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by Peter S. Armstrong, Ph.D.
Reviewed by Linda J. Young, Ph.D.
following book review was originally published in the Psychologist-Psychoanalyst,
(the newsletter of the Division of Psychoanalysis of the APA)
Volume XXII, no. 4, Fall 2002.
It is reprinted here with permission.
If you’re truly interested in conducting long term analytic work, you’d better not blow it in the first session. Peter Armstrong’s book, Opening Gambits, (Jason Aronson, 2000) explains how to avoid doing this, and does so in a way that distinguishes the first session of psychoanalytic treatment as a topic of special and important interest. The portentous first session to which Armstrong devotes his book is likened to the infant’s first and fateful introduction to its relationship with early caregivers and to the world of objects. According to Armstrong, in psychotherapy, and presumably, in life as well, the possibility of engaging a person is at its height during the initial contact, as is the danger of laying down pathways, or “ruts,” that are difficult to change later on.
Armstrong gives considered, detailed attention to this opening session. His book is informed by psychoanalytic theory painted in broad strokes, with quotations and clinical examples from theorists as various as Freud, Bruch, Rothstein, Winnicott, Sanville, Stone, Greenson, Shafer, Stolorow, Atwood, Ogden, Shor, Kaiser, Strean and Kernberg. Armstrong selects concepts from these and other psychoanalytic theorists to describe components of the opening phase of psychotherapy that seem to hang together intuitively for him in a congenial, commonsensical way. There is little attempt on his part to compare, contrast or in any way critically evaluate the diverse theories from which he selects his examples. Armstrong’s own theoretical background seems to be an ego psychological one, as his stated goals in psychotherapy are to develop an autonomous, independently functioning person, capable of making increasingly successful self-assessments. He does not declare his allegiances, but he appears to identify most strongly with the contemporary intersubjective systems treatment approach of such clinicians as Stolorow and Atwood, at least insofar as their stance of “empathic-introspective inquiry” is congruent with the one he illustrates in his book.
Though stating at the outset that he is describing “the initiation of a treatment that must be practiced as an art” (p. xv), this art can’t help but have a bit of a paint-by-the-numbers quality at times, especially when regimented around completing a number of prescribed tasks (eight to be exact) that Armstrong sees as standard and mandatory in this initial phase. The first portion of the book explores the therapist’s “Stance”--“the most critical element of effective psychotherapy” (p 12). In this section Armstrong includes a wide variety of topics, all loosely relevant to the topic of “stance” but at times seeming to be somewhat casually chosen and arbitrarily organized. Citing various psychoanalysts’ descriptions of how they conduct first sessions, Armstrong samples from a buffet table of theoretics--e.g., “working together,” “the patient as self-healer,” “the holding environment”--in an attempt to paint a picture of the “atmosphere of safety” (the most crucial aspect of stance). The central goal in all of this, is to convey to the patient that talking is a way of working out meanings, and to establish an atmosphere in which free association is tolerated and even valued, as a way of discovering these meanings. Armstrong beautifully explains that to facilitate such talking, the analyst must listen in a way that is respectful of the individual—witnessing and honoring his/her experience, as opposed to reassuring, normalizing and thereby, negating it. Following the section on “Stance” are chapters that discuss “ The Contract”-- its first negotiations, fees and legal issues-- and “Assessment.” The book concludes with an exploration of various topics entitled “Transition to the opening phase,” “The phone call,” “My first session with a patient,” and “Special cases.” Introducing nearly every chapter and then concluding the book are clinical vignettes from a fictional case Armstrong has created to represent an amalgamation of his experiences with patients.
The organizational structure of Opening Gambits is a bit elusive, and this is especially so with regard to the fact that there is no obvious theoretical rationale justifying why certain topics are afforded overarching headings or titles of chapters. Nonetheless, it is a book that is earnestly and enthusiastically written. It is enjoyable to read as well as informative and, while written more for the beginning therapist, invites even an experienced clinician to consider anew previously held assumptions and reflexively performed ways of doing things. And, in this era of industrialization of health care and the psychopharmacological quick fix approach to problems of daily living, this book is a refreshing antidote. It reminds us that the mind of the individual is not synonymous with, nor reducible to, brain chemistry, and that talking with a person really matters, still.
Armstrong comes across as a thoughtful clinician who honors the individual as unique and each psychoanalytic encounter as a similarly unique developing dialogue. He seems to truly believe that a psychoanalytic conversation is like none other and that the unfolding and interpretation of specific meanings communicated by the patient over time is a worthy endeavor and one deserving of protection. Armstrong appreciates as well, the idea that transference meanings are ascribed to any and all aspects of the therapy and that there is no such thing as a segregated business aspect to the relationship that is exempt from the accrual of such meanings. Armstrong is constant in his encouragement to the reader to be mindful of the communicative implications of even the most seemingly mundane of negotiations and communications that are involved in the agreement to pursue psychotherapy. He is acutely aware of the potential iatrogenic significance of all manner of therapist-directed intervention and seems to have as a goal the unobstructed unfolding and articulating of transference paradigms that emerge when patients are afforded the space and time in which to do so and the undivided attention of the therapist. It is Armstrong’s assumption and a fundamental raison d’être of the book, that the crucial moves the therapist makes in the first few sessions facilitate the blossoming of such a conversation or wither it to a never-to-be-analyzed demise.
But for me, there is a counterpoint to the manifest content of the book that is every bit as important, and it beats like a steady, albeit doleful, refrain throughout. This counterpoint derives from an invisible but palpable intruder in the analytic space, its presence making it quite clear that the therapy chess game is not played out in a vacuum but rather, unfolds within a specific context that imports its rules and imparts its meanings onto the game. Simply put, the gambits available to the players are themselves influenced by outside forces that effectively strive to diminish the degrees of freedom available to the players. Armstrong refers to these forces with the nomenclature of “managed care,” “licensing boards,” and “mental health clinics” and describes the procedural artillery employed at their disposal. These include, for example, external limitations on the number of sessions available, rules about record keeping, requirements for informed consent, limitations on privacy and confidentiality, and stipulations regarding the content of contracts –all of which tug and yank at what otherwise would be the “art” of the psychotherapist’s gambits. Armstrong often refers to these gambit-killers with the attitude of, “I wish I didn’t have to mention this but I do.” And to his credit, he does. So while the “gambits” Armstrong manifestly focuses on refer to the volley of implicit and explicated meanings developing between therapist and patient, this other powerful strategic competitor inserts itself between the lines of the story. In some ways it trips up the players, and throws an interesting wrench into the intent and message of the book as well. Armstrong, in a way, becomes a therapists’ “Everyman,” and as we watch him try to navigate his way between legal and societal demands and the demands of his professional judgment, he provides us with something invaluable--namely, a reflection of ourselves. In this reflection we can observe the various ways our profession collectively tries to grapple with a competition in which our professional identities and livelihoods are at stake.
Like the rest of us, Armstrong at times seems desperately to want to wish these intruders away. At other times he appears to minimize their importance or to try to effect some form of compromise with them so as to appease or keep them at bay. Sometimes he sounds downright frustrated and angry, and appeals to our professional organizations to react politically to these issues.
For instance, in defending his psychoanalytic stance against the presumption that “technique” should direct the treatment and that outcome research might be used to recommend preferred treatment for particular diagnoses, he retorts, “Outcome research is fraught with problems and it is not the therapist’s responsibility to be aware of all other known problems and treatments…” (p. 171). And, as early as the introduction to his book, Armstrong tells us that the new wave of health insurance and managed health care that has resulted in the drastic shortening of psychotherapy may have augmented the importance of the first session, but he concludes, “This has nothing to do with the subject of this book” (p. xii).
Personally I’d love to be able to agree with both of his statements. And I imagine I am not alone in wishing that the “subject” of the book— be that the book itself, the patient, or the subject called ourselves and our profession would have “nothing to do with” the contextualizing societal forces that threaten to vitiate the heart of psychoanalytic work, most notably professional judgment and the freedom and responsibility of the parties who mutually participate in the psychoanalytic process. However, the development and implementation of standards of care and practice, ethical and treatment guidelines, reporting laws, limitations on confidentiality, and the growing use of “evidence based treatments” to perfunctorily consign diagnostically categorized people to specific, prescribed kinds of treatments, are all too real to ignore. So, despite the probability that the “managed care” Armstrong repeatedly refers to in its circumscribed definition may be dying in the water presently (two years after Opening Gambits was first published), the larger and more extensive ways in which the practice of psychoanalysis is being “managed” simultaneously on several fronts cannot be ignored.
For the most part, Armstrong in fact does not ignore all this, and he is too sensitive a clinician to not be aware of the implications and consequences when clinicians conform their practices to such bureaucratic guidelines. He continues to run the gamut, uncomfortably embracing simultaneous contradictory “stances” which again mirror the diverse ways members of our profession cope with the problem. While on one page he defiantly proclaims that the psychoanalytic therapist need not be knowledgeable about alternate forms of treatment, on another he communicates with resignation his feeling that he has no choice but to follow the dictates of a licensing board in providing written forms for his new patient to read and sign. Admitting that “…the codification of the treatment contract diminishes the therapist’s freedom of judgment and constrain(s) the development of a contract that reflects the specific needs of a unique therapeutic dyad” (p. 121), he makes a compromise with this directive (and with himself), waiting until the end of the first session before delivering that which he wishes he didn’t have to deliver in the first place. And in all of this, he attempts to downplay his accommodations by trying diligently to assimilate these intrusions under the rubric of psychoanalysis through his willingness to “talk about it” with the patient.
Armstrong’s struggle is the struggle of our profession. The particular compromises he makes are among the myriad compromises most of us consider and, at times participate in individually and collectively, as we try to assume a “stance” --not just with patients, but with the societal forces that regulate which chess pieces we have at our disposal, and the amount of professional discretion and autonomy we are permitted as we work out our own strategic moves.
Armstrong underlines the importance of this struggle with his mention of it in nearly every subject he addresses in the book. But I think he might have gone even further. The struggle to keep psychoanalysis alive exists in more than just decisions regarding what forms, if any, should be given to patients. It exists, as Armstrong himself implies, in the fundamental assumptions we have about the work and about those with whom we work.
And it is a struggle which paradoxically, but not unexpectedly, makes an appearance even in the assumptions underlying Armstrong’s “work” of writing a book. It exists in the ironic reality that Armstrong has come awfully close to writing a formulaic “how to” book on a subject which he himself eloquently communicates, can never, and should never, be manualized. And he would not have been able to do so without categorizing the individuals with whom he works, and engaging in generalizing assumptions about them. Whether it is in sections called “the meek patient” and “the compliant patient” or in statements such as “in many ways husbands are the most obvious of the compliant patients” (p. 210), Armstrong engages in the kind of disturbing groupings that he himself criticizes with such statements as, “No diagnostic category ever begins to reveal the many varieties of human experience much less the endless possibilities of what a patient may present and may be capable of accomplishing” (p. 175). These are also the disturbing groupings that “managed care,” and the entities derived from it, use to format patients and de-individualize treatment. The very fact that he includes a section entitled “special cases”--e.g. “the patient with previous therapy,” “the compliant patient,” “the reluctant spouse”-- implies that there are other cases which, in his opinion, are not that special--i.e., that are commonplace or generic. This subtly impersonal tone appears even less subtly in statements such as, “I discuss certain symptoms that I have met in the first session” (p. 138) making Armstrong sound as if he has forgotten that he is meeting with a person, rather than with a collection of “symptoms.” All of this rings somewhat discordantly with his otherwise more humanistic appreciation for the complexity and uniqueness of the individuals who consult with him, for the singularity of each psychoanalytic encounter, and for the artistry of the psychoanalytic process.
Could we consider the idea that in contradicting himself in this way, Armstrong speaks the ambivalent voice of a profession that has been seduced and, at times forced, to make untenable compromises? Such a compromise is expressed in extreme form when he writes a chapter entitled, ”My first session with a patient,” focusing on the tasks he tries to accomplish but without there being any actual patient. Instead, there is a hypothetical entity, an abstraction, needed to create the illusion that the tasks, goals and procedures of the first session are almost pre-fabricated gambits that can somehow be learned and memorized, existing apart from the actual living, breathing, meaning making individuals who play them. Armstrong seems not fully aware of the idea that the more he employs this thinking, the more he gives up ground sacred to psychoanalysis, unwittingly conceding it to those who desire to “manage care.” For once he no longer insists that there is, after all, no such thing as “the meek patient,” but always and only a unique individual who presents himself in certain ways that can only be understood within a context of idiosyncratic meanings specific to that individual, he unwittingly and paradoxically contributes to the very problem he identifies and decries in his book. That is, he unwittingly enables those who attempt to create and then justify procedures, formats and manualized treatment plans that can then be applied lock, stock and barrel to a specific category-- e.g., the meek patient.
Armstrong concludes his book with a vignette from a hypothetical session in which he and his patient address the patient’s having forgotten a session, and together they explore the unconscious motivational meanings associatively linked to the patient’s sacrifice of that hour. Some of the specifics include the patient having “forgotten” the session while he was tied up at work, as well as recollecting having been forgotten himself by a father who frequently sacrificed his son to his own work life. Interestingly, the word “gambit” itself connotes a sacrifice, in its definition as “an opening in which the player seeks by sacrificing a pawn or piece to obtain some advantage.” Opening Gambits, if read carefully, alerts us to the temptation and danger of sacrificing that which is most important, via forgetting about it, in a misguided and frantic attempt to stay “at work,” reaping the dubious “advantages” of being certified, licensed and ultimately “managed” health care workers.
Opening Gambits is manifestly about a creative, unfolding chess game between therapist and patient. In it, Armstrong skillfully offers guidance to therapists which if heeded, might prevent the creation of “ruts” that are difficult to get out of. Indeed, to consider carefully, as Armstrong has, how to create conditions whereby an individual, ongoing therapy can unfold over time is crucial to a productive psychoanalysis. The unexpected surprise of the book however, is in its potential to open up dialogue about the conditions we as a profession consider crucial in keeping psychoanalysis as a profession, alive and ongoing as well. Whether he intends this or not, Armstrong demonstrates how some of the ruts we, as a profession, had best not get stuck in, are already upon us. These ruts are the tread marks of an insidious competition that keeps trespassing onto the chess game. It is one that threatens to sacrifice our patients as pawns to be “forgotten” about to such an extent that they no longer exist other than in manualized abstraction, and to “rook” us into participating in the constraint of our free movement across the board. In so doing, it threatens to take from us our most valuable pieces, leaving us in danger, ultimately, of being check-mated. Opening Gambits opens up what could be an extraordinarily meaningful conversation about the work that Armstrong thoughtfully honors with his careful analysis of opening moves. It is an invitation to strategize carefully, if we are to avoid being left with no gambits to speak of.
Dr. Young has an independent and private psychoanalytic practice in Ann Arbor and Northville, Michigan and is the Vice President of the Academy for the Study of the Psychoanalytic Arts. She can be reached at (734) 665-9692 or by e-mail at email@example.com