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associations: “…the moment-to-moment variations in the sequence of elements in the stream of free associations… reflects the interplay of the forces in conflict” (Arlow 1979, p. 83). The patients’ unconscious fantasies at the roots of free associations (Arlow 1991, Papiasvili 1995) are themselves generated in association with developmental thoughts about their body at each libidinal phase - complicated by their experiences with others throughout childhood, adolescence, and later life (Blackman, 2010, chapter 10). For patients with a history of early trauma when (unconscious and/or conscious) symbolic functioning was not yet firmly established, or when traumatization later in life led to a regressive breakdown of the symbolic function, an impairment of symbolic functioning may lead to repetitive enactments of trauma and/or to somatizations. Depending on a variety of other available ego functions, e.g. reality testing, presence of judgment, motivation and impulse control in at least some areas of functioning, and enough object constancy necessary to establish a trusting viable working alliance, some analysts may begin treatment of such patients in the manner suggested by Jane Hall (1998): analytic psychotherapy, sitting up, once or twice a week, with the initial aim of addressing their chief complaints and exploring their dynamic underpinning. This approach affords the patient a gradual introduction to the free associative process. After a period of time, the analyst might ‘deepen the treatment’ (Hall, 1998) and suggest analysis proper if the patient is motivated and capable of integrating new material. Importantly, the quality of free associations in response to the analyst’s interventions can be used by the analyst as a guide in deciding when to recommend a more intensive analytic experience that includes more associations that generate more material for interpretations. During the dynamic-diagnostic assessment (Blackman, 2010), the presence of too much primary process (condensed, symbolic thought) in consciousness, at the expense of reality testing, logical thought, and communication (secondary process), may indicate a serious developmental deficit which requires either keeping away from or carefully calibrating any instruction of free association (Freud 1939, Hoch and Polatin, 1949, Kernberg 1975). Non- psychotic patients who are overwhelmed and preoccupied by fantasy often need a reality check/ “reconstruction upward” (Lowenstein, 1958; Kanzer, 1953) before delving into free associative processes. Either t oo little or too much of the primary process in consciousness may be indicative of an underlying psychotic process, in which case any encouragement of free associations may be counter-indicated (Freud 1938, Blum above). However, there are non-psychotic patients whose ‘ too little primary process’ may be indicative of an underlying moderate to severe character pathology who may benefit from various modifications of the use of free associations within a Transference Focused analytic Object Relations approach (Kernberg 1983, 2015 below). Alternatively, Relational approaches (below) offer ways for patients to experience a “warming” in the relationship with the therapist before their access to symbolic or condensed thoughts would be useful to them (Renik, 1999; Mitchell, 2001). Self psychology (below) and Intersubjective approaches with minimization of free association (Stolorow, 2013; Goldberg, 2001) have been known to work with patients with
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