Applying Current Literature to Clinical Practice
In a 5- to 10-slide PowerPoint presentation, address the following:
Provide an overview of the article you selected.
What population is under consideration?
What was the specific intervention that was used? Is this a new intervention or one that was already used?
What were the authors claims?
Explain the findings/outcomes of the study in the article. Include whether this will translate into practice with your own clients. If so, how? If not, why?
Explain whether the limitations of the study might impact your ability to use the findings/outcomes presented in the article. Support your position with evidence-based literature.
THE ANALYST IS PRESENT
Viewing the Psychoanalytic Process as
Performance Art
Alan Michael Karbelnig, PhD
South Pasadena, California and New Center for Psychoanalysis,
Los Angeles, California
Since its establishment as a profession, psychoanalytic practitioners have strug-
gled with understanding the true nature of their work. Many remain devoted to
Freuds medical model (Freud, 1958) and aspire to establish a logical-
positivistic basis for psychoanalysis. Others view the field more broadly, and
consider psychoanalysis a distinctively humanistic discipline. This paper sug-
gests that the bifurcation may be resolved by focusing on clinical as opposed to
theoretical psychoanalysisan emphasis that illuminates its artistic elements.
Psychoanalysts work may be likened to performance artists, primarily because
they work to create an experience in their patients. In addition, they give with
their psyche-somas, reminiscent of how actors use their bodies as instruments;
they face each session in a fashion akin to how painters face the white canvas
or writers the blank page; and they choose from an infinite number of possible
models for coconstructing ways of understanding their patients experiences.
Regardless of past or future theoretical differences, psychoanalysts provide
creative, transformative experiences most accurately described as transforma-
tional encounters. Psychoanalysis is a verb, a process. While it alleviates pain
caused by various mental disorders, it also assists individuals in discovering
their individuality, authenticity, and singularity. In support of the artistic foun-
dation of the psychoanalytic process, the paper includes three scenes that
demonstrate how patients experience precipitous, essential breaks in their re-
petitive, internal dramas, resulting in them experiencing themselves as beings,
capable of change. It thereby demonstrates how psychoanalytic practitioners
This article was published Online First July 28, 2014.
Alan Michael Karbelnig, PhD, ABPP, Private Practice, South Pasadena, California, and Senior
Faculty and Training and Supervising Psychoanalyst, New Center for Psychoanalysis, Los Angeles,
California.
Correspondence concerning this article should be addressed to Alan Michael Karbelnig, PhD,
ABPP, 625 Fair Oaks Avenue, Suite 270, South Pasadena, CA 91030. E-mail: [emailprotected]
gmail.com
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Psychoanalytic Psychology 2014 American Psychological Association
2016, Vol. 33, Supplement 1, S153S172 0736-9735/16/$12.00 http://dx.doi.org/10.1037/a0037332
S153
mailto:[emailprotected]
mailto:[emailprotected]
http://dx.doi.org/10.1037/a0037332
bring something new to life, further validating how psychoanalysis qualifies as
an artistic endeavor.
Keywords: psychoanalysis, transformational encounters, intersubjectivity, hu-
manism, hermeneutics
In 1896, when Freud coined the term psychoanalysis (Gay, 1988, p. 103), he created a
technique specifically applicable to patients with mental disorders. Consonant with this
initial view of the process, the first psychoanalysts treated individuals suffering from such
Victorian-era termed disorders as obsessional neurosis, hysteria, and melancholia. Yet,
even in those early years, Freud and other practitioners struggled with the actual nature of
their work. Some patients presented with distinct symptoms such as anxiety or depression;
others sought help for concerns about their work, their relationships, or other, wide-
ranging elements of their life experiences. Were these pioneer psychoanalysts actually
treating distinct mental illnesses, or were they helping individuals explore the meanings
of their lives? By the mid-20th century, the burgeoning controversy regarding the precise
aims of psychoanalysis flowed into two distinct streams.
Many psychoanalytic practitioners remained devoted to the exclusively medical vi-
sion. They applied techniques such as confronting ego defenses exposing the emotion-
ally painful, unconscious conflicts patients were maskingthereby reducing psycholog-
ical symptoms. Using the sine qua non of the psychoanalytic process, these analysts
focused on transference as the vehicle for their treatment. Such psychoanalysts typically
sought scientifically based sources of information. They pursued observational studies of
infants, researched cognition and emotion, conducted outcome studies, and otherwise
leaned toward the scientific in an effort to establish an empirical basis for psychoanalysis.
They believed the field would persist as one intervention among many, alongside psy-
chopharmacology and cognitive behavioral therapy, in the cadre of treatments for mental
illness.
Other psychoanalysts, particularly during the last 50 years, applied their techniques
with broader strokes. They utilized their training to help those with difficulties that defied
traditional medical categorization, such as persons who felt socially alienated, failed to
achieve romantic intimacies, felt personally inadequate, or found their lives meaningless.
Although not hostile to science, these psychoanalysts worked, wrote, and researched in
more humanistic realms. They sought information outside of their fieldin literature,
philosophy, and historyto find support for their work. They believed these disciplines
offered greater insights into human subjectivity than could the sciences alone. They
viewed their work as hermeneutical and exploratory rather than as a process solely
intended to cure illnesses. Orange (2011) noted that because of Freuds stronger insis-
tence on the status of psychoanalysis as a natural science, our awareness of psychoanalysis
as hermeneutics has arrived only recently (p. 2).
Despite its having been tossed and turned by the streams of scientism and humanism,
psychoanalysts, regardless of their particular theoretical orientation (Freudian, Jungian,
Kleinian, etc.), have consistently relied on, and written about, four foundational tenets: the
idea that an unconscious mind exists, that some kind of force or drive motivates human
beings, that individuals tend to form repetitive psycho-behavioral patterns (the repetition
compulsion), and that these unconscious features tend to be projected onto the psycho-
analytic relationship in the form of the transference. The four foundational themes were
originally delineated by Freud (1914/1958), and later elaborated on by others including
Lacan (1978); Rangell (2006), and Harari (2004). Of course psychoanalysts also have
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S154 KARBELNIG
attended to other signs of the unconscious, such as dreams or parapraxes, but these four
elements provided steady points of reference.
Unlike physicians, armed with stethoscopes, syringes, medications, EKG machines,
thermometers, and other forms of technology for evaluating and treating patients, psy-
choanalysts greet their patients solely with their beings. They bring no interventional
technologies to the process. They offer reverie, containment, interpretation, confrontation,
empathy, and similar rhetorical or interpersonal influences to promote transformation in
their patients. Whereas artistry certainly comprises a component of what other profes-
sionals provide, psychoanalysts work entirely within the interpersonal relationship, ren-
dering the artful element of their services more central.
The Shorter Oxford English Dictionary (Trumble, Brown, Stevenson, & Siefring,
2002) defines art as the application of skill according to aesthetic principles, esp. in the
production of visible works of imagination, imitation, or design and as skillful execution
of workmanship (p. 122). Inarguably distinct from each other, art and psychoanalysis
nonetheless share critical features, by definition and by practice. Psychoanalysts apply
skills according to aesthetic principles (taking the form of technique arising from theory),
produce visible works (evident in the transformational experiences for their patients), and
execute their workmanship (through the interpersonal effects just noted). Although they
may not formally identify it as such, their artistry may be likened to a form of performance
art.
The Nature of the Psychoanalytic Process in Real Time
This paper delves into the psychoanalytic process from the inside, meaning the subjective
experience of the session, as it actually unfolds, in real time. Psychoanalysts create and
manage intensive interpersonal relationships intended to be transformative for patients.
They concern themselves with the beings of patients. Therefore, their clinical work, given
its artistic nature, resides in the realm of humanism. For the purposes of this paper, the
word humanismfraught with different and conflicting meaningsrefers to constella-
tions of philosophical and ethical perspectives that emphasize human subjectivity and
privilege the value and agency of human beings. And that returns this discussion of the
psychoanalytic process one that could never be reduced to an equation back to the
arts, especially performance art. The psychoanalytic process requires spontaneity and
improvisation by psychoanalysts, rendering it an artistic production. Psychoanalysts have
a unique opportunity for responsively and actively treating individuals whose relief from
suffering requires a certain kind of change: A transformative experience of enduring
significance.
Therefore, in place of the word psychotherapy, or psychoanalysis, I propose the phrase
transformational encounters because this more accurately describes what actually occurs
in psychoanalysts offices. The psycho component of the word psychotherapy or psycho-
analysis implies a fixed physiological entity, such as a liver or kidney, while in truth the
psyche is more verb than noun. An extremely dynamic entity, psyche arises out of many
complex determinants biological, cultural, historical, social, and more. The therapy
component suggests treatment of an illness that represents but one feature of how
psychoanalysis can be utilized. In a similar vein, analysis implies a sequential, linear
process that fails to account for the dynamism and creativity of actual psychoanalysis.
Individuals, patients, analysandsvariously namedseek the assistance of profes-
sionals called psychoanalysts for a variety of reasons. Orange (2011) called them fellow
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S155VIEWING PSYCHOANALYSIS AS A PERFORMANCE ART
sufferers (p. 4), and explained how the word patient derived from the Latin, patior, which
means to suffer, to undergo. Once these individuals consult psychoanalysts, they engage
in sets of meetings thatprecisely because the transference forms the cornerstone of the
process consist of interpersonal encounters intended to achieve a form of transforma-
tion. As previously noted, these transformational encounters correspond uniquely and
fundamentally with performance art; conversely, these have little in common with clinical
procedure as it is currently accepted and defined in medicine.
But one example of the central role that artistry plays in the psychoanalytic
process, psychoanalysts make choices about design elements of the space in which
they apply their interventions well before meeting their first patient. The more
conservative psychoanalysts consulting room may tend toward the spare, and appear
more traditionally office like. Such strategic choices may ensure that projections are
focused more onto the analyst. They reduce possible distractions caused by ornate
furnishings. In contrast, psychoanalysts who privilege the relational elements of the
process may make decorative choices intended specifically to buttress, even comfort,
patients when they experience uncomfortable emotional states. These analysts em-
phasize patients emotional safety over the potential for distraction. Their walls may
be softened by paint, and three-dimensional dcor, such as books, lamps, and paint-
ings, may purposefully create the feeling of a living room in a comfortable home.
Psychoanalysts plan, deliberately and creatively, setting the stage for their transfor-
mational encounters. Winnicott, who apparently worked in a rather classical fashion,
nonetheless demonstrated a warm personal style in his actual interactions with his
patients (Little, 1990). Orange (2011) wrote of Winnicott, his style, including his
office, seems to have been informal, unpretentious, and welcoming (p. 163).
When the patient enters the consulting room, the curtain lifts. The psychoanalytic
performance begins. The patient meets the psychoanalyst, trained in a variety of psycho-
analytic theories, having undergone years of psychoanalysis, and ready to receive what-
ever patients care to report, describe, or enact. The psychoanalytic process subsequently
unfolds in accordance with the theoretical leanings of the psychoanalyst but, more
important, in a manner influenced by the unique features of each therapeutic dyad
(Freedman, 1980, p. 259). Whether the initial session or the 50th one, the psychoanalytic
process differs sharply from standard procedures in physicians offices. Patients present-
ing with a sore throat to a specialist in internal medicine will be subjected to a fairly
consistent set of procedures including examining the mouth, throat, and neck and ordering
laboratory tests to assess for an elevation in white cells. Patients presenting for psycho-
analysis can expect no such standardized procedures. On the contrary, the process will
vary, usually quite markedly, depending on the personalities of the participants, their
aesthetic styles, and the theoretical orientation of the psychoanalyst.
Patients in psychoanalysis may have similar experiences with psychoanalysts of the
same theoretical school. If consulting conservative psychoanalysts, for example, they may
well find a commonality in the use of silence, in the frequency of questions asked, and in
the generally more passive approach. But even such commonality in technique would vary
greatly depending on the specific qualities of each unique psychoanalystpatient dyad.
Psychoanalysts cannot help but use their personal styles to establish an intimacy that is
mutual but asymmetrical (Aron, 1996, p. 43). Their tools consist of their personalities
and styles, a variety of interpersonal influences as noted earlier, and a focus on the four
tenets and other signs of unconscious processes. Their work progresses in a fashion
analogous to the way a director of modern dance uses choreography, a painter uses
brushes, or a writer uses the keyboard.
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S156 KARBELNIG
A feature of the first 100 years of its existence, psychoanalysis tended to spawn
competing schools that suggested if not required practitioners to adopt certain attitudes
and apply certain techniques in conducting their work. Generations of psychoanalysts
learned to put their singularities (Ruti, 2012) aside to attend to certain proscribed
elements of the psychoanalytic process. They might, for example, explore stages of
psychosexual development (if Freudian), archetypes and imagery (if Jungian), envy and
aggression (if Kleinian), environmental impingements (if influenced by Fairbairn, Win-
nicott, or other British object relations theorists), or the subtle dance of interaction during
sessions (if self-psychological, intersubjective, or relational).
Their patients, in turn, have as many stylistic variants as their psychoanalysts: Some
present with triangular love situations that fit the Freudian model, and others with
aggressive fantasies that comport with the Kleinian model. Jungian theory may work well
with persons actively reporting dreams, particularly if they have mythological or anthro-
pological themes. Some patients are highly emotional; others more cognitive. Some wait
passively in silence for their psychoanalysts to speak; others express highly personal,
emotionally vulnerable information when first greeted in the waiting room.
As I argue when presenting the performative aspect of psychoanalysts actual work,
these personal, stylistic featuresin psychoanalysts and in their patientstypically prove
more significant than the theory guiding the process. Theory results from a collective
enterprise featuring argumentation, criticism, and revision. Burke (1954) wrote, Theory
(literally, a looking-at, or viewing) plays a large part, not only in the technique of the
physician, but in the patients response (p. 125). Psychoanalysts will continue to
elaborate on old, or to develop new, ways of viewing the mind as well as the psychoan-
alytic process. I submit, however, that personal stylesinfluences that have been mar-
ginalized in psychoanalytic theory developmentare, in truth, crucial elements of the
transformational process. (Such styles even influence choice of or comfort with a partic-
ular theory). For example, the personality of an extremely gregarious, outgoing psycho-
analyst trained in traditional Freudian analysis will arguably have a greater effect on the
process than his or her devotion to that theory. A rather cold, emotionally distant
psychoanalyst trained in the Relational school may similarlyalthough immersed in an
entirely opposite theoretical perspective emphasizing a more engaging, interpersonal
approach demonstrate more of the neutrality characteristic of the earlier, more conser-
vative schools. These ideas resonate with Stolorow and Atwoods (2002) suggestion that
the impact of the analyst, of his interpretive activity, and his theoretical preconceptions,
whatever they may be (p. 102) must be considered primarily from the viewpoint of the
subjectivities of psychoanalysts and their patients.
Psychoanalysts working within certain theoretical viewpoints make spontaneous and
highly creative decisions, on a moment-to-moment basis, during each psychoanalytic
sessionmuch like artists standing before their canvases and authors sitting before their
keyboards. Theory, which risks objectification of psychoanalysts and patients if adhered
to excessively, influences the process such as the genre of an artist or a writer influences
their craftsmanship. Psychoanalysts devoted to more traditional themes of neutrality and
abstinence demonstrate creativity in the way they time their interpretations, suppress
certain emotions, such as sympathy, avoid asking questions, and eschew offering reas-
surance. Lacanian analysts, steadfastly focusing on linguistic features of the work, make
spontaneous decisions about selecting which words to pursue. Self-psychologists, inter-
subjectivists, or relationalists similarly make certain strategic decisions regarding em-
pathic attunement.
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S157VIEWING PSYCHOANALYSIS AS A PERFORMANCE ART
Just as artists encounter limitations related to the medium with which they work, that
is, the size of the canvas on which they paint or the piece of marble that they sculpt,
psychoanalysts face numerous limits including their personhood, the varieties of inter-
personal influences already noted, and session length and frequency. Countless creative
choices nonetheless exist. In fact, limitations are notorious catalysts for innovation.
Previous Views of Psychoanalysis as Art
When he moved from the suggestive technique to the analytic one, Freud (1905/1953)
compared suggestion to painting and analysis to sculpture. He wrote that sculpture
proceeds per via di levare, since it takes away from the block of stone all that hides the
surface of the statue contained in it (p. 260). Loewald (1980), one of the first psycho-
analysts to consider his work as primarily artistic in nature, explicitly compared psycho-
analysis to drama. He believed that psychoanalysts and their patients together create,
produce, and perform a play. He wrote, in the mutual interaction of the good analytic
hour, patient and analyst each in his own way, and on his own mental level become
both artist and medium for each other (Loewald, 1980, p. 369). Winnicott (1955) referred
to psychoanalysis as an art (p. 24). Of him, Orange (2011) wrote, Both process and
spirit embodied a two-person creative aliveness (p. 162).
Bion (1965) described psychoanalytic work as a transformation, analogous to the
artists painting that is a product of the particular artists approach (pp. 8 9). According
to Jacobus (2005), Bion viewed the psychoanalytic encounter as a site of turbulence, a
mental space for further ideas which may yet be developed (p. 258). Years before
Hoffman (1998) presented his dialectical-constructivist model, Bion (1991) had already
documented the dual role of the analyst observing and participating, acting as subject and
object at the same time. Lacan (1979) viewed psychoanalysis as fundamentally an artistic
endeavor, writing, psychoanalysis is perhaps the only discipline comparable to those
liberal arts, inasmuch as it preserves something of this proportional relation of man to
himselfan internal relation, closed on itself, inexhaustible, cyclical (p. 406). Psycho-
analytic methods, he added, were derived from that fundamental art of psychoanalysis . . .
constituted by that intersubjective relationship which, as I said, is inexhaustible since it is
what makes us human (p. 406). Szasz (1988) believed that psychoanalysts activities
would constitute, and be classified as, art rather than science (p. 208).
Bollas (1987) described the psychoanalytic process as a performance in the sense that,
to find their patients, psychoanalysts must look for him within ourselves (p. 202) and
added we are being taken into the patients environmental idiom, and for considerable
stretches of time we do not know who we are, what function we are meant to fulfill, or our
fate as his object (pp. 202203). Symington (2002), described how patients engaged in
psychoanalysis mourn, wrote, if the death is photographed, it does not become emotion-
ally real; if it is painted, it does (p. 68). More recently, Ringstrom (2001, 2007, 2008,
2012) explored the role of improvisation in the psychoanalytic process. He contended, as
do I, that psychoanalysts must be emotionally present, responsive, prepared to engage with
a variety of personalities, and that psychoanalysis may be likened to drama. Ringstrom
(2012) believed the improvisational metaphors of scripts, assigned roles, dramatic arches,
and sequences allow psychoanalysts to expect (and direct) the other to be in each
present moment (p. 470).
Scholars outside of psychoanalysis have similarly commented on the artistic elements
of the field. Burke (1966) argued that not only literary, but all fields of human study, such
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S158 KARBELNIG
as psychoanalysis, cannot understand human motivation without considering its neces-
sarily theatrical, dramatic elements. By applying the dramatistic (p. 63) lens to any
human production or experience, Burke (1966) intended that literary critics, audiences,
and professional observers of human behavior, including psychoanalysts, generate heu-
ristic or exploratory responses (as opposed to closed, deterministic conclusions). Toward
this end, he proposed a dramatistic terminology (built around a definition of man as the
symbol-using, symbol-misusing, symbol-making, and symbol-made animal) (Burke,
1966, p. 63). Human motivation is performed, he suggested, through the dramatistic
pentad: act, scene, agent, agency, and purpose (Burke, 1945, p. 538). He wrote that, the
difference between a thing and a person is that the one merely moves whereas the other
acts (Burke, 1966, p. 53).
Writing from a multidisciplinary perspective, Burke (1954) opposed the growing
reliance on purely deductive studies in all fields. He thought poetry revealed the con-
centration point (p. 66) of human desire. Considering scientific approaches to under-
standing human motivation a form of rationalization, he recommended a corrective (p.
66) in the form of a rationale of artnot however, a performers art, not a specialists
art for some to produce and many to observe, but an art in its widest aspects, an art of
living (p. 66). Encountering the many varieties of the human experience, psychoanalysts
immerse themselves, in their daily work, in their patients theatrical constructions of their
lives. Their manner of engaging them similarly resides in the realm of the dramatic, as
Loewald (1980) also noted.
Butler (1997, 2005) suggested that humans, on some level, perform their actions, their
feelings, and their speech. She wrote, Language is the name for our doing: both what
we do (the name for the action that we characteristically perform) and that which we
effect, the act and its consequences (Butler, 1997, p. 8). Although referring to identity
formation, rather than to the artistry of psychoanalysis, Butler (2005) writes that when we
speak of our selves, we become speculative philosophers or fiction writers (p. 78). In a
similar vein, Orange (2011) observes how psychotherapies, generally, focused on lan-
guage. She adds, language, resonant and heavy with history, is its medium, and the
participants inhabit it, as other artists inhabit their media (p. 22). Psychoanalysts utilize
elements of literary criticism and applied philosophy, respectively, as they illuminate
the ideologies and narratives of their patients. From within psychoanalysis, and from
outside the discipline, many scholars compare the psychoanalytic process, and even the
experience of being human, to drama or theater.
The Artistic Nature of the Psychoanalytic Process
Hoffmans (1998) dialectical-constructivist model offers a clinically useful, descriptive
view of the psychoanalytic process without adhering to a specific psychoanalytic theory.
It clearly acknowledges the artistry inherent in the psychoanalytic process. Unlike Freud-
ian or Jungian recommendations for technique, for example, Hoffmans model invites
flexibility in theoretical modeling and in clinical method. The phrase dialectical-
constructivist concisely if broadly defines the nature of the interpersonal, contractual
service called psychoanalysis. The dialectical component of the phrase refers to the
manner in which psychoanalysts become engaged in relationship with their patients in
dichotomous and paradoxical ways; the word constructivist allows psychoanalysts and
their patients to either choose from myriad extant theory or create their own, unique
models for explaining recurrent unconscious themes.
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S159VIEWING PSYCHOANALYSIS AS A PERFORMANCE ART
Beginning with the dialectical component of psychoanalytic work, Hoffman (1998)
described a paradoxical process. On the one hand, psychoanalysts receive invitations into
any number of enactments propelled by their patients unconscious schemata, their own,
and the combination of the twoa concept captured by Ogdens (1994) idea of the
analytic third (p. 4). Essentially all psychoanalytic theorists have agreed that the uncon-
scious inner world or the internal object worldwhich I prefer to call the internal
dramainfluences if not possesses the psychoanalytic relationship itself. On the other
hand, by virtue of the service they sell, psychoanalysts pull away from their relationships
with their patientsimmersed as it is with unconscious, dramatic themesand reflect,
plan, intervene. The dialectical component of Hoffmans model consists of this back-and-
forth, this dance of engagement and dis-engagement, of subjectivity and objectivity, of
being invited into enactments and then withdrawing to interpret them or intervene in some
way.
Regarding the constructivist element, psychoanalysts, in partnership with their pa-
tients, create models of what motivates a particular patient, of their internal unconscious
drama, of the meaning of the repetition compulsion, or of how those themes map onto the
psychoanalytic relationship. They offer interpretations, confrontations, empathic attun-
ement, or other ways of engaging patients. The creativity inherent in the psychoanalytic
process resides primarily within the constructivist component of Hoffmans (1998) model.
Psychoanalysis emergednot from magic or in isolationfrom Freuds early writ-
ings. Its roots lie in millennia of writings in philosophy, history, political science,
literature, and more. Psychoanalysts use the hand of human historyits humanismin
offering ideas about what motivates patients, how their unconscious internal dramas were
forged, the nature of the repetition compulsion, and the third element (Ogden, 1994, p.
4) that dynamically possesses psychoanalytic relationships.
Regardless of their theoretical stance, psychoanalysts ideally strive for presence in real
time, shoring back natural feelings when they consider what would be most effective in
fomenting transformation. Psychoanalysts embody separate professional and personal
personas, but their subjective selves persist, of course, across their varied social roles. In
some ways, psychoanalysts behave much like actors who similarly manage their emo-
tional experiences while performing. Actors skills may often be judged in terms of their
effectiveness in either hiding their feelings or demonstrating emotional states alien to
their authentic selves. Further, they behave differently when on stage. They adjust their
theatrical work in reaction to the varied states or styles of different audiences.
In much the same fashion, psychoanalysts occupy a distinct professional role and,
regardless of their particular doctrine or style of practice, modify their professional
behavior to comport with their patients unique styles. Not only psychoanalysts, but also
their patients play roles in a way that Butler (2005) called performative, affected by
what Burke (1966) called their terministic screens (p. 44). Exemplifying his concept,
and referring to dream interpretation, Burke described a man who
reports his dream to a Freudian analyst