon the individual therapist, as in many questions of technique. However,

6 to approach it in general, one might say that, once confident of his internalized notion of the setting, confident that it has become part of his analyzing ego, the analyst can then modify it appropriately in an effort to respond to the patient’s needs. Some patients simply can’t work within the setting as given. This was the case with my patient, Mr. Y. [CASE MATERIAL DELETED FOR WEB VERSION]…. Here I am halfway through my talk, in which I am supposed to set the table for the week’s discussions, and I must confess to not yet having answered precisely the question, “what is the setting?” Although I’m sure you all have a good idea of what it is, I preferred to leave it undefined, to allow a sense of its meaning to accrue as I spoke, and for us now to compare your non-expressed definition of the setting with what various analytic thinkers have said about it. All I said at the start was that it was an arrangement of space and time, and a contract for behavior between two participants, without more detail. Nonetheless I notice that most of us have respected the setting today without too much acting out. Our setting here is an agreement to meet at a particular time and in a particular place, for me to talk for a very long time without interruption, while you, for the most part, remain quiet and presumably attentive to my words. We have a contract that addresses issues of physical space (and time), and our behavior. Violations of this unspoken contract often invite a restless, aggressive or irritated reaction - for instance if I decided to talk about something useless to your education, or if you were noisy (recall how angry one gets in a movie theater when someone talks nearby, or a cell phone rings and destroys the magic of the moment.) These reactions suggest that there are potent dynamics underlying the implicit contracts in the setting. If that is so, it is all the more pertinent in our professional work, where much more is at stake than in non-clinical situations. Winnicott at an early stage in his work described the setting very simply as the “summation of all the details of management.”7 Stone preferred to call it by a different name, the “psychoanalytic situation.” He described it as “the common and constant features of the analytic setting [arrangement of time and space], procedure, and personal relationship in both conscious and unconscious meanings and function.”8 He understood that one could not separate out the physical arrangement from the interpersonal relationship. Winnicott later summarized Freud’s idea as follows, adding a dose of humor to his text: “At a stated time, five or six times a week, the analyst would be reliably there, on time, alive, breathing. For the limited period of time prearranged (about an hour) the analyst would keep awake and become preoccupied with the patient. The analyst expressed love by the positive interest taken, and hate in the strict start and finish and in the matter of fees. Love and hate were honestly expressed, that is to say not denied by the analyst. The aim of the analysis would be to get in touch with the process of the patient, to understand the material presented, to communicate this understanding in words. Resistance implied suffering and could be allayed by interpretation. The analyst’s method was one of objective observation. The work was to be done in a room. . . that was quiet, yet not dead quiet and not free from ordinary house noises. The analyst. . . keeps moral judgment out of the relationship, has no wish to intrude with details of the analyst’s personal life and ideas. In the analytic situation the analyst is much more reliable than people are in ordinary life; on the whole punctual, free from temper tantrums, free from compulsive falling in love, etc. There is a very clear distinction in the analysis between fact and fantasy, so that the analyst in not hurt by an aggressive dream. An absence of the talion reaction [punishment as retribution] can be counted on. The analyst survives.” Despite this being a version of Freud’s definition, one can see here the influence of Winnicott’s own contribution, and that of other object relations theorists, by his emphasis on

7 the manner of expressing love and hate, and the analyst’s “surviving” the patient’s affect. It is curious to me, however, that Winnicott seems to be so sure that a clear distinction can be made between fact and fantasy, but that is not our main subject today. I believe he was trying to emphasize the physical aspects of the setting as “reality,” as opposed to the projective aspects. However, as we all know well, the subjectivity of these aspects is not reducible simply to “reality vs. fantasy.” Also making this definition a little dated is the idea that the analyst relies only on objective observation, since we know quite well that the analyst’s subjective reactions are also key data for understanding the patient. Nonetheless, Winnicott emphasizes certain essential elements of the analyst’s behavior in the setting the effort to help put feelings and experiences into words, to have the patient’s experience be the sole focus of attention, to be neutral and non-judgmental, to be reliable in his personal behavior, to “survive.” By “surviving” he means that the analyst is able to endure (and not succumb to) the extremes of the patient’s emotions, from affectionate, loving (and sometimes seductive) feelings, to expressions of rage and hostility - and at the same time maintain a therapeutic setting in which these affects are not rejected, but explored. Bleger preferred to use the label of “psychoanalytic situation,” as Stone had done before him. By that he meant the “totality of phenomena included in the therapeutic relationship between the analyst and the patient.”9 He separated these phenomena into two parts. He labeled as “process” that part of the material of treatment that is studied, analyzed and interpreted, and he separated it from what he called “non-process,” meaning the part that “is made up of constants within whose bounds the process takes place.” In acknowledging that however, Bleger still noted that it is a mistake to leave the setting unanalyzed simply because it may remain quiet or “outside of process.” This was the case with my patient, where, had there not been the intrusion of her predicament with the payment, it might have remained “quiet”, but it could have been an error to leave such a quiet setting unexplored forever. This is sometimes difficult technically, since it is often hard for the patient to perceive this behavior as dynamically motivated. Only when we can see apparent non-resistance as “resistance hiding behind compliance,” can we begin to be more successful in bringing it under the microscope of analytic observation. Rycroft referred to the setting in this way: “Psychoanalytic treatment is not so much a matter of making the unconscious conscious, or of widening and strengthening the ego, as of providing a setting in which healing can occur and connections with previously repressed, split-off and lost aspects of he self can be re-established. And the ability of the analyst to provide such a setting depends not only on his skill in making ‘correct’ interpretations but also on his capacity to maintain a sustained interest in, and relationship with, his patients.”10 You can hear in Rycroft’s description an object relations idiom. He contrasts the earlier topographical theory (“making the unconscious conscious”) and structural theory (“widening and strengthening the ego”) with a focus on the relationship with the patient and the therapist’s personal capacities, in the context of a two-person psychology. Marion Milner (1955) introduced the fruitful notion of the setting as a frame.11 Her contribution stems from the function of the frame of a painting. Both in psychoanalysis and in painting, the frame creates a boundary between the enclosed contents and the outer world. Modell, following Milner, views the frame “not only as a constraint but as [something] that. . . encloses a separate reality. . . .The ‘frame’ of the psychoanalytic setting is separated from ordinary life as it institutionalizes a unique contractual as well as communicative arrangement between the two participants.”12 The ability to move between the two different realities is important diagnostically, and plays a role in deciding among treatment alternatives and technique (analysis or psychotherapy), and the degree to which the patient can tolerate the analyst’s abstinence. The Rat Man was instinctively able to

8 recognize this difference; many borderline and severely narcissistic patients are not. Discussing further the metaphor of the frame, Modell goes on to remind us that the illusion of transference has often been compared to the illusion of the theater: “In both instances the affects that are experienced are ‘real’ but the affective experience occurs within a demarcated frame.”13 And we are on similar territory in pointing out the analogy to play, as Winnicott has done, where there are rules for conducting the game, and guarding the play space from “external reality.” The full gamut of emotions is experienced, but in a clearly separate “transitional space” that is safely enclosed. As in the theater, this allows for the expression of fantasy and illusion, and thus for loosening of the bonds of reality that could hamper creative imagination. In the therapeutic situation, it allows access to unconscious fantasy and primary process material, once the safety of the frame is established. (The setting, or the frame, is not automatically safe. It is the therapist’s job not only to construct it, but to work in a manner that convincingly and consistently guarantees its safety.) Thus the paradox that the very fact that there is a set of rules governing the play is what allows it to occur freely and safely. The setting, or frame, permits the “separate reality” of the transference relationship to achieve its full affective quality, protecting the “imaginary” field from the intrusions of “outside reality.” John Kafka has written eloquently of the multiple levels of reality that exist in the treatment situation, with particular attention to the role of time in their construction.14 Winnicott’s work on transitional object phenomena (including the transitional space of the treatment situation) and their relationship to play has been crucial in understanding the creative and growth-promoting aspects of the treatment: “Playing facilitates growth and therefore health; playing leads into group relationships; playing can be a form of communication in psychotherapy; and lastly, psychoanalysis has been developed as a highly specialized form of playing in the service of communication with oneself and others.” 15 And, “psychotherapy is done in the overlap of the two play areas, that of the patient and that of the therapist. If the therapist cannot play, then he is not suitable for the work. If the patient cannot play, then something needs to be done to enable the patient to become able to play, after which psychotherapy may begin.”16 (Here he was making no distinction between psychotherapy and psychoanalysis.) The patient who is suitable for psychoanalytic treatment must be able to make the distinction between the transitional space of the analytic setting, and external reality. In other words, he must be able to experience and tolerate the “as if” nature of the treatment that, when protected by the rules of the setting, permits the transference field to take form. Ogden has noted that “the capacity for mature transference (as opposed to delusional transference) involves the capacity to generate an illusion that is experienced at the same time as real and not real.”17 Recall Freud’s observation that the love the analysand feel’s toward the analyst is both “real” and “unreal.” This fits Winnicott’s definition of the transitional object, transferred from the realm of concrete objects into that of “human objects.” Winnicott’s concept of the holding environment adds a further dimension. He states that the analyst’s constancy and reliability in listening, his authenticity, and his attending primarily to the patient’s needs and not to his own, repeat aspects of the early childhood relationship with the parents. He wrote that “it often takes the form of conveying in words, at the appropriate moment, something that shows that the analyst knows and understands the deepest anxiety that is being experienced, or that is waiting to be experienced.” These analytic functions are analogous, but not identical, to a protective parental relationship, so that analysands may experience being emotionally “held” by the analytic setting, just as the mother actually held the child during infancy.18 This is another instance of different but simultaneous “realities” occurring in treatment. Patients who are unable to accept the

9 paradox of these multiple realities inside and outside the frame are not able to shift among the realities of the transference, the therapeutic setting, and the actuality of the therapist as an ordinary person. The absence of the fantasy dimension of transference leads it to become overly literal and concrete.19 One need not travel far from the idea of “holding” to reach the notion of “safety,” which Joseph Sandler has elaborated. By the successful application of his various functions (reliability, constancy, exclusive focus on the concerns of the patient, etc.) in the setting, the analyst enables the patient to experience a sense of safety in the treatment, a prerequisite to therapeutic regression. Sandler considered this a vital ego function: the “feeling of safety is more than a simple absence of discomfort or anxiety, but a very definite feeling quality within the ego; . . .We can. . . regard much of ordinary everyday behaviour as being a means of maintaining a minimum level of safety-feeling; and. . . much normal behaviour as well as many clinical phenomena (such as certain types of psychotic behaviour and the addictions) can be more fully understood in terms of the ego's attempts to preserve this level of safety.”20 Modell considered the setting to be part of the mechanism of therapeutic action, and not just something that facilitates the action. “We believe that there are elements of caretaking functions implicit in the object tie of the patient to the analyst, functions that are part of ordinary psychoanalytic technique.21 He notes that Loewald said the analytic setting represents a new object tie.22 “In addition to these ‘real’ elements, there is the fantasy that the analytic setting functions in some magical way to protect the patient from the dangers of the environment, a fantasy similar to that of perceiving the analyst as a transitional object.”23 These fantasies can and should be interpreted. As noted above, in the treatment of most neurotics the “holding environment” functions, as it were, silently. But “where there is ego distortion, the analytic setting as a holding environment is central to the therapeutic action.”24 It is striking how rarely the issue of confidentiality is mentioned in descriptions of the analyst’s behavior in the setting. In my research for this paper, I did not come across it even once. Yet confidentiality, a feature of the therapist’s conduct, is essential for successful treatment. “Confidentiality and trust are so deeply embedded in psychoanalysis that to envision effective treatment without them is not possible.” 25 The concept of the frame helps to understand this: “The purpose of the analytic frame is to create a boundary line between the world of social interaction and the consulting room, in more than the geographic sense. Confidentiality is a chief feature of that boundary; it extends the frame beyond the notion of a given time, place and setting, to an essential principle of the relationship.”26 The setting tries to optimize the conditions for the emergence of illogical, primary process material, by means of free association, so as to gain access to the unconscious sources of emotions and behavior. “This is a shared making of meaning by the analytic dyad, and is part of a willing suspension of reality, for a therapeutic purpose. All of this needs the protection of the analytic setting to allow its “as-if” function to play out fully in the evolving transference. Once we cross the border to the social sphere [by violating the rule of confidentiality], with its more traditional properties of language and speech and meaning, where words are closer to actions [and] are not explored for their unconscious derivatives, . . .we have lost the essence of the process.” 27 It should be self-evident that there is a close relationship between confidentiality and trust, reliability, and safety. I hope that I have shown how paying careful attention to the setting is necessary for successful psychotherapy and psychoanalysis to occur. At times there is a need for subtlety and care in working within the frame, that is part of the therapist’s craft. So just imagine the damaging effect upon our task when the therapist is involved in deliberate breaches of

10 the treatment setting, in other words, when he engages in boundary violations, destroying the boundaries (physical, contractual, behavioral) imposed by the requirements of the therapeutic setting. By all measures, acting outside of the frame harms not only the individual treatment, but the profession itself, since we all have an interest in preserving the reputation and integrity of our field. Actions that deviate from the therapeutic task of trying to put actions and feelings into words, that place the needs or desires of the therapist above those of the patient, that rationalize bodily contact between therapist and patient, or that impair the reasonable effort to establish an atmosphere of trust, are the ways in which such boundary violations can occur. Looking at the key functions of the setting and its maintenance help to put this issue into perspective. Before ending, I feel that it would be an oversight on my part to not acknowledge the challenges in establishing a therapeutic setting, for many practitioners in Eastern Europe and the Former Soviet Union. There are patients who are difficult to treat in all cultures and

11 societies, but the absence of a psychological culture, and the population’s lack of familiarity with psychodynamic therapies, has imposed an added burden on practitioners in Eastern Europe. Added to this, of course, is the fact that you were new therapists, still learning how to work, internalizing the rules of conduct for treating patients, trying to consolidate a new identity, and yet being forced to work with difficult patients unused to this kind of treatment - all of which posed a challenge to your skills. The historical and cultural backdrop, economic constraints, lack of space, and lack of therapeutic traditions, imposed additional burdens on the establishment of the setting in treatment. The situation has improved in many parts of the region, but remains a challenge in many others. For a long time I have been impressed with the ability of practitioners in the East to improvise, in an effort to bring good treatment values to the profession. In writing this paper, I was reminded more than once of some words of Milan Kundera that have always intrigued me. In his speech accepting the Jerusalem Prize for Literature in 1985, he declared that “great novels are always a little more intelligent than their authors.”28 What does this have to do with the setting? I think that there is an important analogy to be made, and this will serve as my conclusion. Just as the form of a successful novel carries meanings and effects beyond the words of the author, and the novel’s “wisdom” requires the author to follow and respect his characters’ wills, so too, successful treatments always feel more wise, or more therapeutic, than the application of the therapist’s own philosophy or technical skill is able to produce. I think that this is because the actions of the setting, among other elements inherent in the proper conduct of the treatment, carry their own genius with them, beyond the therapist’s application of his will or intelligence. It is the job of the therapist to respect this, to guard it, and minister to the vicissitudes of the setting as the therapy advances. The result of this work, like the growth of the farmer’s crops or the author’s characters, involves functions beyond those that exist in the caretaker himself. If the setting is properly administered, the natural processes of growth will be re-established. In this way, the therapist must remain modest before the powerful affects the treatment elicits, and accept the role of inquisitive student or researcher, as he applies his technique and watches the treatment unfold with his assistance. He learns and grows from it too - this is one of the permissible gratifications of the work. We do not force the patient to improve, rather we apply a process, both with its verbal and non-verbal components, that has psychodynamic and therapeutic functions embedded in it.

Literature

1. Modell, Arnold, Other Times, Other Realities - Toward a Theory of Psychoanalytic Treatment (Cambridge; Harvard University Press, 1990), p. 23 2. Modell, A. (op. cit.) 3. Freud, S., The dynamics of transference (SE 12), pp. 97-108 4. Modell, A., “The Holding Environment” and the Therapeutic Action of Psychoanalysis (Jl Amer Psychoanalytic Assn: 24:285-307), 1976, p. 285 5.Modell (1990, op. cit.)

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6. Sandler, J., Countertransference and Role Responsiveness (Intl Rev Psychoanalysis 3:43-47), p. 44 7. Winnicott, D.W., Clinical varieties of transference (1956), in Collected Papers, (New York, Basic Books, 1958) 8. Stone, L. The Psychoanalytic Situation, (New York; International Univ. Press, 1961), p. 9 9. Bleger, Jose, Psychoanalysis of the Psycho-analytic Frame, (Intl. Jl. Psychoanalysis; 48:511519), 1967, p. 511 10. Rycroft, C., Psychoanalysis and Beyond, (London: Chatto and Windus), 1985 11. Milner, M., The Role of Illusion in Symbol Formation, in New Directions in Psychoanalysis (New York, Basic Books, 1955), p. 86 12. Modell, A. The Psychoanalytic Setting as a Container of Multiple Levels of Reality: A Perspective on the Theory of Psychoanalytic Treatment, (Psychoanalytic Inq; 9:1), 1989, p. 78 13. Modell, A. (Ibid. p.79) 14. Kafka, J.S., Multiple Realities in Clinical Practice, (New Haven: Yale U. Press), 1989 15. Winnicott, D.W., Playing and Reality, (Routledge: London and New York), 1971, p. 41 16. Winnicott, D.W.. Ibid., p. 54 17. Ogden, T.H., Playing, Dreaming, and Interpreting Experience: Comments on Potential Space, in From, G and Smith, B.L., The Facilitating Environment - Clinical Applications of Winnicott’s Theory (Madison, CT: Intl Univ Press), 1989, p. 271 18. Winnicott, D.W., Metapsychological and Clinical Aspects of Regression Within the Psychoanalytic Set-up, in Collected Papers, (Basic Books, 1958) 19.Modell, A., (1989, op. cit.) p. 79 20. Sandler, J. The Background of Safety, (Intl Jl. Psychoanalysis 4:352-256), 1960 21. Modell, A., The ‘Holding Environment’ and the Therapeutic Action of Psychoanalysis, (Jl Amer Psychoanalytic Assn: 24:285-307), 1976 22. Loewald, H.W., On the Therapeutic Action of Psychoanalysis (Intl Jl Psycho-anal, 41:1633), 1960

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23. Modell, A., Object Love and Reality, (New York: Intl Univ Press), 1968 24. Modell, A., (1976, op. cit.) 25. Goldsmith, G., Confidentiality and the Psychoanalytic Relationship (paper read at 11th PIEE Summer School, Kiev), 2004 26. Goldsmith, G., Ibid. 27. Goldsmith, G., Ibid. 28. Kundera, M., The Art of the Novel, (New York: Harper and Row), 1986, p. 158