The analyst’s sham(e): collapsing into a one-person system

It is common knowledge that there has been a monumental shift in the psychoanalytic paradigm. The analyst was expected to “know” and “interpret” the content of a patient’s mind or the motivation of a patient’s behaviour. While treatment process mostly centres on the concerns of the patient, it is now clear to us that the subjectivities of both patient and therapist influence the course of treatment. The newer understanding of “intersubjectivity” is that intersubjectivity is, whether or not it is acknowledged or articulated. This article focuses on the analyst’s subjectivity, which although is an accepted reality, is rarely clinically conveyed. Rather, it continues to remain hidden. Whatever remains hidden is often subsumed in shame and is therefore not available for reflection or investigation. We analysts are typically wounded healers. Our wounds, and in fact all the particulars of our histories, effect how we organise and metabolise the subjectivities of our patients.

Treatment of alcohol dependence

Some people repeatedly put themselves or others at risk by drinking. One view is that such people could drink sensibly if they were more considerate and used more will power. Another increasingly accepted view is that many such individuals are in a state, existing in degrees of severity, in which the freedom to decide whether to change their drinking, and to adhere to that decision, is reduced compared with other drinkers. This state partly depends on perceived pay-offs for changing, and on acquired dispositions, which are less accessible to conscious control. Such persons become aware of a wish, or urge, to drink, which overcomes rational thought. They may then make up an explanation, for example, ‘No wonder I feel like a drink, I've had a hard day’. Such individuals benefit from help to unlearn those patterns, and to learn different approaches to problems. Discussion, care, and encouragement from others can bolster their will to do so. Assistance to set-up controls within or from outside themselves may help. Some people can do this without external help, and others with the help of Alcoholics Anonymous (AA) alone. This approach argues that dependence on alcohol should be managed like other relapsing disorders, such as diabetes and asthma, by using long-term monitoring coupled with intermittent or continuous treatment. Research into alcoholism spanning 50 years has shown that the attitudes of the agency and the therapist influence patients’ outcome, as they may do for many illnesses. The therapeutic alliance is a strong predictor of outcome in the treatment of alcohol dependence. However, agencies must also be prepared to set limits on drunken behaviour at the clinic and telephone calls when intoxicated. And for patients who repeatedly relapse, resumption of treatment should sometimes be made conditional on complying with a new treatment plan, such as supervision of medication. Showing respect, enhancing dignity, conveying accurate empathy, adopting objective and not moral criteria, involving the family, and reducing hurdles to seeking help have been shown to improve compliance, and often outcome, for alcohol dependence.