External and internal reality: the impact of the current socio-economic crisis on the analytic dyad.

Int J Psychoanal (2014)

doi: 10.1111/1745-8315.12240

External and internal reality: The impact of the current socio-economic crisis on the analytic dyad Anna Christopoulos 1Valaoritou Street, Athens, 10671, Greece – [email protected] (Accepted for publication 5 March 2014)

This paper addresses the impact of the current economic crisis on the psychic functioning of the patient and the analyst, their relationship and collaboration. This intrusion of ‘external reality’ is multidimensional, and thus with multiple meanings. The critical role of the economic factor brings various dimensions of money into play, such as self-preservation, power as well as aspects of psychosexual development. In addition, the crisis involves symbolic loss of basic ideals such as honesty and social responsibility. Patient and analyst are affected in similar and different ways in their respective roles as well as according to the specific intrapsychic functioning of each. Moreover, unique characteristics of the crisis often create a crisis in the analysis. In order to avoid deformation of the analytic relationship, the analytic dyad must examine and work through the multiple meanings of the crisis as well as the meaning of the impact of the crisis on the analytic relationship for both patient and analyst. This complex transferencecountertransference interplay poses specific challenges to the analyst. After discussion of these issues, clinical material is presented that demonstrates how they appear in analytic practice today. Keywords: economic crisis, external-internal reality, transference, countertransference

The complex inter-relationship between external and internal reality, a source of interest and controversy in psychoanalysis since its inception, has come to the foreground more prominently as the current global socio-economic crisis impacts on psychoanalytic practice. Concern about this impact is reflected in recent psychoanalytic literature from several vantage points (Aisenstein, 2013; Berger and Newman, 2012; Cantrione, 2013; Lotto, 2009; Morantes, 2012; Murdin, 2012; Sonnenberg, 2013; Tuckett, 2011; Uselli, 2013; Wolff, 2012). In this paper, I will focus on the effects of the current socio-economic crisis on the psychic functioning of the patient and the analyst, their relationship and collaboration. I will concentrate particularly on how the crisis may impact on the analytic process, creating a crisis in the analysis itself. I am referring to the moment when it becomes evident that the patient cannot – or says that he1 cannot – continue to pay the agreed fee as a result of his financial losses due to the crisis. This intrusion of ‘external reality’ on the 1

I will refer to both patient and analyst as ‘he’ throughout this paper for purposes of brevity.

Copyright © 2014 Institute of Psychoanalysis

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analytic situation catalyses complex transference and countertransference2 vicissitudes. The analytic dyad is called upon to examine and work through the meaning of the crisis for each, as well as the meaning of the impact of the crisis on the analytic relationship. Although difficult, this process provides particular opportunity to analyse issues that might not otherwise come to the fore, thus enhancing fruitful transformation of the analytic relationship as well as the development of the analysis as a whole. In this sense, the term crisis encompasses multiple meanings of its Greek origin, kreinin, which include evaluation, judgement and clarification of issues, thus constituting a crucial turning point, with the opportunity for positive change or, alternatively, the possibility of negative outcome. To be sure, the impact of external parameters on the analytic process is frequently encountered in a multitude of ways in everyday psychoanalytic practice, and as such is a continual source of interest, concern and controversy (Oliner, 1996). Differences in implicit and explicit theories between psychoanalytic orientations regarding this relationship lead to controversy in clinical technique as to how to most effectively approach the impact of external reality on the analytic situation (cf. Arlow, 2008; Ferro, 2006; Gibeault, 2010; Inderbitzen and Levy, 1994; Kernberg, 2011; Klein, 1952; Kogan, 2004; Segal, 1994). I will review the existing literature on this topic and then elaborate on these issues in terms of their current immediacy, that is, the impact of the current socio-economic crisis on the analytic situation, referring to three clinical cases to demonstrate how they appear in contemporary analytic practice.

‘External reality’ and the psychoanalytic situation The relationship between external reality and analytic work is a cornerstone of psychoanalytic inquiry (Freud, 1913, 1924, 1926; Inderbitzen and Levy, 1994; Oliner, 1996). All major theoretical orientations acknowledge the mutual, reciprocal effects of external and internal reality. External reality is considered to impact critically on the development of the internal world; the latter, that is, unconscious fantasy, drive derivatives and defensive function significantly affect perceptions of external reality which, in turn, can “stimulate and organize the re-emergence of unconscious fantasy” (Arlow, 2008, p. 28; Ferro, 2006; Kernberg, 2011; Klein, 1952; Segal, 1994). Moreover, there is general agreement that a basic aim of analysis is to help the patient distinguish between the two, and to understand their interplay. However, controversy exists amongst major psychoanalytic orientations as to how this is best approached in terms of clinical technique (Oliner, 1996). Kleinians view the individual’s perception of external reality as determined by, and thus reflecting unconscious fantasy and past experiences through processes of projection and introjection (Klein, 1952; Segal, 1994). Therefore, clinical technique consists of transference interpretations aiming to reach the deepest level of activated anxiety. A most frequently cited 2

I am using the term countertransference as it is most often used in the contemporary literature (Jacobs, 1999), that is, as including both the affective responses (King, 1978) and unconscious reactions (Freud, 1910; Reich, 1951) of the analyst towards the patient.



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The countertransferential pressures were thus particularly intense and needed careful attention at each step of the cyclical analytic trajectory up to the point that a decision was agreed upon by both patient and analyst as to how to proceed. The reverberations for both members of the analytic dyad have continued since and remain objects of analytic inquiry. In conclusion, although the issues catalysed by the socio-economic crisis may have appeared in other forms in the analytic work, the crisis provided the opportunity for investigation and working through of this material, in each case leading to important developments in the analysis. I believe that exchange among colleagues from different regions of the world, each of which are affected somewhat differently by this global crisis, will lead to our better understanding of its impact on clinical psychoanalytic practice. This seems particularly significant in view of the continuation and global expansion of the crisis at this time.

Translations of summary alite interne et externe : l’impact de la crise socio-e conomique actuelle sur la dyade analyRe tique. L’auteur de cet article examine l’impact de la crise economique actuelle sur le fonctionnement psychique du patient et de l’analyste, leur relation et leur collaboration. Cette intrusion de la « realite externe » est multidimensionnelle et a donc de multiples significations. Le r^ ole crucial du facteur economique met en jeu une pluralite d’aspects relatifs a l’argent, tels que l’auto-conservation,le pouvoir ainsi que les caracteristiques du developpement psycho-sexuel. De plus, la crise economique entra^ıne une perte symbolique des ideaux de base tels que l’honn^etete et la responsabilite sociale. Patient et analyste sont affectes de facßon a la fois semblable et differente en fonction de leurs r^ oles respectifs et du fonctionnement intrapsychique specifique qui les caracterise. Qui plus est, les caracteres singuliers de la crise creent souvent une crise dans l’analyse. Afin de parer a une deformation de la relation analytique, la dyade analytique doit examiner et perlaborer les multiples significations de la crise ainsi que le sens de l’impact de la crise sur la relation analytique du c^ ote du patient et de l’analyste. La complexite de cette interaction transfero-contre-transferentielle lance un defi particulier a l’analyste. Apres avoir discute de ces questions, l’auteur s’appuie sur du materiel clinique pour illustrer comment celles-ci se manifestent aujourd’hui dans la pratique analytique. € €t: die Auswirkungen der aktuellen sozio-o € konomischen Krise auf die und innere Realita “Außere analytische Dyade”. Der Beitrag untersucht den Einfluss, den die aktuelle wirtschaftliche Krise auf das psychische Funktionieren von Patient und Analytikerin, ihre Beziehung und ihre Zusammenarbeit aus€ ubt. Dieses Eindringen der „€außeren Realit€at” ist multidimensional und hat deshalb zahlreiche Bedeutungen. Die entscheidende Rolle des wirtschaftlichen Faktors bringt mehrere Dimensionen des Geldes ins Spiel, etwa die Selbsterhaltung, die Macht sowie Aspekte der psychosexuellen Entwicklung. Dar€ uber hinaus geht die Krise mit einem symbolischen Verlust grundlegender Ideale wie Ehrlichkeit und sozialer Verantwortung einher. Patient und Analytikerin sind in ihrer jeweiligen Rolle und je nach ihrem individuellen intrapsychischen Funktionieren auf €ahnliche und auf unterschiedliche Weise betroffen. Dar€ uber hinaus erzeugen die typischen Merkmale der Krise h€aufig auch eine Krise in der Analyse. Um eine Deformierung der analytischen Beziehung zu vermeiden, muss die analytische Dyade die multiplen Bedeutungen der Krise sowie die Bedeutung ihres Einflusses auf die analytische Beziehung und beide Beteiligte € untersuchen und durcharbeiten. Dieses komplexe Zusammenspiel von Ubertragung und Gegen€ ubertragung konfrontiert die Analytikerin mit spezifischen Herausforderungen. Im Anschluss an die Diskussion dieser Themen wird klinisches Material vorgestellt, das illustriert, wie sie in der heutigen analytischen Praxis zutage treten. sterna e realta interna: l’impatto dell’attuale crisi economica sulla coppia analitica. QuesRealta to lavoro affronta il tema dell’impatto dell’attuale crisi economica sul funzionamento psichico del paziente e dell’analista, sulla loro relazione e collaborazione. L’intrusione della ‘realta esterna’ e multidimensionale e pertanto si declina in una molteplicit a di significati. Il ruolo critico del fattore economico fa entrare in gioco vari aspetti del denaro quali l’auto-conservazione, il potere nonche aspetti



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the treatment, and the analytic work evolved in a more fruitful manner. Kogan considers that insistence on a focus on the patient’s internal reality may be due to the analyst’s defensive denial of the external situation in an effort to counteract feelings of helplessness and passivity in the face of the traumatic external reality. Positing that external reality of a collectively traumatic nature differs from reality under normal or stable life circumstances. Kogan concludes that it is essential for the analyst to include acknowledgement of the external reality, in order to provide a containing function and thus facilitate exploration of the patient’s internal response to the external situation, based on the meanings it has for him. Finally, she underscores that the nature of the collective, traumatic external reality is of significance with specific meanings for the populations impacted, meanings which must be taken into account in clinical work.3 In this sense the current global socio-economic crisis has particular and, to my mind, unique meanings which need to be elaborated in current clinical practice.

The economic crisis: Similarities in impact on patient and analyst The crisis impacts on patient and analyst, and on the analytic relationship and work, either explicitly or implicitly from the moment the crisis begins to manifest itself in the external world. Patient and analyst are affected in their external lives, as well as in terms of the intrapsychic response each has to this external reality. As the financial dimension is basic, money and its many meanings come to the fore. For both patient and analyst, self-preservation and power, two essential factors initially noted by Freud (1913) in On beginning the treatment, may be threatened with the loss of personal income and all it affects – standard of living, comforts, or even basic survival. In addition, the crisis may catalyse internal reactions to other meanings of money – such as the oral, anal, narcissistic and oedipal, as Freud and others have noted (Abraham, 1923; Fenichel, 1954[1914]; Ferenczi, 1976[1914]; Jones, 1967[1918]), or with respect to archaic anaclitic needs, dependency and envy as emphasized by Klein (1957). Contemporary writers have additionally observed that the unconscious meanings of money may reflect identifications with significant others, particularly parents, as well as cultural background. A societal transference to money has also been noted (Herron and RouslinWelt, 1992). The quest for money is even postulated to represent the quest to deny mortality itself (Klebanow and Lowenkopf, 1991; Krueger, 1986, 1991). Patient and analyst are also affected by the meaning of the broader social changes brought about by the crisis – the deterioration of fundamental institutions such as medical care, social services, education and so forth. These changes signify the symbolic loss of basic ideals such as social respon3

The obvious and profound differences in the nature and magnitude of the impact of war and that of the current socioeconomic crisis are a case in point.



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sibility and honesty since the crisis has been brought about at least to some extent by greed, corruption and exploitation. The values of psychoanalysis – truthfulness, self-knowledge, empathy, as well as the value of psychoanalysis itself – come into question in this context. (Glick, 2012). Moreover, the individual sense of personal power for both patient and analyst is strongly affected for reasons specific to the current crisis. Although similar to others (e.g. the socio-economic crisis in Argentina), this crisis differs significantly because of its global nature as well with respect to its causes – complex, invisible forces of international economics (Alamar, 2003; Dorella, 2013; Dubcovsky, 1982; Eisold, 2012; Haaken, 2009; Neuberger, 2002; Revault d’Allones, 2012). Difficulty in understanding the situation for the average person – including patient and analyst – adds to the sense of powerlessness which is further compounded by uncertainty about the future. Social change and a new social reality thus has a multifaceted impact on the psyche of patient and analyst, demonstrating in a most sobering way how this can happen as has been noted by Freud and others (Freud, 1938; Lieberman, 2012; Waelder, 1936). Each patient and analyst reacts to these dimensions of the crisis – threats to self-preservation, power, basic values and ideals, oral, anal, oedipal, narcissistic – in terms of the internal, personal meaning that these changes have for him, according to his intrapsychic life and individual history. A person with a history of early, global traumatic deprivation may plunge into a paralysed depression, whereas someone with a more robust upbringing may be galvanized into action. Someone with narcissistic vulnerability may be overwhelmed with feelings of humiliation because of personal loss of income as well as envy of those who have more. The differential impact is most starkly demonstrated by suicides committed by very affluent individuals while others of the working class who have difficulty in meeting basic expenses may have minimal psychic difficulty.

The economic crisis: Differences in impact on patient and analyst Although the crisis may have a different effect on patient and analyst from various perspectives, two appear to be most critical. One fundamental difference has to do with the analyst’s financial dependence on the patient. A second difference has to do with the analyst’s dependence on the patient for his professional survival. The analyst’s financial dependence on the patient first and foremost affects his self-preservation and may then touch on all the other aforementioned dimensions that money may encompass – oral, anal, oedipal, anaclitic, narcissistic and so on. Freud himself, in his correspondence with Fleiss, quite openly admitted that his mood was influenced by how he was paid (Gay, 1988) and referred to his well-paying patients as “goldfish” (Masson, 1985, p. 385). Freud recommended that analysts should acknowl-



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edge their need and desire for money rather than play the part of the disinterested philanthropist (Freud, 1913). The analyst’s dependence on the fee for his sense of self-worth has been observed (Jacobs, 2012; Lieberman, 2012).4 Related to this is the analyst’s dependence on the patient for his professional self-preservation and identity. The analyst needs to have patients in order to be an analyst: there is no analyst without a patient, to paraphrase Winnicott (1975). The current economic crisis compounds the problem as it adds to the crisis in psychoanalysis as a field that has preceded the current economic crisis for years. In fact, some of the underlying causes of the crisis in psychoanalysis are integrally related to the more recent economic crisis. The societal idealization and investment are in the immediately tangible, instantly gratifying, the quantifiable, the observable, rather than the internal, the affective (Kristeva, 1998, 2000; Minerbo and Yazigi, 2000). The results – a diminution in referrals, a reluctance in patients to come at a frequency of three to five times per week, lack of reimbursement by insurance or government – has led to anxiety and concern about being able to practise psychoanalysis, something that is further compounded by the recent further decrease in analytic patients due to the current economic crisis. The analyst’s sense of self-worth is thus doubly threatened under the current circumstances. To be sure, there are differences in impact of the crisis economically as well as in terms of psychoanalytic practice world-wide, between countries and continents (Glick, 2012; Hirsch, 2012), and the need for comparison across cultures has been noted (Dimen, 1994; Jacobs, 2013). In all contexts, however, when the economic crisis intrudes on the analytic dyad, complex transference–countertransference ‘dynamics’ (vs. “vicissitudes”) are set forth that require great care in order for the analytic relationship to survive without deformation.

The impact of the crisis on the analytic work: Transferencecountertransference vicissitudes and challenges for technique The moment when the patient says that he cannot, or when it becomes otherwise evident that he cannot pay the agreed fee as a result of financial loss due to the crisis, catalyses a crisis in the analysis for two interrelated reasons. Firstly, a decision has to be made as to how to approach the issue – that is, as a purely practical matter or, alternatively, as the object of analytic inquiry that must be explored and worked through in order to come to a decision regarding the analytic contract. Secondly, a decision has to be made with respect to the until now agreed upon fee with possible ramifications regarding if and how the analysis will continue. The extensive psychoanalytic literature to date on the patient’s difficulty in paying the fee under ordinary circumstances clearly indicates the second viewpoint (Eissler, 1974; Gedo, 1981; Herron, 1992; Hoffling and Rosen4

However, the relative dearth of literature on this topic is striking and has been attributed to various factors such as the analyst’s shame at this dependence and his vulnerability, guilt about his interest in being paid, difficulty with his own symbiotic needs (Beltsiou, 2005; Lieberman, 2012; Myers, 2007).




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baum, 1986). It is underscored that avoidance of such inquiry constitutes the analyst’s collusion with the patient, an enactment that can lead to the deformation of the analytic process (Haynes and Wiener, 1996; Krueger; 1986; Weissberg, 1989). The analyst’s countertransference is considered of critical importance, but very frequently problematic, with avoidance and denial of thoughts and feelings regarding the fee and changes that need to be made (Allen, 1971; Jacobs, 2012; Myers, 2007). Under the current circumstances of the crisis, certain additional countertransferential difficulties may emerge, making it difficult for the analyst to maintain his analytic stance. The reduction in income since the first inklings of the crisis in 2008 has been noted to affect the countertransference of analysts in several ways (Lieberman, 2012). The analyst may now be especially vulnerable as many, if not most of his patients, suddenly appear with the same issue and his practice and livelihood imminently threaten to dissolve. In some cases, the analyst may even be so overwhelmed by the stunning speed and magnitude of the impact of the crisis that his ability to think is at least temporarily destabilized or even immobilized. Because there may be pressure from the patient to make a decision immediately as he feels he does not have funds, the analyst’s maintenance of the analytic stance – creating an analytic space by giving time to investigate and work through the issue – may essentially mean that the analyst will not get paid for that time, and by several patients, constituting a significant loss of income. The analyst’s self-preservation is thus immediately in conflict with his analytic stance and function, to care for his patient in the best possible way. Thus, the crisis may involve an attack on the analyst’s identity. This may be compounded by the effects of the shared reality by patient and analyst, leading to the analyst’s identification with the patient as a victim of the crisis, a sense that he and the patient are joined against common enemies responsible for the situation or are mutually engaged in a process of mourning. The analyst may also hesitate to investigate the patient’s situation out of fear that the patient may experience this as a denial of painful external reality, lacking understanding and empathy, or even an attack (Inderbitzen and Levy, 1994; Raphling, 1992). For all these reasons, the analyst may approach the problem with payment only as a practical reality or hasten to arrive at a decision without fully exploring the meaning for the patient and himself. However, the decision to approach the patient’s problem as a focus of analytic inquiry immediately poses a challenge to the analyst, namely, to chose the most useful clinical approach in order to distinguish the ‘external’ from the ‘internal’ realities in question. As already noted in the literature, the basic differences in clinical methodology have to do with the extent to which the external reality is included as such in the analytic inquiry. Such differences notwithstanding, I believe that the patient’s approach to the problem is important to note to begin with, as it may reveal significant intrapsychic components at work. How does he describe his difficulty? Does he speak openly about his financial situation, giving the analyst a clear picture of limitations and possibilities? Does he propose a solution or wait for the analyst to do so? And if the patient does propose a solution, what is it? Copyright © 2014 Institute of Psychoanalysis


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To stop the analysis altogether, to come less often, to pay a lower fee? And how does he feel about this? And then there is the patient who never mentions the crisis at all, or who denies its impact while his associations indicate that remaining with the same fee arrangement is harmful to him. Under the circumstances of the current economic crisis it is essential to clarify external financial parameters as much as possible – have the patient’s finances become such that he can cover his living expenses but not analysis, or at least not the fee he was paying? Or is there a change in finances, but not one that actually prevents the patient from paying the fee – for example, the patient has savings but does not want to spend them on analysis, indicating that important internal factors are involved in the patient’s stance? The patient’s response to the analyst’s position of focusing on the situation as a source of analytic inquiry must also be taken into account. Does he consider this as a matter of course, an enraging affront, indicative of the analyst’s disbelief or a lack of empathy as to his situation? Each reaction has a unique internal meaning for every individual patient. This meaning must be explored, in the contexts of the patient’s personality organization and history as well as the specific moment of the analytic relationship, particularly dimensions of transference and countertransference. It is of critical importance that the analyst turns the focus of psychoanalytic inquiry onto himself through self-reflection (Arlow, 1993; Chused, 1991; Sandler, 1976) in order to examine his internal response to the patient’s position. This includes confronting the basic factor of his own self-preservation – what he can afford to offer the patient and yet preserve his livelihood and what he feels he can receive as a minimum to feel satisfactorily compensated for his work. The analyst is faced by the conflict between his own needs and desires and those of the patient, which may result in his feeling guilty or angry towards the patient. The analyst may feel also guilty for being in a better financial situation than the patient, or for not being in a better situation and therefore not in a position to provide the care that is needed. He may also have difficulty in acknowledging his dependence on the patient and try to maintain the illusion of omnipotence (Jacobs, 2012). The dangers of countertransference enactments are many, but exploitation and reaction formation are the most common (Herron, 1992). For example, the analyst may propose to see the patient less often or may accept a lower fee than what is therapeutically indicated – in order to preserve a livelihood of some kind and to protect against narcissistic injury and loss if the patient stops analysis altogether. There is also the danger that the analyst may overinvest in the analytic process in an effort to compensate for the financial loss and its meaning. Feeling an increasing loss of a control over finances and all that they comprise, as well as the symbolic loss of ideals, the analyst may feel compelled to invest far more in what he can control – his work. Reflection and working through of these multi-dimensional countertransferential aspects is critical in order for the analyst to have the necessary clarity to decide what he can propose to the patient – a lower fee, delayed payment, fewer sessions or even stopping the analysis. And then once more, the patient’s response to the analyst’s proposal must be the object of anaInt J Psychoanal (2014)



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lytic investigation – whether it is gratitude, envy of the analyst for being able to offer a reduced fee, guilt for accepting it, rage at the analyst for not being able to do so. Again, the patient’s response will depend on and reflect important dimensions of intrapsychic life that can be available for further analytic work. And again too, once the patient has responded, the analyst is called upon to consider his reaction to the patient’s response, and the meaning that this has for himself, the patient and their relationship. Even the final decision that is reached by the dyad as to how they will proceed remains an object of analytic investigation throughout the course of the future clinical work or, in the case of interruption of the work, mourning. This process, although difficult, provides an opportunity for understanding many issues as I hope is evidenced by the following clinical examples.

Clinical examples Mr J Mr J, a 40 year-old businessman, had been in analysis four times per week for a little more than a year. He had originally sought help after having a series of anxiety attacks and corollary somatic symptoms shortly after getting engaged. He was very frightened and puzzled by his symptoms as he felt happy in his life especially having made this commitment to a woman he loved. As soon as his analysis began he was tense and hostile with me. He often asked me my opinion about things, becoming very angry when I would try and understand the meaning of his questions rather than answer them. At other times he would remain silent, exuding what I experienced as a constrained but intense aggression, saying at the end of the hour that there was no point to what we were doing. Although I would frequently feel irritated at him, and at times despairing, I also had a feeling of wanting to stay next to him to weather the storm. I was undoubtedly influenced by what I had heard about his childhood – when he was 2 years-old, his mother left the family. Although Mr J saw his mother once every week thereafter, he said that she was passive and distant. As a result he felt he had “no relationship” with her. His father, as long as the patient could remember, demanded that his children take care of him. Mr J’s only memories of caretaking were of an aunt teaching him to dress himself. It was within this atmosphere in the analysis that the crisis broke out. The patient was furious, bitter and sad. He felt that at the moment when his life was finally becoming more fulfilling and he was receiving what he deserved, all this threatened to be taken away from him. Thus, the crisis was recapitulating the collapse and losses of his very early life, when his mother left the family and he lost the basic care and nurturance he needed. Now he lashed out, desperately looking for who to blame and was only partly satisfied by finally condemning the government for betraying him, failing to provide basic support and care which paralleled his father’s inability to provide a basic holding structure in the years after his mother’s departure. Copyright © 2014 Institute of Psychoanalysis


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Soon after, following the summer holiday, he announced that he would have to stop analysis as he could no longer afford it. The crisis was severely limiting his income, although he had indications that things could change financially in the future. He was quite tense, saying that, although he often did not like coming to analysis, he knew it helped him and was sorry to be stopping. Although I was not entirely surprised by his announcement – at this time these issues were coming up with many of my patients – it was for me somewhat unexpected as Mr J had not previously indicated that his finances were so dire as to necessitate stopping analysis. I wondered whether it was entirely a financial issue, or whether other factors were also involved. I thought about the abruptness of his announcement, the timing (after the holiday), the general atmosphere in the analysis, and that he thought to stop entirely rather to consider alternatives – coming less frequently, negotiating a lower fee, paying me later, etc. With all this in mind, I responded by saying that although the crisis and its impact were an unfortunate reality, it was, in my opinion, important to look at his idea to stop coming more closely. Mr J spontaneously said that his income had become minimal and unpredictable and he was covering his basic expenses with difficulty. His fiancee had lost her job. He was owed a substantial sum of money from various companies, and had some possible lucrative offers for the future. His parents had not offered to help and he would not ask them, as he thought they might not help him, which would enrage and disappoint him once again. My sense was that Mr J’s communications to me showed how the economic reality of the crisis had catalysed multiple transferential meanings. In part, he wanted to end a painfully ambivalent relationship with me, to abandon me as he had been abandoned during the summer break, and in his early life, and to deprive me as he was being deprived by the crisis and by his parents in the past. But I was also struck by his telling me that he was owed money and had lucrative prospects, on the one hand, and yet thought to stop, on the other. I turned our attention to these matters, asking him whether, in addition to the economic reality, there could be other reasons that this issue had arisen now. Mr J insisted that it was all a matter of financial reality, rejecting any of my interpretations to the contrary. Only when I suggested that, by telling me about his future prospects, he was communicating something to me – perhaps letting me know that he wanted me to offer him some kind of arrangement that would allow us to continue, but was afraid to ask, thinking I might refuse him, a situation much like that with his parents – was he able to acknowledge that something besides the concrete reality might be involved in what he was telling me. I was not entirely sure as to whether Mr J’s financial situation – despite his monetary difficulties – really meant that he could not pay for analysis at all, and that he thus had to stop entirely, as this idea seemed to have multiple transferential meanings. However, I thought that the only way to elucidate these meanings was to continue our work. My internal response was comprised of two feelings. Firstly, I felt a strong pull to continue his analysis, feeling that this was vital for Mr J’s emotional and physical well-being. I had Int J Psychoanal (2014)



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the sense that to stop or to meet less often would be a repetition of the trauma of his early losses. A lesser frequency would also not allow us to work in fruitful way. Secondly, I was fairly certain that I could trust him to pay me at some point, given his previous responsible behaviour and his mention of his potential future prospects. After reflecting on the parameters of my financial reality, and considering what arrangement would be most consonant emotionally for me, I decided to offer to see him for the same fee and that he could pay me as he felt able to. I chose this arrangement as lowering the fee would make me feel that I was in a position of deprivation, in light of his prospects, and might also foster a deleterious passive regression in him. Mr J accepted my offer with what I felt was genuine gratitude. As our work continued, he reverted to asking me questions and withdrawing into hostile silence when I did not answer directly. In time, we came to see how the sources of this behaviour could also be discerned in many issues with the fee arrangement. He felt I was depriving him with my silence, and he was depriving me in turn with his silence, as well as by delaying my payment. In this way, he was turning passive into active, doing to me what he felt was being done to him. He was also putting me in the position he felt he was in so that I could understand his experience now and in the past. It also became increasingly clear to us that his thought to stop was an unconscious attempt to recreate the trauma of his mother’s abandonment, and a test to see whether things could be different, if I was interested in and cared enough to continue with him without the gratification of immediate payment. This in turn would fulfil his unconscious infantile wish, to be cared for without having to reciprocate – in our case, to pay me immediately. We also came to see how these dynamics played out with respect to his financial exchanges in the external world. He revealed that he was very inhibited in asking for payment due to him, as he had been in asking for help from me. This unconsciously created a repetition of the original deprivation, but also had to do with a fear that he would be denied what he was owed and would then be filled with a murderous rage towards those depriving him of his due. In time he was able to generate more income and to collect it, and then paid what he owed me in full, thereafter resuming regular payment of his fee.

Mr T Less frequently, certain patients do not bring up the crisis at all in their associations. This is particularly striking when the economic crisis is at the epicentre of the external world as evidenced by constant references in the media and in everyday conversations. There are many reasons that the issue may not come up in analysis. The patient might not be directly affected and is narcissistically absorbed in his own problems. The patient may also be unconsciously guilty as he sees that others are suffering and he is not. He may also deny the reality of the crisis due to a characterological tendency to approach difficulties of all kinds in this way. This was the case with Mr T, a 42 year-old married father of three children, who had come to see me two years earlier as he was having symptoms Copyright © 2014 Institute of Psychoanalysis


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of undifferentiated anxiety that bordered on panic, as well as various associated physical complaints – gastrointestinal upset, somatic weakness, a feeling of heaviness in his body. Medical examination did not show any organic basis for his symptoms. Mr T was distressed by his symptoms but completely bewildered as to any of their possible causes. He asserted that everything in his life was satisfactory – his marriage, his relationship with his children, his small business. He did not elaborate on these further, and was strikingly laconic and concrete whenever I asked him to tell me more about his life. He answered: “Fine. I have nothing to complain about” in response to inquiry of any kind. My overall impression was of someone who was very concrete in his thinking, unable to make connections of any kind between things, strikingly unable to talk about thoughts, feelings or any part of his inner life. He was reminiscent of patients with alexithymic or ‘operatoire’ thinking (Marty and DeBray, 1989; Smadja, 2005). His lack of psychological mindedness and capacity for introspection made me seriously question whether he would be able to benefit from psychotherapy. However, rather surprisingly, he mentioned that he had had a consultation with someone who recommended pharmacological treatment which Mr T did not think would get to the root of the problem. Rather, he preferred a talking therapy. Thus, I suggested a once-weekly psychotherapy, face to face, adapted to a mode of working with patients with a psychic organization such as his (Aisenstein and Rappaport de Aisemberg, 2012; Taylor, Bagby and Parker, 1997). In our sessions, Mr T characteristically talked about his symptoms at length, unable to connect them to anything else, although it emerged that they were not constant, but waxed and waned at different times. He would repeatedly state that he could think of no reason for these symptoms as everything was fine in his life. However, he never talked about any aspect of his world spontaneously – work, his marriage, children. When I pointed this out to him he replied, in a puzzled manner: “What is there to say – everything is fine. I am not much of a talker”. As the crisis developed, and was increasingly evident in daily life as well as constantly in the media, most of my patients voiced at least concern if not fear about their prospects. For a long time Mr T said nothing, but finally asserted that he believed that all would be well with his business and with the general economy. He did not believe the very negative, frightening predictions of local and foreign economists. He was a positive person and believed that it was important to think positively. Mr T’s reaction activated considerable anxiety in me. His unsubstantiated blanket statements, at odds with every economic indication, reflected a level of denial that worried me not only about his psychic functioning in general and his difficulty in tolerating reality, but about how this stance might influence his behaviour deleteriously. In particular I was afraid that he might not take necessary action to protect his business and thus find himself in financial danger. Although I said nothing, my anxiety may have been communicated to him as he remarked several sessions later that, while he was sure all would be well, it was true that his belief was not based on anything factual but Int J Psychoanal (2014)



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only on his way of approaching life, which he felt was positive and had served him well thus far. What was to be gained by thinking negatively? I thought about Mr T’s stance and my reaction to it and considered that his position reflected a lack or dysfunction of signal anxiety, which would enable defensive coping mechanisms to anticipate possible dangers. This was generally characteristic of his functioning. In this instance, I considered that I experienced the signal anxiety for him, and somehow communicated that to him. I then thought that it was my task to further communicate and demonstrate its use to him. Thus, I said it seemed to me that one basic use of acknowledging the negative and its possible dangers was that it enabled a person to prepare for potential problems, much like storm warnings. To ignore or deny such dangers left one vulnerable and exposed to sudden painful experiences that could be overwhelming. Thinking about possible difficulties a little at a time, and experiencing the related anxiety incrementally might allow a person to build up ways to face the problems if they should arise. Mr T reflected on this and said that it made sense. However, he really did not see that there was reason for concern. Yes, things were difficult, but why should we think they wouldn’t improve soon? In time, his symptoms of undifferentiated anxiety and somatic complaints re-emerged in an exacerbated state, initially with no clear precipitant in view. It soon became apparent, however, that this was linked to serious economic difficulties that his business was beginning to encounter, which also posed problems in paying my fee. As we were able to make a connection between the two, Mr T reflected on what I had told him about acknowledging potential future problems. Perhaps, he said, that just as we noted with the current situation, in general he could not see problems arising and was then caught off guard when they appeared. But this was not something he did deliberately – he just did not see that things were so terrible. This was true about his life in general and always had been since he was a young child. For the first time, Mr T began to talk spontaneously about his past. His parents had divorced and he had grown up with his mother who left him alone at home for hours on end from a very young age to go to work. He did not see his father for years. There were very few other people in their lives as the mother had difficulty in forming and maintaining relationships. The patient recalled having a fear of death, as well as severe gastro-intestinal upsets when he went to school for the first few years. However, he recalled these years as “Fine – unremarkable. There was nothing horrible to complain about.” Mr T then announced that he would not be able to afford continuing his treatment at the same frequency and proposed that he come every two weeks at the same fee. I thought that his proposition had multiple meanings, including a reaction to the recent developments in our work – his coming to understand the impact of denial in his life, as well as the experience of remembering and describing his early childhood. In order to explore the meaning of his proposition, I asked him how he had thought about the situation and had come up with this particular proposal. After reviewing his finances in a concrete manner, he said that he felt Copyright © 2014 Institute of Psychoanalysis


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that he needed to continue, but could not think of another way. When I suggested that other options such as asking to pay a lower fee seemed unthinkable, he replied that it was not up to him to suggest such an agreement, as it would burden me and put me in a disadvantaged position. He did not want to do that to me as he felt I was trying hard to help him as best I could. Reflecting on how I felt about this, I determined that it was something I was able to do without resentment. By contrast, I felt that if I saw him once every two weeks I would lose touch with him emotionally, and that our work would be severely compromised. I considered that these transference–countertransference manifestations were related to his early experiences with his mother that he had just been talking about. Thus I pointed out that the current economic difficulties were in a way a repetition of his circumstances growing up, and that his reaction to me may be related in some way to how he had felt towards his mother. Mr T responded that in fact this was so – he had considered his mother a heroine for working so hard to take care of them under such difficult circumstances, and without ever complaining. I wondered, then, whether he had felt that he himself could not complain for any reason, given his mother’s stance. Had he felt he needed to be like her, although his position as a child was very different from hers? Perhaps his fears and somatic problems at school were his only way of showing how he felt. Mr T said that this made sense to him but that he had no memories of thinking about these things in any other way than he had. After I proposed to see him at a lower fee, an offer he accepted, a melancholic atmosphere appeared in our work. Mr T talked about seeing small children selling flowers on the street, and suddenly became very tearful, thinking about how lonely and sad they must be. He was extremely surprised and bewildered at his reaction saying that he had no idea why he was crying. When I connected his thoughts and feelings about these children to his own experiences in childhood that had recently come to the fore in our sessions, he considered this but again reasserted that his own childhood had been unremarkable. However, in time material of a similar nature again emerged, giving us the opportunity to work further on a deep underlying depression related to the literal and emotional unavailability of others in his early life.

Mrs R Mrs R, a 40 year-old professional woman and married mother of three children, initially came to see me because of frequent episodes of feeling as if she had made a terrible mistake and that serious, if not catastrophic consequences would ensue. Usually this had to do with a situation at her work in a prominent advertising agency. At such times Mrs R would become increasingly agitated, spending hours or even days ruminating about what had happened, unable to think about anything else, with difficulty sleeping at night. Usually, she would later recognize that her reaction was unfounded, that is, that she had not made any mistake or, in the rare instance where she had, that it was insignificant and her reaction was grossly disproportional to the situation. She noted that when she had some Int J Psychoanal (2014)



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distance from these episodes, she was particularly perplexed by them, as her work was very well regarded. Although she had had these problems for years, she had now come for help as these episodes had become more frequent and as she was concerned about the effect they might have on her children who saw her so distressed. Her husband was also very worried about her and had encouraged her to come, as had her co-workers. Initially in our work together, Mrs R talked almost exclusively about her presenting problem. She was initially unable to connect these difficulties to anything else in her life. It soon became clear, however, that when she feared that she had made an error, it was usually somebody else’s, but Mrs R experienced it as if it were hers. Often this feeling emerged in situations where there was conflict between others besides herself. Exploration of this material brought to the fore the highly conflictual relationship between her parents while she was growing up. The parents were continually embroiled in a battle, verbally castigating each other, fights that would frequently escalate into screaming matches. Mrs R remembered feeling confused, frightened and very lonely as a child in this environment. I felt moved, saddened by these accounts, and had the image of a small vulnerable girl who needed protection in the past as well as now, particularly as I increasingly had the sense from her account of her current life that she was not treated well by others. This was especially apparent in the professional realm where Mrs R gave the impression that she was being exploited to a significant degree, particularly financially, being paid a very low salary as well as being treated in a demeaning manner despite her significant talent. Moreover, a similar situation seemed to characterize her marriage, as she felt that her husband imposed far more responsibility on her than he undertook himself and also treated her contemptuously. I felt myself increasingly pulled toward assuming a maternal caretaking stance towards Mrs R. The meaning of this transference–countertransference dynamic became clearer as Mrs R remembered her childhood as one where she felt emotionally estranged from the members of her family, a result of the general climate of hostility that permeated family life. The father demeaned mother, saying she was his last choice as a partner, and continually complained about many aspects of her behaviour. She, on the other hand, did nothing to try and meet father’s demands – for example, improving her slovenly appearance or poor cooking. Mrs R portrayed mother as a whiny “loser”, although she noted that mother had a successful small business of her own. After father left her for another woman, she remarried, to a man who in time became emotionally abusive towards her and was always threatening to leave her. Father, by contrast, seemed satisfied in his stable second marriage. Over time, changes in Mrs R’s ostensibly agreeable stance toward me slowly began to emerge, particularly through cancellations. Although up to this point she had cancelled sessions due to necessary business travel, she now started to cancel for reasons such as taking her son to football practice or staying at home with the children so that her husband could play golf. She asked to reschedule these sessions, ostensibly oblivious to the way they Copyright © 2014 Institute of Psychoanalysis


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differed from cancellations for work. I found myself feeling irritated, with a sense that she was both trying to demean me and to see what my limits were, as if I was being tested by a provocative child. The economic crisis started to become evident at this time. Shortly thereafter, Mrs R stated that she would have to cut down on the number of sessions as she could not continue at the same fee because of changes in her salary. The company director had informed employees that they would either have to take a significant salary cut for the company to stay afloat in the current economic climate – or they would have to leave the company. Mrs R felt she had to accept this situation both out of loyalty to the company and because she felt she had few other choices given the severe cutbacks of all the advertising agencies. She proposed to continue coming once a week as she had no other source of income to help pay with analysis. As I listened to Mrs R, I detected a wariness in myself. While very conscious of the unfortunate circumstances of the advertising industry, which were as she described, I also had some questions as to whether Mrs R’s proposal to decrease session frequency was entirely based on external factors. I thought about her generally provocative stance towards me, as well as her tendency to put herself in a position of a victim. I also wondered about her telling me that she thought to “cut down” to once a week, rather than to explore other options. Was she doing me to me what had been done to her – “cutting down” on sessions as her salary had been “cut down”, thus attacking the analysis and me as she felt she had been attacked, an identification with the aggressor? Was this also a form of projective identification whereby she was putting me in the position she felt she was in, thus attempting to communicate her experience? Was there also a selfdefeating component involved whereby, in the process of attacking me, she was also attacking herself by depriving herself of the frequency she needed? With all these thoughts in mind I said that although I realized that her professional situation, like that of many others, was seriously affected by economic difficulties, it was in my opinion important to talk more about all this, beginning with what she proposed as a solution, that is, her thought to reduce the frequency of our work together. Mrs R’s response indicated that she could not see any other options. She saw that money was obviously important to me, as it was to most people, and I would want to be paid what I was used to getting. An image of me as a mercenary, calculating, unfeeling figure emerged, which she was able to link to her experience of her father, who had until this point in our work been a rather vague presence. I also felt that, as we both knew that our work would be very seriously compromised by such a reduction in session frequency, she was placing herself in the role of the victim as well as an aggressor, severely limiting my ability to help her. When I pointed this out, Mrs R was able to see this. I, in turn, considered my own financial needs and decided that I could see her at a lower fee, but at the same frequency as it would be too difficult to work productively otherwise. She accepted this offer but with reluctance saying that she would try, but she was unsure whether she could make ends meet for long if her salary did not improve. Int J Psychoanal (2014)



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In the months that followed, our work revolved around Mrs R’s subservience both in her marriage and place of work. She felt that she was treated in a demeaning fashion both by her husband and her employer, accepting this treatment although she was very resentful. With me, there were inklings in the analytic discourse indicating that the tables were turned, that is, that she tended to treat me with underlying contempt, as if to see how I might react to this stance. As I pointed this out, Mrs R was increasingly able to see it and concomitantly to take a more assertive position in other areas of her life. Soon thereafter, however, she announced that she would have to immediately stop analysis “for a while” as she had just realized that her money was running out –she had gone to the bank and was shocked upon seeing her balance. She was agitated and confused as to how this had come to be, and it emerged that she had not been paying much attention to the input and output of expenses. She had also expected a bonus and salary increase that her employer promised her, but this had not been forthcoming, although he had said that it would be in the next months. Mrs R also mentioned in passing that her children had started private school. She thought it might be a good idea to stop analysis until the time she was repaid by her employer. However, she was not sure she could trust him as he often made promises he did not keep and also portrayed things in a way that were favourable for him, but involved dishonest and exploitative financial practices, ultimately to his benefit and at the expense of others, including herself. Although I felt that she genuinely distressed, I wondered how Mrs R had allowed her finances to reach the point that they had. Was this an unconscious attack on the analysis and me, in part because of the progress she had been making – a negative therapeutic reaction due to her guilt in resolving the identification with her mother as well as an envious attack on my ability to help her? I had a sense that this recent threat of interrupting the analysis was making me feel trapped and that she was trapped with me. I also wondered whether the comments about the deceptive, exploitative employer might also have to do with her behaviour towards me. I considered that her reference to private school for the children was an indication of the devalued position she placed me in and our work together. In an effort to get out of the ‘trap’ of deciding quickly without being able to explore all that was happening, I told her that we needed time to look at all that was unfolding. She responded by agreeing, but also said that she did not have the money to do so. I told her that we could suspend fee payment while she looked at her finances – what her expenses were and what she hoped to be paid – while simultaneously looking at what this might mean in terms of our relationship and her relationships with others. She agreed, arriving a few days later with a “spread-sheet” of incoming and outgoing expenses. I was struck by this spread-sheet, and asked her about it. Associations led to the idea of a sheet that covers things up, and soon thereafter Mrs R disclosed that in fact there was something she had not shared with me. She had a sum of money in an overseas account, savings Copyright © 2014 Institute of Psychoanalysis


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from her earnings throughout the years. This was something she did not want to touch, except to help pay for the children’s private school tuition. These revelations brought to the fore Mrs R’s difficulty in directly expressing her resentment and competitive feelings as well as her underlying need to devalue me and our work. She feared that I would take all of her prized possessions and leave her destitute, and that her only recourse was lying and manipulation. Her need to present herself as a victim while secretly deriving satisfaction in demeaning me and putting me in a difficult position became increasingly more evident. Mrs R began to think that these experiences and behaviours were also characteristic of her way of being in her professional life and marriage. Eventually, associations indicated that Mrs R was identified with her mother who, through passive victimization, derived pleasure from torturing the father. Gradually, Mrs R became more forthright and assertive at work, gaining a salary increase which was particularly significant given the general economic climate. In time, she was able to give me an increase in my fee with a feeling of gratitude that was evidenced in our work for the first time.

Conclusion I hope that this clinical material illustrates the multi-dimensional and complex relationship between the external reality of the economic crisis and its internal reverberations on patient and analyst. In all three cases, the economic and socio-cultural dimensions of the crisis catalysed specific intrapsychic dynamics and issues for the patient, culminating in a crisis in the analysis when the patient presented difficulties in paying the fee. The difficulties activated various transferential–countertransferential vicissitudes, posing a challenge to me as to how most fruitfully to approach this situation so as to clarify and elucidate the contributions of external and internal reality, in order to come to a decision about the future of the analytic work with each patient. As evidenced by the previous review of the literature, there were various possibilities, according to different psychoanalytic orientations. Although my approach differed in some respects with each patient due to his/her specific situation, certain aspects were common in all three cases. To begin with, I did not respond to the patient’s position as primarily a practical issue to be resolved but rather as an object of psychoanalytic inquiry to elucidate intrapsychic meanings – in order to arrive at a practical decision. To my mind, this crisis in the analysis involved the convergence of several interrelated factors – the external and internal impact of the economic crisis on the patient, on me and on our relationship as it had evolved up that point in time. Analytic investigation of all these factors was indicated in order to resolve the situation in the most propitious way. Otherwise, valuable information regarding the patient’s internal world as well as transference–countertransference manifestations could be lost. Moreover, I could be




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catalysing a deleterious enactment leading to potential distortion of the analysis.5 The creation and maintenance of this analytic stance was difficult, especially initially when I was inundated with similar problems with many patients. At the same time, I was continually internally negotiating between my own financial needs and my professional needs and responsibilities, i.e. to function as an analyst, giving the necessary time and space for the necessary psychoanalytic inquiry. In order to do so, I had to come to terms with the possibility of incurring financial loss, and my internal reaction to this, which in the main was an intense anger at the state of affairs in the world, followed by an intensification of investment in my work. To be sure, I was in the fortunate position to be able to do so. Despite my anxiety about the possibility of financial losses, I was not under the threat of total financial collapse. The patients’ anxiety about their financial situation, in combination with the collective anxiety around me, invoked in me a sense that proceeding with promoting psychoanalytic inquiry required great care. My acknowledgment of the external reality of the crisis seemed critical to me for several reasons. To begin with, focusing only on the internal dimensions could create such intense pressure for the patient regarding potential financial obligations – that he would incur an accumulating, unaffordable debt – that might lead him to decide to stop treatment immediately. Acknowledgement of the socio-economic reality was also important in view of the inevitable aggression involved in psychoanalytic inquiry (Raphling, 1992) which I felt was more intense for someone under conditions of collective traumatization. My thinking was very much in line with that of Khair-Badawi (2011), Kogan (2004) and Puget (2003) regarding the role of the analyst in periods of collective external trauma. Moreover, not acknowledging the external reality could put me in the position of someone who was frighteningly oblivious to the patient’s situation as well as that of the world around us. I could not be trusted to contain my own or the patient’s anxiety catalysed by the crisis (Kogan, 2004) and could become a persecutory object of fear and mistrust. Moreover, the patient could also feel impelled to ‘convince’ me of the external reality, and thus defensively remain on this aspect of the situation at the expense of analysing other, deeper dimensions. Clarification of the patient’s finances was also important in this regard. With certain patients, spontaneous explanation of their circumstances was sufficient to obtain a satisfactory sense of the personal ‘external’ financial reality. This was not however always the case and I believe it is sometimes necessary to explore the patient’s difficulties in revealing their financial circumstances, so as to gain a better understanding both of the intrapsychic and transferential dimensions underlying this difficulty. However, equal care was needed not to get caught up primarily by aspects of external reality due to an identification with the patient, and a fear of being experienced as aggressive. 5 It could of course be argued that the position that I took was a form of enactment in and of itself, but it was, finally, one that I felt had fewer dangers for the analytic work.



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The countertransferential pressures were thus particularly intense and needed careful attention at each step of the cyclical analytic trajectory up to the point that a decision was agreed upon by both patient and analyst as to how to proceed. The reverberations for both members of the analytic dyad have continued since and remain objects of analytic inquiry. In conclusion, although the issues catalysed by the socio-economic crisis may have appeared in other forms in the analytic work, the crisis provided the opportunity for investigation and working through of this material, in each case leading to important developments in the analysis. I believe that exchange among colleagues from different regions of the world, each of which are affected somewhat differently by this global crisis, will lead to our better understanding of its impact on clinical psychoanalytic practice. This seems particularly significant in view of the continuation and global expansion of the crisis at this time.

Translations of summary alite interne et externe : l’impact de la crise socio-e conomique actuelle sur la dyade analyRe tique. L’auteur de cet article examine l’impact de la crise economique actuelle sur le fonctionnement psychique du patient et de l’analyste, leur relation et leur collaboration. Cette intrusion de la « realite externe » est multidimensionnelle et a donc de multiples significations. Le r^ ole crucial du facteur economique met en jeu une pluralite d’aspects relatifs a l’argent, tels que l’auto-conservation,le pouvoir ainsi que les caracteristiques du developpement psycho-sexuel. De plus, la crise economique entra^ıne une perte symbolique des ideaux de base tels que l’honn^etete et la responsabilite sociale. Patient et analyste sont affectes de facßon a la fois semblable et differente en fonction de leurs r^ oles respectifs et du fonctionnement intrapsychique specifique qui les caracterise. Qui plus est, les caracteres singuliers de la crise creent souvent une crise dans l’analyse. Afin de parer a une deformation de la relation analytique, la dyade analytique doit examiner et perlaborer les multiples significations de la crise ainsi que le sens de l’impact de la crise sur la relation analytique du c^ ote du patient et de l’analyste. La complexite de cette interaction transfero-contre-transferentielle lance un defi particulier a l’analyste. Apres avoir discute de ces questions, l’auteur s’appuie sur du materiel clinique pour illustrer comment celles-ci se manifestent aujourd’hui dans la pratique analytique. € €t: die Auswirkungen der aktuellen sozio-o € konomischen Krise auf die und innere Realita “Außere analytische Dyade”. Der Beitrag untersucht den Einfluss, den die aktuelle wirtschaftliche Krise auf das psychische Funktionieren von Patient und Analytikerin, ihre Beziehung und ihre Zusammenarbeit aus€ ubt. Dieses Eindringen der „€außeren Realit€at” ist multidimensional und hat deshalb zahlreiche Bedeutungen. Die entscheidende Rolle des wirtschaftlichen Faktors bringt mehrere Dimensionen des Geldes ins Spiel, etwa die Selbsterhaltung, die Macht sowie Aspekte der psychosexuellen Entwicklung. Dar€ uber hinaus geht die Krise mit einem symbolischen Verlust grundlegender Ideale wie Ehrlichkeit und sozialer Verantwortung einher. Patient und Analytikerin sind in ihrer jeweiligen Rolle und je nach ihrem individuellen intrapsychischen Funktionieren auf €ahnliche und auf unterschiedliche Weise betroffen. Dar€ uber hinaus erzeugen die typischen Merkmale der Krise h€aufig auch eine Krise in der Analyse. Um eine Deformierung der analytischen Beziehung zu vermeiden, muss die analytische Dyade die multiplen Bedeutungen der Krise sowie die Bedeutung ihres Einflusses auf die analytische Beziehung und beide Beteiligte € untersuchen und durcharbeiten. Dieses komplexe Zusammenspiel von Ubertragung und Gegen€ ubertragung konfrontiert die Analytikerin mit spezifischen Herausforderungen. Im Anschluss an die Diskussion dieser Themen wird klinisches Material vorgestellt, das illustriert, wie sie in der heutigen analytischen Praxis zutage treten. sterna e realta interna: l’impatto dell’attuale crisi economica sulla coppia analitica. QuesRealta to lavoro affronta il tema dell’impatto dell’attuale crisi economica sul funzionamento psichico del paziente e dell’analista, sulla loro relazione e collaborazione. L’intrusione della ‘realta esterna’ e multidimensionale e pertanto si declina in una molteplicit a di significati. Il ruolo critico del fattore economico fa entrare in gioco vari aspetti del denaro quali l’auto-conservazione, il potere nonche aspetti




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pertinenti allo sviluppo psico-sessuale. Inoltre la crisi comporta la perdita simbolica di ideali fondamentali quali l’onest a e la responsabilita sociale. Paziente e analista sono colpiti in modi simili e differenti nei loro rispettivi ruoli e secondo le specifiche modalita di funzionamento intrapsichico di ognuno. Inoltre, le eccezionali caratteristiche della crisi spesso provocano una crisi nell’analisi. Per evitare le deformazioni della relazione analitica, la coppia deve esaminare ed elaborare i molteplici significati della crisi, nonche il significato del suo impatto sulla relazione analitica, sia dal punto di vista del paziente che da quello dell’analista. La complessa interazione del transfert e contro-transfert mette particolarmente alla prova l’analista. Alla discussione di questi temi fa seguito la presentazione di materiale clinico, al fine di dimostrate come questi aspetti si presentano nella pratica analitica oggi. mica actual sobre la dıada ana“Realidad externa e interna. El impacto de la crisis socioecono lıtica”. Este trabajo se ocupa del impacto de la crisis econ omica actual sobre el funcionamiento psıquico de pacientes y analistas y, ademas, sobre su relaci on y colaboraci on. La intrusi on de la “realidad externa” es multidimensional y, por ello, tiene m ultiples significados. El papel crucial del factor econ omico pone en juego distintas dimensiones del dinero, tales como la auto-preservaci on y el poder, ası como aspectos del desarrollo psicosexual. Ademas, la crisis involucra la perdida simb olica de ideales basicos como honestidad y responsabilidad social. Paciente y analista se ven afectados de maneras similares y diferentes en sus respectivos roles y, asimismo, seg un el funcionamiento intrapsıquico especıfico de cada uno. Por otra parte, las caracterısticas singulares de la crisis a menudo crean tambien una crisis en el analisis. Para evitar que se deforme la relaci on, la dıada analıtica debe examinar y elaborar los m ultiples sentidos de la crisis, ası como el significado de su impacto sobre la relaci on analıtica tanto para el paciente como para el analista. Este complejo interjuego de transferencia y contratransferencia plantea desafıos especıficos al analista. Luego de examinar estos temas, se presenta material clınico que demuestra c omo aparecen en la clınica hoy.

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The impact of the economic crisis on occupational injuries.

Accounting for material reality in the analytic subject.

Current perspectives on attachment and bonding in the dog-human dyad.

Factors of the Rotter Internal-External scale.

Ebola crisis: the unequal impact on women and children's health.

The individual and socioeconomic impact of osteoarthritis.

The financial system and the current economic crisis.

The impact of negative affect on reality discrimination.

Prediction models need appropriate internal, internal-external, and external validation.

Dysphagia: current reality and scope of the problem.

The role of internal and external constructive processes in evolution.

[The relevance of internal and external participation for patient satisfaction].

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Internal consistency of demographic assumptions in the shared socioeconomic pathways.

Effects of the nursing mother-infant dyad on the family.

Economic stress in the workplace: The impact of fear of the crisis on mental health.

Understanding the impact of the economic crisis on child health: the case of Spain.

The variation in the health status of immigrants and Italians during the global crisis and the role of socioeconomic factors.

Modelling the effects of seasonality and socioeconomic impact on the transmission of rift valley Fever virus.

Impact of the Syrian Crisis on the Hospitalization of Syrians in a Psychiatric Setting.

Timelines in the management of adrenal crisis - targets, limits and reality.

Current status of laparoscopic and robotic ventral mesh rectopexy for external and internal rectal prolapse.

The influence of muscle length on one-joint shoulder internal and external rotator muscle strength.