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Publications: Book Reviews
Review of Affect Intolerance in Patient and Analyst

Title: Affect Intolerance in Patient and Analyst
Author: Coen, Stanley J.
Publisher: Northvale, NJ: Jason Aronson, 2003
Reviewed By: Fonya Lord Helm, Fall 2005, pp. 69-71

This book is an excellent account of Dr. Coen’s work with patients who have great difficulty tolerating the affect that is aroused by the usual analytic interventions. Instead of becoming interested in analyzing, such patients communicate powerful affects that also affect the analyst’s capacity to stay excited by and interested in analyzing. Coen describes his efforts to contain his own discouragement, his own disagreeable affect and his disappointment in their “failure.” He describes how he eventually decided to continue with such patients, when earlier in his career, he would have discontinued the treatment.

“In the past, in agreement with my skilled colleagues, I probably would have told Mr. R that we should discontinue his treatment because he was insufficiently motivated to change. If his motivation for change increased, then it might make sense for him to return to treatment. By doing so, I would have been making the treatment problem his failing rather than accepting it as a joint problem for both of us. For patients like Mr. R., who have been rejected, criticized, attacked, and blamed, such a therapeutic stance can aggravate the problem, heightening the residues of past trauma in the present treatment. The patient can easily experience the therapist, like the parent of childhood, as making the patient solely responsible for what has gone wrong between them (cf. Bromberg 1983). In contrast, the therapist’s… joining the patient in struggling with the treatment impasse rather than putting it back on the patient offers a new developmental perspective. Such patients will insist that the therapist, unlike the parent before him, own his contributions to the treatment dilemma. They may seem to torture the therapist forever about his failings with them. These patients may need to take a very long time in which they live out such treatment struggles before they can or want to allow themselves more open and vulnerable collaboration with the therapist” (p. 78-79).

Dr. Coen integrates both drive theory and object relations theory in his work. He focuses on an experience-near concept of affect, however, and is astute in his understanding of both patients’ and therapists’ discomfort with loving feelings, rage and hatred, and the dangers of desire and need. He notes wishes to regress in both patient and therapist.
His definition of regression, however, is quite specific, and focuses on object relationships, rather than a decompensation of ego functions or the appearance of more primitive material, oral or anal, constituting an id regression from oedipal material.

“By the wish to regress, I refer to wishes to return to more infantile modes of relatedness to the other, experienced as a vitally needed parental object. However, I am referring specifically to yearnings for a pathological object relationship as opposed to healthy competence, growth, and individuation. I regard as progressive, despite their infantile nature, any childlike longings for an object relationship in which one can further develop oneself. By mutual regression I refer only to instances in which the therapeutic couple seeks to share a pathological object relationship that precludes separateness. It is crucial that we differentiate wishes for an object relationship that aims to destroy separateness and competence from one that seeks to promote them. Regressive wishes for a destructive relationship lead to crippling and stagnation, within the treatment and outside it” (p. 136). This description reflects the central thesis of the book: that the relationship and affective exchange between the analyst and patient needs to go in the direction of becoming more growth-producing, more loving and more thoughtful and collaborative.

Coen further delineates his ideas about regression:

“I do not find it helpful to regard as an ‘inability to regress’ the fear of needs, wishes, and feelings found in rigid characters—obsessional, sadomasochistic, paranoid, schizoid (Coen 1992, Shapiro 1981). In point of fact, their intolerance of affect and need is broader than their fear of regression. I believe, in agreement with Inderbitzin and Levy (2000), that the concept of regression does not clarify such fears of needing and feeling. Similarly, I do not find it helpful to invoke the therapist’s regression in the service of the patient to explain allowing ourselves to feel need and affect toward our patient. I will therefore not emphasize the useful aspects of the therapist’s regression but will focus instead on how the therapist’s wishes to join patients in mutual regression derail constructive treatment process” (p. 137).

Coen describes the role of a mutually constructed sadomasochistic engagement in order to avoid loving relatedness between patient and therapist. “Angry, dissatisfied, antagonistic feelings can be safer for both patient and therapist than the openness and vulnerability of feeling close and loving” (p. 140).

He gives a very interesting clinical example of his wish to relate to one of his patients as an admiring and desiring father, primarily for his own needs. He was struck by her avoidance of working with a dream in which she “pulls from the ground two tuber-like root vegetables described offhandedly as phallic. Because of the dirt on these vegetables, she is initially reluctant to eat them. When she finally bites into one, it tastes wonderful; she feels ecstatic but is concerned that she may not have enough to eat. Although she was easily able to connect this dream with her hunger toward me in the transference, she avoided, despite my interventions, the images of pulling out, biting, and swallowing” (p. 141). Coen wondered if it would be best to engage her hungry wishes toward him, yet he noticed that her wishes to castrate did not make him anxious, and found himself thinking of Arlow’s (1966) advice to a supervisee to interpret both the defense and the wish since the patient could not do it herself.

Coen’s conscious concern was that his patient would be too frightened of her aggressive wishes, but in the next session, he got an opportunity and interpreted his patient’s wish “to pull out, bite, and swallow the power of my genitals” (p. 141). He was then surprised, however, that the patient did not seem to respond at all to his intervention, but several sessions later, the patient said she had felt criticized. She was afraid Coen would be angry at her for wanting to challenge his power and authority, but then through further analytic work realized that she had blocked out envy and rivalry toward her father, brothers, and husband, also, and became more comfortable with the wishes to challenge and rob them of their power and authority (p. 142). In this example, Coen was functioning well as an analyst, even though some would have waited longer to make the intervention about castrative wishes. He relied heavily on his own absence of anxiety in his decision to go forward. His patient was helping him understand the effect of his intervention, by letting him know her feelings were hurt. She felt criticized by him for being too aggressive, too interested in taking his power and authority for herself. He worked well with the disruption, helping her use the information to further understand her history and become more comfortable with her aggressive fantasies. Since Coen was not distracted by feelings of anger at her aggression and her power grab, at least not consciously, he was able to manage the situation well. This patient remained unaware, however, that another reason that she felt criticized was that Coen’s intervention brought her closer to her aggressive wishes, when she was trying to get further away. Her feeling of being criticized was another line of defense to keep away awareness of her aggression. Coen chose to bypass both defenses in this instance, rather than interpret them, and his choice seems to have worked well.

Coen notes that as long as we can “shift back and forth between sharing in our patient’s inner world and getting sufficiently outside it so as to be able to contain and interpret that patient’s needs and conflicts” (p.142), we are still functioning as a therapist or analyst and can understand our patient’s needs and our own. The problem comes, however, when the patient’s regression is no longer benign, but malignant (Balint, 1968), or can be conceptualized as a negative therapeutic reaction. Coen understands well that the therapist participates in creating these regressions, but he also contributes something more in his understanding that the therapist, when faced with very borderline or psychotic patients, is under a lot of pressure and cannot avoid becoming derailed at times (p. 144). Fragile, socially isolated patients, for example, can become delusional about their analysts and therapists, and such situations can lead to the therapist’s loss of perspective and paralysis (p. 144-145).

Coen describes the “therapist’s masochism and concomitant paranoid anxiety [that] lead the guilty therapist to want to fail, to perceive resistance as aggression by the ‘persecutor’ patient, and to focus too exclusively on negative transference and aggression, ‘hindering…perception of the patient’s love and what is good in him, which in turn increases the negative transference’ (Racker 1958, p. 559)” (p. 144).

Coen also is aware that the willingness to escape the role of therapist in favor of another more regressive relatedness to the patient occurs and the therapist is not just the unwilling victim of the patient’s efforts to destroy his or her therapeutic function. “It would be psychoanalytically naïve to believe that the therapist’s unwilling victimization does not also involve a willing surrender” (p. 142-143).

Since we cannot avoid such regressions with certain patients, Coen advocates understanding more about how we contribute to such situations. He credits Balint (1968) with understanding that interpreting transference overemphasizes the attachment to the analyst and underemphasizes pleasure in autonomous functioning and “regressive relatedness to that part of their world that exists between their objects” (p. 145): “Balint believed also that the Kleinian method of interpreting what patients cannot possibly grasp for themselves exaggerates their sense of deficiency, thereby encouraging submission to and idolization of the seemingly omniscient analyst; this in turn aggravates feelings of aggression, envy, competitiveness, and destructiveness toward the analyst” (p. 145).

Coen believes that all of us therapists have this same temptation and wish to overwhelm and immobilize patients by interpreting their unconscious, showing them what they cannot see for themselves (p. 146), even though at times we need to do just that. We are less comfortable with waiting for our patients to become ready to change and develop in their own ways.

No doubt we all at times wish to control and subjugate our patients, and be idealized. In fact, by acting differently than we do in social situations and not telling our patients about us, we act more the way parents or teachers treat children and we set up the psychoanalytic situation with its conventions, including the use of the couch and not seeing the analyst for most of the session. Westen and Gabbard (2002) have noted that the demand characteristics of both the psychotherapeutic and psychoanalytic situations include making the therapist more powerful and the patient more infantile, and creating a setting for conversation about intimate matters that leads to important feelings of love and other intense feelings (p. 124). It is a matter of degree. There are times, as in the example Coen gave of the patient who was eating the root vegetables, when what works is to bypass the defenses and interpret what the patient isn’t consciously aware of. Because Coen wasn’t anxious, though, he thought that the material was pretty close to the surface, and wouldn’t be too startling to the patient. He was right. He was able to get her to elaborate about her feelings of criticism, which she had been able to bring up after a few days.

Coen advocates collaboration and sensitivity on the part of clinicians interested in understanding each other’s work, especially work from a different clinical perspective. He is advocates an approach of putting pieces of the puzzle together, rather than having a rousing, polarizing debate. He notes that the style of psychoanalytic discussion is improving and leading to a greater exchange of clinical information. He recommends emphasizing the importance of being interested in the discussant’s and the audience’s ways of approaching the material, and that they are in a unique position to understand stalemates and impasses that the treating analyst will not see. He encourages sensitivity in handling this situation, especially for the junior or vulnerable clinician.

We clinicians allow ourselves to be vulnerable, if we are presenting detailed process material freely, in a spirit of collaboration and inquiry, and any rigid adherence to any particular theoretical view is indicative of a need to disavow such vulnerability and protect ourselves from unwanted feelings of guilt, shame, aggression and sexual excitement. We need to acknowledge our needs to be idealized and our wishes for deep attachment and love. What we are trying to do is so complex that it cannot be captured by any theoretical system. Because the process takes place 80 to 90 per cent outside conscious awareness, it makes us anxious, and we cannot reliably tell anyone what we are doing and how we do it. The work of the Boston Change Process Study Group has been helpful here, especially their concept of the microprocess that takes place on a small scale at the “local level,” where present moments emerge (Stern, 2004, p. 149). Their focus on the nonverbal communications that occur constantly outside the conscious awareness of both participants has been helpful in getting everyone to acknowledge that it is impossible to understand and articulate everything when presenting a case. Coen is very aware of the importance of these nonverbal communications in the exchange of feeling in the therapeutic couple.

Coen advocates open clinical writing that is alive in its communication of affect to the reader and metaphorically alive content that will allow the reader to play with the material, in order to generate new ideas. He discusses Schwaber’s and Arlow’s written exchanges about her (Schwaber’s) case that became polarized when Arlow pointed out that, in her attention to the transference-countertransference, the content of the conflict was neglected. The discussion became “either-or” instead of “both-and,” and each ended up advocating one particular aspect of analytic treatment. There are fads in psychoanalytic interventions, and it is easy to get stuck in the ideas of one’s time. For example, Arlow is gifted in his understanding of the power of metaphor and its ability to open up many pathways of inquiry, and Schwaber is sensitive to psychoanalytic interventions that emphasize close attention to the countertransference as a way of understanding the patient’s contribution to the functioning of the therapeutic dyad.

This situation of the latest interventions of choice that is part of our need to move forward and have something new for our patients and ourselves poses a fascinating dilemma. Coen is looking for something authentic in the work that makes us know it is good work. He is hoping that it will be possible to distinguish good therapeutic work from therapeutic work that is written about persuasively and is convincing for that reason, whether it is good or not. I am not sure that they can be separated, because the affect that is communicated in persuasion is part of what it important. Arlow persuaded a generation of analysts that his views were useful to patients and other analysts. His lively writing and personally engaging style made it possible for him to interest many practitioners in his ideas. Schwaber writes beautifully and convinces us that she is an excellent clinician, because of her thoughtful approach, her empathic position and her attention to the details of her patient’s defenses. Both are fine clinicians as judged by their peers and each has a method of practice that is embedded in a particular time and place.

We have to acknowledge that we are susceptible to the power of persuasive colleagues, the influence of our psychoanalytic culture, and the influence of our larger culture, just as we are susceptible to our own wishes to abdicate our position as psychoanalyst and join the patient in a regressive object relationship. It is the communication of powerful affect in both cases that pulls us in. This book provides both extremely interesting clinical material and a solid understanding of the importance of increasing our tolerance of our own affect and that of our colleagues and patients. I recommend it with enthusiasm.

Stern, D.N. (2004). The present moment in psychotherapy and everyday life. New York: W.W. Norton & Company.
Westen, D. and Gabbard, G. O. (2002). Developments in cognitive neuroscience: II. Implications for theories of transference. Journal of the American Psychoanalytic Association 50:99-134.

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