Modern psychoanalysis

1. Introduction

Version followed: Hyman Spotnitz's modern psychoanalysis as set out in Modern Psychoanalysis of the Schizophrenic Patient: Theory of the Technique (1969; 2nd ed. 1985; YBK reprint 2004), and Spotnitz & Meadow, Treatment of the Narcissistic Neuroses (1976/1995). Technique details follow the "modern school" as taught at the Center for Modern Psychoanalytic Studies (CMPS, New York) and the Boston Graduate School of Psychoanalysis (BGSP), as summarised in Ernsberger's 1976 Modern Psychoanalysis article on Freud and the modern school. Margolis's papers on the contact function and the object-oriented question are used for those two techniques. The default format is individual adult treatment on the couch. Ormont's group extensions are included only where marked. The books are drawn on only in part (the YBK sample, pp. ~67–70 plus the index, and an excerpt of Spotnitz & Meadow). Page numbers given "via" a secondary source come from that source [uncertain on exact pagination].

What it is. Modern psychoanalysis adapts Freud's method for preoedipal ("narcissistic") conditions: schizophrenia, severe depression, borderline, character and psychosomatic disorders, and neurotic self-sabotage. Spotnitz developed it from the 1940s with severely regressed patients [source: Editorial Board 1976 via Winborn; Wikipedia, Modern psychoanalysis].

How change happens. Symptoms such as withdrawal, depression, fragmentation and somatic complaints are read as a narcissistic defense. Murderous or aggressive impulses toward the object are bottled up and turned against one's own ego or body to protect the object [source: Editorial Board 1976 via Winborn; Wikipedia, Hyman Spotnitz]. The analyst first fosters a narcissistic transference, in which the patient experiences the analyst as like himself. Inside that transference the patient can gradually put aggression, and later love, into words toward the analyst instead of acting on it or attacking himself. The analyst works mainly through emotional ("maturational") communication, guided by the feelings the patient induces in the analyst, not through intellectual insight. Resistances to "saying everything" are resolved in a set order, and interpretation comes late [source: ICPS/BGSP, About Modern Analysis; Ernsberger 1976, pp. 27–29]. The aim is a patient freed from destructive repetitions and stabilised in emotional maturity, not a return to the premorbid state [source: Spotnitz 1985, pp. 34, 288–9, via Nobus].

2. Framework

Format [source: Ernsberger 1976, pp. 20–23; Spotnitz & Meadow 1995, p. 30]

• Setting: couch, with verbal communication. The couch is kept to aid regression and to limit action. By prior agreement a patient may leave it once he can verbalise aggression.
• Frequency: negotiated. For preoedipal patients, "Once or twice a week is often the optimal number" (Ernsberger, p. 21). Across the school the range runs from one session a year to six a week, and individual work can be combined with group.
• Session length: no length is stated in the sources [uncertain]. The usual 45–50 minutes is my assumption [synthesis].
• Duration: open-ended, usually several years. Ask the patient to commit to about two years, "the minimum period necessary to develop the narcissistic transference" (Ernsberger, p. 22). Do not volunteer an estimate of total length.
• Dose of talk: the analyst's talk is rationed in "units of communication." One unit is roughly "a mouthful of milk": one question or one very short statement. Schizophrenic patients get 2–5 units per session and oedipal-level patients 10–100. Stay under five units "until the narcissistic transference has been resolved." Keep the first 20 minutes as quiet as possible, and talk a little more near the end to help the patient leave [source: Spotnitz 2004, pp. 67–69].

Phases. The phase names are taken from Ernsberger (pp. 24–25) and Cohen 2001. The table layout is my own [synthesis].

Order of resistance work. Spotnitz sets priorities among resistances (1969, pp. 116–117, per the YBK index). Ernsberger (p. 28) lists them in this order:

1. Treatment-destructive: anything that would end treatment early.
2. Status quo: comfort in repetitive communication.
3. Resistance to progress: fear of new thoughts and feelings.
4. Resistance to cooperation (teamwork).
5. Termination resistance.

Work on the highest-priority resistance present. Each resistance is first recognised and understood, then managed, then worked through (Spotnitz 2004 index, pp. 66–71, 111–112, 125–127).

3. Guiding principles

• "Say everything" is the goal, not an instruction [source: ICPS/BGSP; Ernsberger, p. 23]. Do not give the free-association rule. Tell patients they may "talk about anything they want to talk about." Treat whatever stops them saying everything as the work.
• Resistance comes first [source: Ernsberger, p. 28]. In each session, ask yourself which resistance is operating now and which has priority. Then choose an intervention for that resistance only.
• Intervene only to resolve resistance [source: Ernsberger, pp. 27–28, 38]. Do not educate, reassure or chat. If a remark does not address the current resistance, leave it unsaid.
• Communicate in minimal doses [source: Spotnitz 2004, pp. 67–69]. Count your units. "Too little communication is as deleterious as too much" (p. 69). Both too much and too little cause harm.
• Follow the contact ("demand feeding") [source: Wikipedia, citing Meadow; Ernsberger, p. 28; Cohen 2001]. Speak mainly when the patient reaches for you, and in the form the patient uses. The patient regulates how much stimulation he gets.
• Do not contradict the patient's perceptions [source: ICPS/BGSP; Wikipedia]. Do not correct or debate early on. Emphasising difference breaks the twin-like bond that makes talking safe.
• Aggression before libido [source: Editorial Board 1976 via Winborn]. Help the patient voice hatred, including toward you, before expecting love, intimacy or insight.
• Words, not deeds [source: Spotnitz & Meadow 1995, pp. 43, 53, 65]. The patient may feel anything and say anything, but may not act it out. "The appropriate way to discharge his feelings is to put them into words."
• Discharge alone does not cure [source: Spotnitz & Meadow, pp. 43, 65]. Venting gives temporary relief. The patient must also learn to regulate discharge.
• No sympathy cure [source: Spotnitz & Meadow, pp. 41, 52–53, 68]. Supportive warmth can harden the defense and increase self-attack. Watch for the thought "Poor fellow, he needs my help" (p. 68) as a countertransference warning.
• Do not seek understanding for its own sake [source: Spotnitz 1985, pp. 166, 169, via Nobus]. With regressed patients, "No effort is made to help him understand it." Pushing for understanding can itself become resistance to talking.
• Induced feelings are data [source: ICPS/BGSP; Spotnitz 2004 index, pp. 154–166; CMPS slide]. Ask whether what you feel is objective countertransference (induced by the patient) or subjective (from your own history). Use the objective kind to choose interventions.
• Emotional communication over intellectual insight [source: Wikipedia, Hyman Spotnitz; Editorial Board 1976]. Interventions should carry a feeling-tone that meets the patient's state, not explain it.
• The analyst is a "maturational agent" [source: Spotnitz, Psychotherapy of Preoedipal Conditions, p. 16, via CMPS slide]. Judge each intervention by whether it helps the patient say more without narcissistic injury.
• Protect the ego (insulation) [source: Spotnitz 2004 index, pp. 36, 112; Cohen 2001]. Do not strip away defenses such as phobias before the aggression behind them can be put into words (Spotnitz & Meadow, p. 70).
• Abstinence and withholding [source: Ernsberger, pp. 19–20, 24]. Give minimal gratification and minimal self-disclosure. Leave the patient "in doubt" about whether a wish will be met. Treat seductive moves as resistance to putting things into words.
• State rules only when they are broken [source: Ernsberger, pp. 21, 23]. The analyst "does not stipulate rules in the initial agreement." Take up a rule only when it is broken, and analyse the breach.
• Interpret late [source: Ernsberger, pp. 28–29]. Early interpretations feel like attacks. Interpret only after the aggression behind the narcissistic transference has been voiced. Ideally the patient arrives at the interpretation himself.
• Keep an inner reserve [source: couples-treatment paper, yorku.ca, p. 2]. When you join or mirror, you do not adopt the patient's beliefs. Keep your own private point of view.
• Vary the technique to the patient [source: ICPS/BGSP]. No intervention is mandatory. Any intervention that resolves resistance to maturation is legitimate.

4. Intervention inventory

Use this decision routine before any intervention. First, silently name the resistance and its priority. Second, notice what you feel (induced feelings). Third, choose the smallest emotional communication that might let the patient say more [source: Ernsberger, p. 28]. The interventions below run roughly in the order they are used across treatment. All example therapist language is my own wording, labelled (illustrative), unless it is quoted and cited.

4.1 Contract negotiation as resistance analysis

• Purpose / when: From the first phone call onward. The contract is part of treatment, not a preliminary step, and resistance analysis starts at first contact [source: Ernsberger, pp. 20–21; Spotnitz 2004 index, pp. 79–82].
• Steps:
  1. Agree on the minimum: times, fee, attendance, and roughly two years of commitment.
  2. Negotiate frequency. Once or twice a week is often best for preoedipal patients.
  3. State no further rules up front.
  4. When the patient asks about length, method or rules, explore the question before answering. Do not volunteer how long treatment will take.
  5. Treat missed sessions, late fees and schedule-change requests as resistance. Investigate first. Grant reasonable requests once the resistance is understood (Ernsberger notes a 24-hour-notice arrangement).
• Language (illustrative): "How long do you imagine it should take?" • "What made today's session the one to miss?" • "Shall we keep the same time, or is there a reason to change it?"
• Watch for / working when: Watch for no-shows, unpaid bills, and threats to quit or to see someone else. These are treatment-destructive resistance and take top priority. It is working when attendance is regular and contract issues become something to talk about, not something to act on.

4.2 "Talk about anything": permission instead of the fundamental rule

• Purpose / when: At the start, in place of the free-association instruction, which can overwhelm narcissistic patients [source: Ernsberger, pp. 22–23].
• Steps:
  1. Invite the patient onto the couch.
  2. Tell them they may talk about anything they want to talk about.
  3. If a topic feels impossible, agree it can wait for now.
  4. Over time, treat what cannot yet be said as the resistance to be resolved.
• Language (illustrative): "You can talk about whatever you like." • "Then don't talk about that yet."
• Watch for / working when: It is working when the range of topics widens and the patient brings up the off-limits topic on their own.

4.3 Minimal communication (dosing in units)

• Purpose / when: Throughout the narcissistic phase, so you neither overstimulate nor starve the patient [source: Spotnitz 2004, pp. 67–69; Spotnitz & Meadow, pp. 66–67].
• Steps:
  1. Count your units. One unit is one question or one short sentence.
  2. Severely regressed patients get 2–5 units per session. Stay under five until the narcissistic transference is resolved.
  3. Say almost nothing in the first 20 minutes.
  4. Give one or two more units near the end to help the patient leave.
  5. Give an extra brief unit when the patient demands it.
  6. Avoid "any uninvited communication or interpretation" (Spotnitz & Meadow, p. 66).
  7. Raise the dose as tolerance grows.
• Language (illustrative): "Mm." • "And then?" • near the end: "We'll stop here for today."
• Watch for / working when: Overexcitation (agitation, flight of ideas, acting out after a session) means too much. Deadness, withdrawal, or "you're not there" complaints that turn into despair mean too little. It is working when the patient tolerates and asks for more contact.

4.4 Following the contact function ("demand feeding")

• Purpose / when: The patient's verbal or nonverbal attempts to reach you decide when you speak and in what form. This lets the patient regulate stimulation and frustration [source: Margolis on the contact function (BGSP, title only); Wikipedia citing Meadow; Cohen 2001; Ernsberger, p. 28].
• Steps:
  1. Wait for a contact: a direct question, addressing you, a remark about the room or about you, a glance, a pause aimed at you.
  2. Respond briefly and in kind: a question to a question, a feeling-tone to a feeling-tone.
  3. Do not start new topics.
  4. If the patient makes no contact, stay silent unless a treatment-destructive resistance needs addressing.
• Language (illustrative): Patient: "Are you even awake back there?" Therapist: "What makes you ask?" or "Would you prefer that I'm not?"
• Watch for / working when: Note how often the patient makes contact and what kind. It is working when contacts become more frequent and more direct, for example moving from questions about the room to questions and feelings about you.

4.5 Object-oriented questions

• Purpose / when: Early in treatment and whenever the ego is fragile. These are factual questions aimed away from the patient's self, so they explore without implying blame [source: Margolis 1983 (title via Wikipedia); Cohen 2001; Ernsberger, p. 28; CMPS slide]. Spotnitz's 1969 text also makes the reverse point: a question that implies the patient is wrong can register as an attack [uncertain: paraphrased from secondary summaries].
• Steps:
  1. Ask about other people, facts, or the analyst, never "why did you…".
  2. Avoid the word "you" when it would imply blame.
  3. Keep it to one short question.
  4. Later, turn the question onto the analyst ("Why would I do that?") before turning it onto the patient.
• Language: "What makes her do that?" [source: Wikipedia, Modern psychoanalysis] • "Where did that come from?" [source: Cohen 2001] • (illustrative): "What did he say then?" • "What am I doing that makes it hard to talk today?"
• Watch for / working when: It is working when the patient elaborates instead of defending or justifying. If the patient hears an accusation, make the question more object-oriented.

4.6 Ego-oriented questions

• Purpose / when: Questions about the patient's own inner experience. Use them once narcissistic resistance is dominant and the ego can tolerate self-focus, or as a later step after object-oriented questions [source: Ernsberger, p. 28; CMPS slide].
• Steps:
  1. Wait until the patient tolerates attention on themselves without fragmenting or attacking themselves.
  2. Ask one short question about feeling, wish or thought.
  3. Go back to object-oriented questions if self-attack rises.
• Language (illustrative): "What did you feel when she left?" • "What would you like to say to me right now?"
• Watch for / working when: It is working when the patient reports feelings, including about you, without self-reproach.

4.7 Ego-syntonic joining

• Purpose / when: Go along with the patient's defense, agreeing with its manifest content or underlying attitude instead of challenging or interpreting it. This reduces pressure for impulse discharge, helps the patient "move out of a repetitive pattern" (MPSP, via CMPS slide), and builds the narcissistic transference. It is the main technique in early phases [source: Spotnitz 2004 index, pp. 181, 187–198; Shechter 2021; nosubject; CMPS joining weekend].
• Steps:
  1. Identify the defense: silence, a hopeless self-image, distrust of treatment.
  2. State agreement with it as if you saw the world from inside it.
  3. Keep your inner reserve; you do not have to believe it.
  4. Say no more, and observe the reaction.
• Language: For a patient who won't talk, treat the silence as protection [source: nosubject example]: (illustrative) "It makes sense not to talk until you know whether it's safe here." For a patient who calls himself a hopeless case, the therapist in Shechter's case simply agreed, and the patient felt relief [source: Shechter 2021]. (illustrative): "Maybe it is hopeless."
• Watch for / working when: It is working when the patient visibly relaxes, keeps talking, and feels understood. If the patient experiences the join as mockery, it is too strong or poorly timed. Go back to quieter mirroring.

4.8 Ego-dystonic joining (including exaggeration and "echoing the ego")

• Purpose / when: Later, once the narcissistic transference has formed. Agree with or slightly exaggerate the self-attacking or resistant position until it becomes ego-alien, so the patient pushes back. Spotnitz says such joins "facilitate the discharge of negative affects" [source: Spotnitz 2004 index, pp. 180, 188–192; Shechter 2021, citing Spotnitz]. Spotnitz called one form "echoing the ego." Another is the "falling apart" join, which mirrors fragmentation, for example the therapist saying he "feels unreal and confused too" [source: Shechter 2021, quoting Spotnitz].
• Steps:
  1. Confirm the patient already tolerates syntonic joins.
  2. Agree with the self-attack or resistance, and amplify it slightly.
  3. Wait for the patient to protest.
  4. Welcome the protest. It is aggression now aimed outward, at you or at the attacking position.
  5. Do not take back the join.
• Language: In Shechter's case the therapist said "Indeed, one of the most hopeless cases ever" [source: Shechter 2021]. (illustrative): "You're right, nobody could stand you for long, me included, probably." • "Maybe you should never say a critical word to anyone."
• Watch for / working when: It is working when the patient argues back, laughs, gets angry at you, and self-reproach drops. Danger signs: the patient takes it literally and concretely, collapses, or has suicidal ideas. In that case go back to syntonic joining or mirroring [synthesis].

4.9 Mirroring and psychological reflection

• Purpose / when: Present yourself as a "twin": an ego-syntonic object who thinks and feels as the patient does. Reflect attitudes and feeling-tones, not words. This is the main early technique with very regressed or preverbal patients and with children [source: Ernsberger, p. 39; Spotnitz & Meadow, p. 71 ("a faithful twin image"); Spotnitz 2004 index, pp. 44–45, 125–127, 202]. In Cohen's group usage, mirroring also means the analyst claims the defended-against impulse as their own, which externalises it [source: Cohen 2001].
• Steps:
  1. Notice the patient's affect or attitude.
  2. Express the same attitude as your own, in a matching tone (sighs, gestures and sounds count).
  3. For the Cohen variant, voice the impulse the patient is defending against as if it were yours.
• Language (illustrative): When the patient sighs with frustration, give a matching sigh and say "What a day." • Cohen variant: "Sometimes I'd like to tell everyone to leave me alone."
• Watch for / working when: It is working when the patient feels accompanied, talks more, and later starts to differ from the twin by asserting their own view.

4.10 Emotional (maturational) communication

• Purpose / when: At any phase, once you have studied the induced feeling. Give an intervention whose emotional tone fits what the patient needs to express. Maturational communication is any intervention that helps the patient say what they feel, think and remember "without causing narcissistic injury" [source: CMPS slide, quoting MPSP; Spotnitz 2004 index, pp. 16–17, 125–127; Ernsberger, p. 40].
• Steps:
  1. Register the induced feeling (see 4.11).
  2. Decide what feeling the patient cannot yet voice.
  3. Give one short statement carrying that feeling, which may be firm, irritable, playful or bored, more than explaining it.
  4. Note the effect.
• Language: In one case, days of sympathetic listening changed nothing, but "a few harsh words" did. The analyst then said rage could go into "feelings and words" rather than thrown objects [source: Spotnitz & Meadow, p. 53, paraphrased]. (illustrative): "Throwing things is out. Yelling at me is fine."
• Watch for / working when: It is working when the patient's affect enlivens and becomes more verbal. If the patient withdraws, the intensity overshot.

4.11 Studying induced feelings (objective countertransference)

• Purpose / when: Continuously. This is the analyst's main diagnostic instrument, and Cohen says it is the main activity in the negative narcissistic stage [source: ICPS/BGSP; Ernsberger, p. 18; Cohen 2001; Spotnitz 2004 index, pp. 154–166].
• Steps:
  1. After each sequence, ask: "What am I feeling now? Where is it coming from? To whom does it belong?" [source: Cohen 2001, group form].
  2. Sort objective (induced by the patient) from subjective (your own history). Sort narcissistic induction (you feel like the patient) from object induction (you feel like the patient's object).
  3. Tolerate hostility without acting on it [Ernsberger, p. 19].
  4. Use the feeling to time and colour your intervention.
  5. Take subjective residue to supervision or your own analysis.
• Language: Internal. When you later disclose a feeling, see 4.16.
• Watch for / working when: Watch for countertransference resistance. Spotnitz describes narcissistic and anaclitic forms, meaning a refusal to notice induced feelings or dependency cravings [source: Spotnitz 1985, pp. 144, 236, via Nobus]. Other warning signs are a rescuing "poor fellow" stance, hopelessness, and rage (Spotnitz & Meadow, p. 68).

4.12 Redirecting self-attack outward (inviting aggression toward the analyst)

• Purpose / when: Use when the patient attacks themselves: self-blame, depression, somatic complaints, or blaming themselves for the analysis failing. The aim is to turn the inward flow of destructiveness toward the analyst, in words [source: Spotnitz & Meadow, pp. 55, 66; Wikipedia; ispso.org on Ormont-style use].
• Steps:
  1. When the patient blames themselves, shift the blame onto the analyst or the treatment.
  2. Invite criticism of the analyst with an object-oriented question.
  3. Accept any verbal attack calmly. Do not defend, and do not retaliate in kind.
  4. Keep the limit on action.
  5. Show that you recognise the patient's anxiety about being destructive. In Spotnitz & Meadow, this recognition led to more spontaneous talk (p. 55).
• Language: ispso.org gives an Ormont-style example: "What do I do that makes you feel my support?" (illustrative): "If therapy isn't working, maybe I'm the one doing it badly." • "What should I be doing differently?" • "You can say anything about me."
• Watch for / working when: It is working when self-reproach falls and criticism of the analyst rises, along with symptom relief. If attacks turn physical or the patient threatens to quit, treat that as treatment-destructive (see 5.1). Remember that venting alone does not cure. Over time, help the patient regulate it (Spotnitz & Meadow, pp. 43, 65).

4.13 Insulation and ego reinforcement (protecting defenses)

• Purpose / when: Use when a defense is holding back aggression the patient cannot yet put into words. Leave the defense in place and lower the stimulation [source: Spotnitz 2004 index, pp. 36, 112; Spotnitz & Meadow, p. 70; Cohen 2001; Spotnitz 1962 "The need for insulation" (title only); CMPS slide].
• Steps:
  1. Do not challenge phobias, withdrawal, or rigid routines early.
  2. Reduce your units of speech and keep your distance (seating, voice, number of questions).
  3. Use syntonic joining to support the defense.
  4. Take up the defense only after the aggression behind it is being voiced.
• Language (illustrative): "No need to change that now." • "Keeping your distance from me seems wise."
• Watch for / working when: It is working when the patient becomes less agitated and less fragmented, and the defense later loosens on its own. If you break through it too early, expect deeper regression (Spotnitz & Meadow, p. 70).

4.14 Consulting the patient

• Purpose / when: Use when you are unsure what to do, when the patient complains about the method, or when you are stuck. Ask the patient what intervention they want. This builds cooperative functioning and invites criticism of you [source: ispso.org; Spotnitz 2004 index, "cooperative functioning," pp. 80–81, 114, 124]. The explicit "consulting" label comes from a secondary source [uncertain whether Spotnitz used it as a named technique].
• Steps:
  1. Ask one short question about what the patient wants from you.
  2. Take the answer seriously.
  3. Act on it if it is reasonable and does not feed a resistance. Otherwise explore it.
• Language (illustrative): "What should I say to you right now?" • "Would it help if I talked more or less?"
• Watch for / working when: It is working when the patient tells you what they need and starts to see themselves as a co-worker in the treatment.

4.15 Analysing breaches and acting out (rules raised when broken)

• Purpose / when: Use when the patient breaks an implicit rule: confidentiality, the couch, payment, contact outside sessions. Outside behaviour also counts if it affects the sessions [source: Ernsberger, pp. 21–23; Spotnitz 2004 index, "breaches," pp. 79–82].
• Steps:
  1. Name the rule only now, briefly.
  2. Ask object-oriented questions about the breach.
  3. If the behaviour is a resistance the patient cannot stop, make that inability the focus of investigation.
  4. Set a firm limit on action that threatens treatment or safety.
• Language (illustrative): "We have an agreement that what happens here stays here. What made it hard to keep today?" • "What stops you from just telling me instead?"
• Watch for / working when: It is working when actions are replaced by talk about the impulse.

4.16 Objective countertransference disclosure and the toxoid response

• Purpose / when: Use later in treatment, once the patient can hear the analyst's feelings without narcissistic injury. Above all, use it to resolve termination resistance [source: Ernsberger, p. 29; Spotnitz 1963 "The toxoid response" (title only); Spotnitz 2004 index, pp. 9, 11, 125, 200–201; Wikipedia]. Ernsberger describes it as giving back to the patient the feelings they induced in you. This exposure "creates an immunological effect" (p. 29). The nosubject summary describes it as reflecting a diluted version of the patient's self-criticism. Accounts differ on detail [uncertain]. I follow Ernsberger's version.
• Steps:
  1. Identify a feeling the patient has repeatedly induced in you, such as exasperation, boredom, or the patient's own self-contempt.
  2. Check that it is objective, not subjective.
  3. Return it in a small, controlled dose, as your feeling, in the patient's own idiom.
  4. Watch the response.
  5. Repeat in graded doses.
• Language (illustrative): "You know, I get fed up with you sometimes too." • "Listening to you, I feel like giving up on you, the way you give up on yourself."
• Watch for / working when: It is working when the patient can take in the feeling, answer it with their own feeling, and not collapse. Being able to do this is evidence that the patient is ready to end treatment.

4.17 Maturational interpretation and working through

• Purpose / when: Use after the patient has put into words the aggression behind the narcissistic transference. Early interpretations are symbolic or reflective. Plain explanation comes later, and at the end interpretation alone clears what blockages remain [source: Ernsberger, pp. 28–29, 40; Spotnitz 1987b on maturational interpretation (cited via Nobus)].
• Steps:
  1. Wait until the patient has repeatedly expressed hostility toward you.
  2. Start with a symbolic or reflective interpretation, attributed to people in general or to the analyst.
  3. Let the patient put it into words.
  4. Give a direct interpretation only when the patient is nearly there already.
  5. Treat the patient stating it unprompted as success.
• Language (illustrative): Symbolic: "Some people get sick rather than get mad." Later: "When you're furious with me, you seem to take it out on your stomach instead."
• Watch for / working when: It is working when the patient elaborates the interpretation rather than agreeing intellectually or feeling attacked. Feeling attacked means it came too early.

4.18 Group extensions: bridging, resistance-joining in group, immediacy (Ormont, modern group)

• Purpose / when: Use in modern-analytic groups only. Bridging is "any technique geared to evoke meaningful talk between group members". In group, join and reflect group resistances rather than confronting them. Keep the work in the present ("immediacy") [source: Cohen 2001, quoting Ormont 1990; Wikipedia, Hyman Spotnitz; psptraining.com].
• Steps:
  1. Address the group-wide resistance before individual ones.
  2. Link members with object-oriented questions about each other.
  3. Ask members to say what they feel toward one another now.
• Language (illustrative): "Who here knows what Ana means?" • "What do you think Joe is feeling toward Ana right now?"
• Watch for / working when: It is working when members talk to each other with feeling, not only to the leader.

5. Handling problems

In this modality, every "problem" below is a resistance to be studied and resolved, not an obstacle to get around. Handle them in the priority order given in section 2 [source: Ernsberger, p. 28].

5.1 Threats to quit, no-shows, unpaid fees (treatment-destructive resistance)

• What it is: The highest-priority resistance; deal with it before anything else [source: Ernsberger, p. 28; Spotnitz 2004 index, pp. 115–123].
• Response:
  1. Respond at once, with object-oriented questions about what the analyst or treatment is doing wrong.
  2. Join the wish to leave ("Maybe this isn't worth it") rather than arguing with it.
  3. Invite the patient to come and say it to you instead of leaving.
  4. Talk more than usual. Spotnitz says the analyst's communication controls the intensity of treatment-destructive resistance (index, pp. 120–122).
• Common precursor: A patient may become aware of rage at someone outside treatment but not at the analyst, and then quit. Find the feeling toward the analyst early [source: yorku.ca couples paper, p. 11].

5.2 Stuck, repetitive sessions (status quo resistance)

• What it is: The patient is content with repetitive communication [source: Ernsberger, p. 28; Cohen 2001].
• Response:
  1. Check your induced feeling. Boredom or sleepiness is information, not a fault.
  2. Join the satisfaction: (illustrative) "Why change anything? This is comfortable."
  3. Use an object-oriented question about what keeps you, the analyst, satisfied with it.
  4. Use a mild ego-dystonic join to stir protest.
  5. In groups, Cohen used a countertransference image to disrupt "symbiotic oneness" [source: Cohen 2001].

5.3 Fear of new thoughts and feelings (resistance to progress) and resistance to cooperation

• Response:
  1. Do not push. Join the reluctance, for example "Not yet" (see 4.2).
  2. For cooperation resistance, consult the patient (4.14) and investigate their reluctance to work with you as a partner.
  3. Take up the resistance at the moment it appears in the transference [source: Ernsberger, p. 28; Spotnitz 2004 index, cooperative functioning]. The specific steps here are my own [synthesis].

5.4 Overwhelm, fragmentation, psychotic material

• Response:
  1. Cut communication to the minimum and keep a quiet first 20 minutes [source: Spotnitz 2004, pp. 67–69].
  2. Do not try to influence or explain psychotic content: "No attempt is made to influence the production of psychotic material" [source: Spotnitz 1985, p. 166, via Nobus].
  3. Use mirroring or a "falling apart" join so the patient is not alone in the confusion [source: Shechter 2021, citing Spotnitz].
  4. Insulate (4.13).
• Own synthesis: Hold to the standard of care regardless of modality. Run a risk assessment for suicide or violence, and coordinate with psychiatry or medication where indicated. The sources do not set out a crisis protocol [synthesis].

5.5 Rage at the analyst, attacks, threats of action

• Response:
  1. Welcome words and stop action. Restate that anything may be said but nothing may be done [source: Spotnitz & Meadow, p. 53].
  2. Accept insults without defending yourself. In the ispso.org account, the stance is that words do not hurt [source: ispso.org].
  3. Distinguish attack from the expression of negative feeling. Ormont describes the analyst as a target of verbal accusation, not a mere object for sadistic impulses [source: ispso.org on Ormont].
• Own synthesis: Set safety limits early. If there is a credible threat of violence, protect yourself and others first; analysing it comes second [synthesis].

5.6 Ruptures from a premature interpretation or a mistimed join

• Signs: The patient feels attacked or mocked and goes silent [source: Ernsberger, p. 28: early interpretations are "ineffective" and experienced as attacks].
• Response:
  1. Do not explain or apologise at length.
  2. Take the blame in one unit, as a syntonic join: (illustrative) "I said too much."
  3. Invite the patient to criticise you (4.12).
  4. Lower the dose and go back to mirroring.
• Status: The repair sequence is my own synthesis built from the principles above [synthesis].

5.7 Silence and withdrawal

• Response:
  1. Treat the silence as a protective resistance and join it [source: nosubject].
  2. Stay mostly silent yourself, as long as the patient is not making contact.
  3. If the silence threatens the treatment, one object-oriented question about you is acceptable: (illustrative) "Is there something about me that makes it better not to talk?" [synthesis on the threshold for intervening].

5.7a Patient's first weeks: "nothing is happening," "you're not there"

• Response: In the narcissistic phase the patient may feel the analyst is not there; this is expected [source: Ernsberger, p. 24]. Do not reassure. Use one object-oriented question or a mirror: (illustrative) "What would you want me to be doing?"

5.8 Demands for advice, reassurance, gratification or self-disclosure; seduction

• Response: Keep minimal gratification and leave the patient in doubt about whether the wish will be met [source: Ernsberger, pp. 20, 24]. Explore the demand: (illustrative) "What would it give you if I told you?" Give an extra unit when the patient demands contact (Spotnitz 2004, p. 69). Treat seduction as resistance to verbalisation [Ernsberger, p. 20].

5.9 Analyst's own difficulties (countertransference resistance)

• Signs: Hopelessness, rage, rescuing ("Poor fellow…"), boredom, or taking sides in couples work [source: Spotnitz & Meadow, p. 68; yorku.ca couples paper, p. 16].
• Response: Name the feeling to yourself. Classify it as objective or subjective, and as narcissistic or anaclitic countertransference resistance [Spotnitz 1985, via Nobus]. Then use it (4.11) or take it to supervision. The training institutes require personal analysis and supervision for this work [source: Wikipedia lists the institutes; the requirement for this specific work is my inference, uncertain].

5.10 Termination: patient won't leave or leaves abruptly (termination resistance)

• Response: Treat both as resistance. Use the toxoid response in graded doses (4.16) and let the patient arrive at their own account of the work (4.17) [source: Ernsberger, p. 29]. The criterion for ending is stable emotional maturity, not symptom relief alone [Spotnitz 1985, pp. 288–9, via Nobus]. A tapering schedule is my own suggestion [synthesis].

5.11 Problems the sources do not address [synthesis]

• Brief or insurance-limited care: The two-year frame may be impossible. Keep the core stance (minimal communication, joining, following the contact, aggression into words), name the limit openly, and treat the patient's reaction to it as material.
• Telehealth, no couch: Turn the camera off or audio-only to approximate the couch. Count your units the same way. Treat requests to see you as contacts.
• Joining misread as sarcasm, or misused by the analyst: Before using a dystonic join, check the transference. Never join out of irritation, which is subjective countertransference. If in doubt, use mirroring instead.
• Collateral contacts (family, other providers): Spotnitz discusses third parties in the contract (index, pp. 79–82) but the text is [uncertain]. My suggestion: keep collateral contact minimal and explore its meaning with the patient.

Sources

Sources

• Spotnitz, Modern Psychoanalysis of the Schizophrenic Patient (YBK sample: TOC, pp. ~67–70, index)
• Spotnitz & Meadow, Treatment of the Narcissistic Neuroses (excerpt)
• Ernsberger, "Freud and the modern school," Modern Psychoanalysis 1976
• Cohen, "The practice of modern group psychotherapy"
• CMPS, Spotnitz concepts slide
• CMPS, "Joining: More Than a Technique" seminar flyer
• ICPS/BGSP, About Modern Analysis
• Shechter, "The Join and Distinction-Union" (2021)
• Nobus, "Between Affect and Signifier"
• Couples treatment paper (modern-analytic), yorku.ca
• Winborn, overview quoting Editorial Board 1976
• ISPSO, "The Hate that Cures"
• Modern psychoanalysis – Wikipedia
• Hyman Spotnitz – Wikipedia
• Hyman Spotnitz – nosubject
• Who Was Hyman Spotnitz? – IMPP

Books and papers cited (cited by title; full text not drawn on)

• Spotnitz, H. (1969/1985). Modern Psychoanalysis of the Schizophrenic Patient: Theory of the Technique. Grune & Stratton / Human Sciences; YBK 2004.
• Spotnitz, H., & Meadow, P. W. (1976/1995). Treatment of the Narcissistic Neuroses. Jason Aronson.
• Spotnitz, H. (1976/1995). Psychotherapy of Preoedipal Conditions. Jason Aronson.
• Spotnitz, H. (1962). The need for insulation in the schizophrenic personality. Psychoanalytic Review, 49(3).
• Spotnitz, H. (1963). The toxoid response. Psychoanalytic Review, 50.
• Margolis, B. D. The contact function of the ego. Modern Psychoanalysis.
• Margolis, B. D. (1983). The object-oriented question. Modern Psychoanalysis, 8.
• Margolis, B. D. (1986). Joining, mirroring, psychological reflection. Modern Psychoanalysis, 11.
• Meadow, P. W. (1974). Research method for investigating the effectiveness of psychoanalytic technique. Psychoanalytic Review, 61(1).
• Ormont, L. (1992). The Group Therapy Experience. St. Martin's.