Reading this book immersed me in a "dialectic" of very mixed feelings. This is a really important book, mandatory reading for psychoanalysts, psychoanalytic psychotherapists, and anyone interested in the current state of psychoanalysis. Seven of the 10 chapters are reprints of earlier papers by Hoffman, and there is an excellent introductory chapter that should be read with care. The meat of the book, in my opinion, is to be found in chapters 3, 7, and 8, titled, respectively, "The Intimate and Ironic Authority of the Psychoanalyst’s Presence," "Expressive Participation and Psychoanalytic Discipline," and "Dialectical Thinking and Therapeutic Action in the Psychoanalytic Process." The book tracks Hoffman’s intellectual development from the earlier to the later papers, except for chapter 2, "Death Anxiety and Adaptation to Mortality in Psychoanalytic Theory," which I first thought was rather irrelevant to the rest of the text but does set up a theme that resurfaces in the final chapters.

Hoffman’s book centers around the tension in the psychoanalyst or psychoanalytic psychotherapist (a distinction that he does not concern himself with) between the analyst’s theoretical position of how to establish the "frame" of the analytic process and conduct himself or herself by following such traditional shibboleths as the "rule of abstinence," etc., and the need to recognize that regardless of the attempt to stay firmly within the "rules," the analyst cannot avoid spontaneous self-expression and make choices that reveal the "truth" about his or her personality and value system. In this Hoffman is undoubtedly correct, but he continues,

Since business is not good for psychoanalysts these days, not many people will be exposed to this "dark malignant underside of the analytic frame" (p. 224). These comments represent the end point of what begins earlier in Hoffman’s intellectual development as what he calls a "limited constructivist view" (p. 165), based on the inevitability of the analyst’s influence on the patient’s material. The papers develop through what Hoffman calls a social-constructivist paradigm and ultimately arrive at a "dialectical-constructivist" view.

Hoffman says that the analyst’s theoretical preconceptions, personality, behavior, and interventions have an ongoing influence on the patient’s material, and often this influence is unformulated and unrecognized by the analyst, in what Hoffman calls a "partially blinding emotional entanglement" (p. xii). Hoffman considers the contemporary focus on this entanglement as part of the postmodern movement, and he extends Gill’s emphasis on transference (1) to an examination of the power of noninterpretive interactions, both analyzed and unanalyzed, and to the analyst as "a moral influence in relation to the patient’s specific choices" (p. xxi).

This major step away from the classical view of the analyst as essentially neutral and a reflector of the patient’s material back to the patient encourages a greater spontaneity and experimentation with interventions by the analyst, a deviation from customary ways of working, having "thrown away the book" (p. xxvii). Hoffman does not advocate the latter but tries to maintain a dialectic between "on the one hand, the core of analytic discipline, which entails the analyst’s consistent self-subordination in the interest of the patient’s long-term well-being, and, on the other hand, the analyst’s personal subjective participation…it is important that the analyst engage with the patient in a way that is sufficiently self-expressive and spontaneous so that a bond of mutual identification can develop between the participants" (p. xxvii).

Hoffman cleverly points out that "to follow whatever one decides is the patient’s lead, to choose to pick up on one or another of the patient’s more or less ambiguous communications, is also to lead the patient in a particular direction " (p. 72), with the result that "there is no objective interpretation and there is no affective attunement that is merely responsive to and reflective of what the patient brings to the situation" (p. 75). So much for classical psychoanalytic technique and for self psychology! Furthermore, "Whatever we can become aware of regarding the cultural, theoretical, and personal-countertransferential contexts of our actions, some things are always left in the dark" (p. 76).

The analyst’s influence especially matters to the patient because of what Hoffman calls "asymmetry," the unique importance of the analyst to the patient in a relationship that is automatically designed to give the healer a central position in the patient’s life. So, he says, suggestion and manipulation are unavoidable, at least at a level that the analyst is unaware of, and often in situations where choices are forced, because the patient puts the analyst on the spot. Hoffman gives several dramatic examples of this from his own clinical experience. In these situations, he says, "Ultimately, there is no escape from the responsibility that falls to the analyst to act with as much wisdom as possible, even while recognizing the action’s subjective foundation" (p. 90). He even argues that informal chatting with the patient can be an important experience for the patient "because it was spontaneous and informal and not explicitly analyzed. If you try to analyze everything, even all aspects of possible enactments, you are bound to suck the life out of the experience" (p. 91).

Hoffman is very aware of the dangers of his position, and he hopes that the analyst’s commitment to the long-range goals of the analytic process will allow a lot of leeway for interludes of spontaneous interaction of various kinds, but he recognizes that "there are many types of interaction that, even if transient, would destroy or throw serious doubt on the analyst’s credibility in working with a particular patient" (p. 191). Herein lies the difficulty of Hoffman’s position, because, as he admits, it is often extremely difficult to walk a line between spontaneous interaction that has a therapeutic effect and spontaneous interaction that can represent such an extreme narcissistic wounding to the patient that the patient leaves the treatment. Hoffman says, "It is commonplace to recognize the narcissistic, exhibitionistic, and exploitative potential of overtly self-revealing behavior" (p. 195). He lists a number of books (p. 194) that have advocated deviation from traditional psychoanalytic practice, and there is no doubt that such deviation is unavoidable. The problem is to keep it in line with the ultimate goal of what is in the best self-interest of the patient, rather than acting out of the analyst’s needs.

Hoffman’s depictions of some of his clinical experiences, such as with the patient Diane or the patient Ken, are provided, and an examination of these experiences reveals just how difficult it is to practice psychoanalysis in the style Hoffman advocates. The patient Diane makes a special request for an early morning appointment. She is a harassed medical student with a very busy schedule and is quite upset. Hoffman tells her he cannot arrange it. She comes in later in the day to her regular appointment, angrily demanding diazepam. Hoffman does not explain why he could not have simply started 45 minutes earlier than his ordinary schedule, something I have often had to do with preoedipally damaged patients, such as those with borderline disorder, who are upset and cannot be asked to wait without taking the risk of dangerous consequences. However, as so often happens in clinical vignettes, everything came out well in the end; the patient marries and lives happily ever after. Hoffman correctly admits, "In that split second, which is the moment of choice and of action, there is no way to know what is the ‘right thing’ to do" (p. 222).

Labeling himself a "constructivist analyst" (p. 255), Hoffman fills this collection of papers with a great deal of repetition and abstractions of a philosophical nature, even using the term "dialectic," which he recognizes has appeared in philosophy in a variety of ways (pp. 199–200). Hoffman’s "dialectic" is not at all similar, in my opinion, to Hegel’s "dialectic," but the shadows of Hegel and Heidegger fall on this book in a number of interesting ways. I doggedly went along, plowing through the abstractions and technical discussions that are replete with impressive evidence of Hoffman’s mastery of the psychoanalytic literature and produce the impression that here is a rather cold and abstract individual who is extremely intellectual, when I suddenly came on a footnote (p. 50) describing his unexpected coronary bypass surgery in 1997, followed later in the book by a comment from an 80-year-old patient that Hoffman was "warm and very human" (p. 260). The presence in this book of the shadow of being-toward-death that begins to show in chapter 2 (and is a major theme in the work of Heidegger) now made more sense. Elsewhere (2) I have discussed how this theme is central in all creative endeavors. Hoffman’s book by itself presents a kind of unformulated dialectic between his high-powered intellectualism and theoretical creativity on the one hand and his humaneness and sudden recognition of his own mortality on the other.

The best protection we have from letting our theoretical conceptions give us rationalizations for the exploitation and use of our patients as selfobjects comes from remembering that, as Cooper (3) wrote, "Although there may be wide disagreement as to what to say to patients, we may enjoy considerable agreement regarding what not to say…what makes psychoanalytic dialogue so unique is less the things that analysts say than the fact that even the most interactive of interpersonal psychoanalysts do not say many things that one would say in ordinary conversation" (p. 39). Readers of Hoffman’s book, especially students and beginning psychoanalytic psychotherapists, should keep Cooper’s admonition in mind.