Thinking With, and About, Patients Too Scared to Think.

Abstract: Patients incapable of higher-order (symbolic) thinking can often not tolerate evidence of the analyst’s separate existence, particularly when that ‘otherness’ becomes evident in the process of the analyst’s reflecting upon and interpreting how the patient experiences or represents the analyst. The patient’s intolerance of the analyst’s efforts to think (reflect upon and interpret) renders the usual psychoanalytic maneuvers employed to stimulate reflective thought ineffective with such patients. Such patients have to learn to tolerate multiple perspectives before they can allow the analyst, or themselves, to think in the other’s presence. The author presents two clinical vignettes that illustrate how the analyst’s efforts to think about the patient were experienced by the patient as both intolerably distancing and as rejecting of an aspect of the patient’s subjective reality. Working psychoanalytically with such patients requires the analyst to forgo the use of narrow interpretations that elucidate unconscious meanings and motives in favor of alternate technical maneuvers capable of facilitating the development of symbolic thinking and reflective thought (insightfulness). These maneuvers include a demonstration of the analyst’s willingness and ability to withstand (rather than ‘interpret away’) how he is being psychically represented by the patient, without becoming destroyed by, or lost within, the patient’s characterization of him. Beside modeling a tolerance of alternate perspectives of one’s self, other non-interpretive maneuvers that help facilitate the development of self-reflective thought include: stimulating the patient’s curiosity about the workings of his own mind by identifying incompletely understood behaviors or reactions worthy of greater psychological understanding, and insinuating doubt about the adequacy of the patient’s explanations of such phenomena.