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Qualities of Engagement and the Analyst's Theory
Judith Guss Teicholz, Ed.D
Supervising Analyst and on the Faculty at the Massachusetts Institute for Psychoanalysis, Westford, MA.
The analyst's loyalty to a single paradigm is sometimes challenged by certain recent developments in psychoanalytic theory-making. Among these are (1) a trend toward metatheory, in which theories are formulated at levels of abstraction that can encompass concepts and technical recommendations from multiple theories; (2) expanded opportunities for influence among authors from diverse theoretical orientations; and (3) an emphasis on qualities of engagement between patient and analyst, which highlight the analyst's unique subjectivity and self-expression. For instance, the analyst's authenticity, spontaneity, creativity, playfulness, humor, and empathy (used as a guide to action) can lead to more affective and improvisational interactions between patient and analyst and to a theory's seeming to play a lesser role.
Using clinical fragments and an extended vignette, this paper explores some of the ways that these intersecting theoretical developments can affect the treatment, the patient, and the analyst's ways of thinking about her work.
Increasingly, certain qualities of engagement are seen as integral to an analyst's approach to the clinical situation. Those that have been recommended, across several analytic paradigms, include empathy Kohut, 1959, 1982, 1984), authenticity (Mitchell, 1993, 1997), spontaneity (Hoffman, 1998), creativity (Kindler, 2003). Playfulness (Winnicott, 1971), and humor (Lachmann, 2000). But, to the extent that we recognize mutual influence in the analytic relationship, we have to acknowledge that the quality of engagement is not the creation of the analyst alone, but is the coconstruction of patient and analyst. In fact the intersubjective nature of the analytic encounter suggests that the successful analyst will remain open to the unexpected, including unexpected challenges to her usual ways of thinking and working. This paper explores recent changes in analytic theorizing, believe to have been impelled, to some degree, by mutual influences among authors. Using clinical vignettes, the paper explores the ways such changes might affect both how we theorize and conduct our work.
Each of our analytic theories tells one part of the story of being human. But every part is connected to all the others, and each story is meaningful in its own way.
Theories and Metatheories
I have proposed elsewhere (Teicholz, 1999) that many aspects of Kohut's most revolutionary ideas have been quietly absorbed into mainstream theory while others have formed the basis for a second revolution, leading indirectly to a cluster of postmodern theories that include Hoffman's (1996) constructivism, Mitchell's (1998, 1999). Here I suggest that the revolution now takes the form of an expansion of theories, so that each one increasingly includes important elements of many others.
I think that at this moment in history the analytic community has reached consensual recognition of the affective, the relational, and the procedural in cure. But even as this new consensus is integrated into our various analytic paradigms, additional sources of disagreement have emerged. For instance, now that we recognize the importance of relationship in the analytic endeavor, we find ourselves arguing about what kinds of relationships – or what qualities of engagement – are essential to psychic growth.
The contenders include such personal and relational qualities as empathy, authenticity, spontaneity, playfulness, creativity, and humor. At first glance it seems that there should be no argument at all, because any person and any relationship could surely benefit from all these qualities. But some theories put forth just one of these qualities; and, even if we could agree on what is best, it turns out that the quality of engagement is never the unilateral product of a single mind, but, rather, the joint creation of patient and analyst. I am sure you have worked with patients in whose presence you have become unusually empathic, while with others you could get nothing right. Similarly, our playfulness, spontaneity, and humor are affected by those we are with. I am always curious about why these qualities, in me, are enhanced or diminished with certain patients: the answers invariably include information from both patient and analyst.
These sometimes mysterious experiences of influence often involve repetitions. But we can also create something new in the analytic dyad – indeed, we must if psychic growth is to occur. Applying findings from infant observation studies to the search for curative factors beyond interpretation and insight, Stern and his Boston Process of Change Study Group (Stern et al., 1998) suggest the importance of "now moments" between patient and analyst. They focus on the analyst's contribution to the something new in these moments.
And yet we know that the "something new", like the quality of engagement, comes not from the analyst alone but through a reconfiguration of what is brought to the encounter by each party that results in a third realm of meaning and experience (Ogden, 1994; Benjamin, 2004). I am suggesting that in this new third realm, the analyst's theory, as much as any other element of her psyche, is likely to be transformed. Thus, the same theory not only looks different as it is practiced from one analyst to the next, but also even looks different as the same analyst practices it from patient to patient.
Meanwhile, the mutual exchange among authors from different theoretical viewpoints may be on the way to creating in the analytic community a new realm of theory, in which important elements from each theory are brought into some new kind of relationship with each other. The result of this process need not to be a lawless eclecticism, but possibly an organic system that brings together and makes sense of what have hitherto been put forth as competing viewpoints.
Many of our different theories already latently include the viewpoints of other paradigms (Teicholz, 2001): what is in the foreground of one theory may be in the background of another, and vice versa. It is in this context, of expansion and increasing influence among theories, that the discussion concerning the relative merits of different qualities of engagement is taking place.
Over the past two decades there has been another trend, one toward what I would call metatheory: the emergence of viewpoints abstract enough to encompass important tenets and clinical recommendations from multiple theories. One example of what may qualify as metatheory can be found in the work of Slavin and Kriegman (1992), who have looked at the psyche through the lens of evolutionary biology and adaptation. Stolorow and his colleagues (Stolorow, Brandchaft, and Atwood, 1987; Stolorow and Atwood, 1992; Orance & Stolorow, 1998) have bradened our sense of clinical possibilities through the introduction of their Intersubjective Systems Theory.
They suggested that a recognition of the intersubjective nature of all relationship – intersubjective in the sense of ongoing mutual influence – leaves the door open for the analytic dyad to forge a necessarily spontaneous therapeutic process that emerges from the interaction between two unique subjectivities. Among the constants in this otherwise uncharted exchange is that the analyst is committed to "empathic inquiry" and recognizes that the analytic relationship may at times serve various selfobject functions for the patient. The ideas of Stolorow and his colleagues are furthered by Lachmann and Beebe's (1996a) project of bringing together infant observation research with experience doing adult analytic work. Lachmann and Beebe see the analytic dyad as a dynamic system, but still assert the curative power of cycles of disruption and repair (Kohut, 1984) in which the analyst's empathy is essential. But they also highlight "heightened affective moments" (Lachmann and Beebe, 1996a), which are likely to involve both mutual empathy and spontaneous engagement.
Multiple perspectives inhabit Lichtenbert's (1989) Self and Motivational Systems theory as well, which brings together under on conceptual umbrella five motivational clusters. Each of the five motivations, by itself, has historically been proposed as the primary motivation in one or another major theory. The motivations include the need for regulation of physiological requirements; the need for attachment/affiliation; the need for exploration and self-assertion; the need for sensual/sexual experience; and the need for antagonism-withdrawal. Lichtenberg (2004. personal communication) sees each of the motivations as an essential aspect of self-experience that must be met with resonance in the relationships of childhood or psychoanalysis. He furthers the integrative project by positing communication as the overarching concept in psychoanalysis and inquiry as the method of communication. Lichtenberg's concept of communication is closely akin to the relational concept of dialogue.
Over a 20-year period the integrative project has also been exemplified in the work of Bacal (1985, 1998; Bacal and Herzog, 2003) and his concepts of "optimal responsiveness" and "specificity". Specificity theory says that what is curative is necessarily specific to the unique dyad and cannot be prescribed. For Bacal (1985, 1998), what constitutes optimal responsiveness or selfobject experience for a given patient can be ascertained only from that patient's unique experience and changing self-states. Thus, Bacal has been an early and sustained voice in favor of expanding the field of analytic interactions. Meanwhile, both Ringstrom (2001) and Kindler (2003) argue for the power of improvisation, in which, I suggest, creative engagement between patient and analyst necessarily transform the analyst's theoretical starting point.
Beyond this expansiveness in theory-making itself, the value of the analyst's openness to multiple theoretical perspectives has been explored by Altman (1995), Altman and Davies (2003), Hirsch (2003), Richards (2003), and Smith (2003), among others. Altogether, I think that the proliferation of metatheory, along with the trend toward mutual influence among theories, has the effect of loosening the hold that any single theory has over a given analyst's ways of thinking and working. This trend is amplified by the emphasis on the analyst's qualities of engagement – such as creativity, spontaneity, authenticity, playfulness, empathy, and so forth – any of which is more likely to draw on the analyst's unique subjectivity than to fit into the more general but potentially rigidifying tendencies of most theories.
Historic and Contemporary
Of course our theories have historically differed along multiple dimensions, many of which still have a bearing on the central questions of our day. In fact, without awareness of these wider controversies, I think our current debate can seem shallow and lacking in the rich complexities of our shared history.
One way that our theories have always differed concerns the psychic contents considered most important in development or cure: Freud's drives, conflict, and defense against instinct; Klein's aggression-infused internal objects and projection/introjection processes; the interpersonal patterns of Sullivanian theory; Kohut's self-in-its-selfobject-milieu; organizations of experience in the Intersubjective Systems theory of Stolorow et al. (1987); and "recognition of mind" in the intersubjectivity theories of Stern (1985), Ogden (1992a, b), and Benjamin (1988, 1990) (see also Teicholz, 2001, for different meanings of the term intersubjectivity in contemporary psychoanalysis).
So, even if we all suddenly agreed on qualities of engagement, we might still disagree about the relative importance of these different content areas of psychic experience.
Historically, different analytic activities are recommended in each of the major paradigms. Interpretation is near the top of the list in most theories-although perhaps less so in the relational and constructivist paradigms. But Kohut (1984) identified two stages of empathy, an understanding phase and an explaining or interpretive phase: he saw them as operating sometimes simultaneously, at other times sequentially. He also urged the analyst to monitor her countertransference as a way to track down unintended influence on the patient and to acknowledge her own contribution to Inevitable ruptures in the analytic relationship.
Traditionally, genetic reconstruction and clarification were understood to lay the groundwork for interpretation. Other analytic activities pertained to protection of the frame, or limit-setting. More recently, relational (Mitchell, 1997) and interpersonal (Ehrenberg, 1992) authors have brought to the fore such activities as confrontation, the giving of interpersonal feedback, and the analyst's self-disclosure or countertransference revelation-all believed to foster psychic growth. Contemporary analysts also propose that enactment is ubiquitous (Jacobs, 1991; Renik, 1998) and that its shared exploration can yield significant therapeutic gain. Others, offering still more ways to think about what goes on between patient and analyst, suggest that negotiation (Slavin and Kriegman, 1992; Pizer, 1998; Russell, 1998), improvisation (Ringstrom, 2001; Kindler, 2003), or the creation of narrative (Spence, 1982) might be central to cure. Most of these activities do unquestionably go on in every analysis, either continuously or occasionally, regardless of the individual analyst's favored theory.
There is also debate about which modes of relating are most instrumental to cure. When I speak of modes of relating, I am referring to how two individuals perceive, experience, or use one anther. We can say that Freudian theory features object-object relating, because the patient is the object of the analyst's observation while the analyst becomes the object of the patient's libidinal and aggressive impulses or fantasies. Kohut (1971) introduced the concept of self object relating, a mode of relationship characterized more by the psychic or developmental function it serves than by its role as the target of impulses. Selfobject relating involves the analyst's processing or regulation of affective experience, which is then unconsciously used by the patient for such functions as self-soothing (omnipotent merger), self-affirmation (mirroring), a sense of likeness and belonging (twinship), or the development of ideals (Kohut, 1984).
More recently, Stem (1985), Ogden (1986, 1992a, b), and Benjamin (1988) have drawn our attention to still another mode of relating-what they refer to as subject-subject or intersubjective relating, by which they mean that each member of the dyad recognizes both herself and the other as separate centers of experience and initiative. But when Kohut (1984) wrote that the ultimate goal of psychoanalysis is to open up mutual pathways of empathy between patient and analyst, he was envisioning what Stern, Ogden, and Benjamin now call intersubjective or subject-subject relating.
Kohut's (1971, 1977, 1984) selfobject relating also resonates with Winnicott's (1951) transitional experience, the two having in common an ambiguity in the developing person concerning the origins of certain psychic experience and functions. In the view of both Kohut and Winnicott, there is a normal stage of development in which the question, "Is this yours or is it mine?" must not be asked as it pertains to the origins of certain experience (Teicholz, 1998, 1999,2000,2001, 2002). For both authors) the unasked question becomes a wellspring of creativity in adulthood. But if the question is asked at the wrong time, the pathway to creativity-transitional space, if you will-is closed down.
Meanwhile the transitional and selfobject concepts have led to new controversy, concerning whether a given theory posits two persons or just one in the analytic relationship. But there is no disagreement about the actual number of minds or bodies in the consulting room. There is only a question of whether different theorists acknowledge a normative quality of experience in which the source of certain aspects of psychic functioning is temporarily not recognized as being located in an outside other. The one-person theory, then, is only an aspect of experience in the minds of some patients and children. But Kohut insisted that the empathic parent or analyst must transiently join the child or the patient in this point of view (Teicholz, 1999).
In fact, I suggest that in a mature or healthy adult, these various modes of relating move between foreground and background of human experience (see Stolorow et al., 1987) and that the analyst uses her empathy to track ongoing shifts in the dominant mode of relating in the patient, while tracking other aspects of the patient's affective experience as well. Closely associated with these different modes of relating are processes of identification and differentiation. Thus, another way to categorize relationships is on the basis of their fostering either differentiation or identificatory processes in the two parties. In early life, both differentiation and identification processes contribute to development or contribute to the accrual of psychic structure (Freud, 1923;
Ferenzci, 1933; Kohut, 1971; Mahler, Pine, and Bergman, 1975; Loewald, 1979). But some analytic theories tend to favor interactions that foster experience more at one of these poles than at the other. For instance, self psychology, whose emphasis is on omnipotent merger fantasy (Kohut, 1984), mirroring (Kohut, 1971, 1977, 1984), twinship (Kohut, 1984), and idealization (Kohut, 1971, 1977,1984), tends to allow both patient and analyst ample experiences of resonance, sameness, sharing, belonging, or mutual idealization, all these seemingly more closely related to identification processes than to differentiation.
By contrast, interpersonal and relational theories tend more toward expression of the analyst's differentiated subjectivity, fostering experiences of separation, individuation, and a sense of one's own uniqueness. But identificatory and differentiating experiences contribute jointly to a robust sense of self that includes feelings of belonging and similarity to others, as well as feelings of being unique among individuals. Clearly both kinds of experience are needed in every development and in every psychoanalysis (Teicholz, 1995, 1996, 1998, 1999, 2000, 2001, 2002).
Other ways to view relationships have included Mahler et AI. 's (1975) concept of object constancy, as well as Klein's (1935) concept of a move from the paranoid-schizoid to the depressive position: both these achievements resonate, conceptually, with Kohut's (1971) establishment of self, as well as with Freud's (1917) resolution of the oedipal crisis. All these developmental achievements, across several theories, are understood to entail a cohesive sense of self as the center of experience and initiative and capable of relating to "whole objects" who art.: similarly recognized as the center of their own experience and initiative. This happens to be the definition of intersubjective relatedness in the writings of both Stern (1985) and Ogden (1992a, b) and is also subscribed to by Benjamin (1988).
Each of these multiple concepts represents a valid way of characterizing some aspect of individual development or the analytic relationship. The myriad elements of these multiple theories interpenetrate in human experience and psychic growth. I propose that each of the modes of relationship I have mentioned-after its initial establishment in early development-continues to operate into maturity by moving in and out of ascendancy in individual experience and functioning. The question, then, is not which of these are most important in any universal sense, but only which has salience for this individual in this dyad at this moment.
I think that our awareness of these many areas of controversy can add depth and complexity to our more recent debate concerning qualities of engagement, which in any analytic encounter will necessarily intersect with shifting content areas, numerous types of interaction, and changing modes of relationship.
MUTUAL EMPATHY, INFLUENCE, AND
THE ANALYST'S THEORY
Any joint endeavor between patient and analyst-if it is to be therapeutically successful-will involve an implicit striving toward mutual empathy, regardless of what other qualities of engagement are called forth. The collaboration required for the coconstruction of meaning-or required to create a personal narrative- that can make sense of and diminish the patient's suffering-probably involves some degree of empathy on the part of each participant, however latent and unspoken. I would even say that confrontations and interpersonal feedback, when they are therapeutic, probably emerge from empathy as well, even though unarticulated, certainly, when empathy is absent, collaboration comes to a halt. In fact, one way of defining impasse is to say that mutual empathy and recognition have broken down (Levenkron, accepted; Teicholz, accepted).
Rather than seeing our different theories, then, as irreconcilable accountings of what goes on in development or analysis, we could see them as helping us to tune in to phenomena in different realms of experience and at different levels of abstraction. If we could agree that most of the concepts and clinical recommendations throughout analytic history have had some validity or clinical relevance, then we might feel freer to select from a wider range of analytic approaches with every patient.
But even if we try to hold fast to a single theory, what the individual analyst can offer and what the patient can make use of, at a given moment, are likely to be influenced by many factors. These might include the ongoing fluctuations in. level of organization and psychic functioning that occur in both patient and analyst; the unique details of the patient's and the analyst's life histories; the salient themes and unresolved issues in the lives of both patient and analyst, especially those related to trauma; the history of the analytic relationship itself; the degree of compatibility between patient and analyst in world-view and linguistic style; and how much safety and holding the patient needs-and experiences-in this analytic relationship. Because patients and analysts differ so richly in all these variables-and because over the course of successful treatments analysts may change in what they can offer and patients will certainly change in what they can make use of-it makes sense that multiple modes of relating and qualities of engagement, as well as communications involving varied psychic content, will be needed from patient to patient, as well as across time with the same patient. (See the work of Bacal [1985, 1:9980; Bacal and Herzog, 2003]. Although using their own terminology, they have made similar points.)
Although every dyad is unique, and what happens in one treatment may not be applicable to others, I nevertheless offer some clinical material. I ask that you read it in the spirit of my comments thus far, in which I have emphasized the cross-fertilization among theories that enables us to understand a patient, an analyst, and their interaction in a number of ways.
VIGNETTE # 1, LISETTA[
My first vignette is gratefully borrowed from the work of Annette Faust, M.D., a gifted candidate the Massachusetts Institute for Psychoanalysis.
The patient, Lisetta, was a recent college graduate, bright and talented, but more than a little lost. At the start of her psychotherapy, her life was in chaos, her affect dysphoric. In a session 18 months into her treatment, she had just been speaking about how she did not like the man she was dating and how he was not treating her well. She went on to muse about what kind of birth control she would use on their upcoming weekend trip together. The analyst, Dr. Furst, interrupted her, saying, "What's this? You're saying you don't like him, he's not treating you well, but you're wondering what kind of birth control?" The patient had a history of destructive relationships with men and during the earlier months of her treatment had repeatedly put herself at risk with strangers. As a child she had felt that her parents were lost in their own worlds, clueless about her problems. And when as a teenager she tried to tell them that she had been molested by an older cousin, they denied her experience and never mentioned it -gain.
The analyst thought of her interruption of the patient and her question, "What's this?" as a confrontation, which no doubt it was. But I also saw the interaction as an expression of profound empathy. Not to have interrupted the patient at that point would have been abandonment, I think, as well as a repetition of the parents' tendency to be lost in their own worlds. As I saw it, the analyst's spontaneous interruption of her patient and the question, "What's this?" carried a much needed series of messages to the patient that were not spelled out, but that we might articulate something like this: "I am your analyst and I'm not lost in my own world. I'm listening to you and I won't sit by quietly when I feel you're putting yourself at risk." The analyst also conveyed the message "I've noticed that you don't always pay attention to important things that you feel, so that you sometimes take actions that go against your own feelings.
Maybe we can work here on getting your actions and feelings more in sync." I felt that the analyst's interruption and question may have succinctly encoded all these messages perhaps imparted to Lisetta at a procedural level of learning in addition to the content of the communication. After that session Lisetta went ahead with her intended weekend trip but did not start a sexual relationship with the man who was not treating her well. She soon broke off relations with him entirely. The next man she went out with treated her much better, and she began to take care of herself in general. Shortly after this session, Lisetta began as well to explore alternatives to the dead, end job she had been in for over a year.
Of course, this session did not occur in a relational vacuum. Before this "now moment", analyst and patient had been steadily generating trust and constructing mutual understanding for many months. In particular the analyst had been a patient, profound, and responsive listener, who had consistently been helping Lisetta make multiple links between her early and current experience, including the transference. At times the analyst had also functioned as kind of an analytic "coach" to Lisetta (Tolpin, 2003), helping her to make important decisions in her life, large and small, on the basis of a shared and evolving understanding of the patient's experience. I believe that it was only because of a prolonged period of these earlier empathic and interpretive interactions that the more confrontational interaction, uncharacteristic as it was, had the power to set in motion several positive moves in the patient's life (Teicholz, accepted).
Additionally, the .question of how to categorize clinical events remains open. We might see Lisetta's analyst as a gifted interpersonalist, whose confrontation led immediately to" significant changes in the patient's extra-transference relationships and work-life. But we might also see the work as self psychological," the analyst being exquisitely attuned and affirming unspoken aspects of the patient's experience. The attunement was to Lisetta's underlying feelings of neglect and abandonment, which were then countered by the analyst's attention and gentle confrontation. The confrontation itself might have felt to Lisetta like a heroic rescue from her usual self-destructive behavior - perhaps solidifying a transient but much-needed idealization at this phase of her treatment. I am deliberately highlighting the ambiguity in our characterization of analytic; interventions here. And I believe that this ambiguity extends to qualities of engagement, as well. Here is another vignette.
VIGNETTE #2, SONYA
Sonya is a 35-year~old chemist directing a large laboratory in the private sector. She is also an accomplished musician. Brilliant and charming, she entertains me and lectures me about art, theater, music, and philosophy, rather than discussing her life problems. We have come to understand this behavior as being somehow related to her having been the "parentified child" of an abusive alcoholic mother and a loving but mostly absent father. Her parents have just come through a vicious divorce, both of them leaning heavily on Sonya as their Rock of Gibraltar and confidante. More recently, her father, aged 68, has remarried someone exactly Sonya's age who is expecting his baby.
Sonya suffers from chronic nightmares and disturbed sleep. Several of her dreams are recurring. In one, she is wandering alone and bereft through a bombed out city (this was long before 9/11); in another she is crying about a rag, doll abandoned upside down in an overflowing garbage pail; and in another, she is trying to save an injured bird. Although Sonya has had other kinds of dreams as well, we have understood these primarily as self state dreams, each seeming to capture some essence of her ongoing childhood experience.
Two years into her analysis, Sonya is speaking of her mother's plans to move from Los Angeles to Boston to be closer to Sonya, her only daughter. Her mother is 60 years old, still young and active. But this is also the mother who was physically abusive and emotionally assaultive and whose younger brother-Sonya's uncle-molested Sonya from the time she was 8 until just after her 14th birthday. During these repeated episodes of sexual abuse, Sonya suffered out of body experiences: she watched everything her uncle did to her from a place high on the ceiling of her bedroom where the abuse took place. Even as a small child, Sonya realized that her uncle's behavior was "bad." But she totally disavowed that these experiences had in any way harmed her. As an adult, Sonya is relentlessly ambitious, perfectionistic, and hard driving; she demands the same of her employees and intimates.
Sonya's beloved father was a performing artist, often away for months at a time. In his absence, it was Sonya's molesting uncle who encouraged her musical talents and scientific curiosity. When the 12, year old Sonya finally screwed up her courage and tried to get her mother's help to stop the uncle's abuse, her mother defended him and turned against Sonya in a rage. Quite often during Sonya's childhood, when she had been alone for hours, playing with her dollhouse or coloring, her drunken mother would enter her room and kick over the dollhouse or small desk, sending the miniature furnishings or coloring book and crayons flying.
In spite of this painful history with her mother, Sonya speaks only in glowing terms of her mother's beauty, accomplishments, and charms. In the session I am about to describe, Sonya is newly married and has just announced her plan to take a day off from her high, pressured job to look at real estate with her mother, who plans to buy ;1 hl)use ne;1r the newlyweds' apartment. As Sonya's analyst, I say, "How do you think you'll feel, having your mother live so close to you!" At first Sonya waxes rhapsodic about what fun it's going to be, having her mother around, the two of them going all the time to art exhibits and concerts. I say, "How sad that these hopes of your mother so often get dashed by her drunken abusiveness." Sonya persists in her positive spin for a few more minutes, almost as if I had never spoken. Then all of a sudden she interrupts herself and says, "If my mother moves to within a 100 mile radius of Richard and me, my life as I know it will come to an end." And I respond, "If you feel your life will end, shouldn't we ask why you're taking a day off from your job to help her move closer to you!"
In our next meeting, Sonya reports that she went home after our last session and called her mother to discourage the move to Boston. Together they came up with two or three alternative moves that her mother could make, to communities where ~he already had friends, colleagues, and job possibilities. In Boston, her mother had no job prospects and would have known no one except for her overextended daughter, Sonya, in a painfully fraught relationship.
From my vantage point, Sonya often set off, full speed ahead, into endeavors diametrically opposed to her own feelings and apparent best interests. At these times, I asked such questions as, "What do we know about you that you might want to consider right now!" I wanted to help her pull together the disavowed parts of her self that otherwise were left out of her decisions and to counter her daunting dissociative tendencies, honed to perfection during the long years of her uncle's molestations.
DISCUSSION OF VIGNETTES 1 AND 2, LISETTA AND SONYA
In both vignettes, the analysts' actions can be seen to fit the clinical approaches of several analytic theories. In each interaction, the analyst's interruption or questioning of her patient seemed spontaneous and authentic. In each case the analyst made note of repetitive relational patterns and approached the patient as an outside other (Benjamin, 1988, 1990). Each analyst confronted her patient with a question about an extratransference behavior that the patient had been discussing in her session.
All these qualities of engagement and modes of interaction seem to place the treatments squarely in the relational or interpersonal schools of analysis. But I also think that both analysts spoke out of a profound, nuanced, and complex understanding of their patients' multiple and contradictory needs and I feelings of the moment and, therefore, on the basis of an empathic connection with them. Both analysts kept in mind their patients' needs for a cohesive, continuous, and esteemed sense of self, as well as their needs for attachment and affiliation. Additionally, Lisetta's analyst felt that, by her patient's compulsive sexual behavior, she may have been seeking a sense of vitality, something lost to her in the milieu of her parents' inattentiveness and neglect.
And Sonya's analyst understood that her patient's supercompetency, workaholism, and perfectionism-though alienating husband and colleagues nevertheless helped her ward off what would otherwise have been unbearable feelings of helplessness. These ways of understanding placed the patients' behaviors in- an adaptive light, affirming the "leading edge" of their functioning (Tolpin, 2003). Most of these ways of thinking and working would fit a self-psychological model.
In each case also, the analyst can be seen as addressing splits in the patient's psyche, such as drawing attention to a contradiction between what the patient is feeling, on one hand, and what she is planning to do, on the other. The interpersonalists such as Bromberg (1998), as well as self psychologists following Kohut (Kohut and Seitz, 1963), are alert to signs of dissociation-to signs of the splitting and walling-off of certain aspects of experience. And, although interpersonalists are more likely to confront, whereas self psychologists are more likely to try to create a safe milieu in which the shoring-up and bringing together of disparate aspects of self experience can go forward, theorists from both schools are interested in the healing of psychic splits and are willing to engage with patients in a variety of ways to move the patients toward integration.
Still another way to think of these sequences is in terms of (American) object relations theory (Kernberg, 1988) in which both patients can be understood to have internalized painful aspects of their early relationships, now being repeated in their adult lives. For instance, in her plans to have sexual relations with a man she does not like and who does not treat her well, Lisetta was reenacting the ongoing experience of her childhood, in which she felt that her feelings were not important to significant others. I think that both Lisetta and Sonya adapted to this quality of their early relationships by making light of their own feelings and tending to go along with whatever others wanted of them. Both these young woman, as children, believed that this was the only way that they could preserve their much-needed, but not very reliable, object and selfobject ties (Kohut, 1977, 1984).
From the viewpoint of contemporary infant researchers meanwhile, we might also say that these beliefs came about as the result of earlier "procedural learning" (Stern et al., 1998), learning that nevertheless was able to be challenged and changed during their analyses-both through implicit or procedural and through explicit or verbally expressed aspects of the therapeutic relationship.
I also think that the successful interactions between patient and analyst in both vignettes emanated from the analysts' naturally empathic immersion in their patients' experience. Granted, neither analyst responded to her patient with a conventional expression of empathy, nor even with an explicit claim to understanding. But through their respective confrontations, both analysts demonstrated a complex and layered understanding of, and empathic resonance with, important aspects of their patients' conscious and unconscious experience. And both used their empathy as a silent and often unconscious guide to the spontaneous actions that they did take. it is even possible that a seasoned analyst, whether interpersonalist or self psychologist, might have worked in ways similar to either of these two analysts, perhaps each telling herself a different story about what was going on.
A BRIEF COMPARISON
Interpersonal theory places its primary emphasis on the here and now, with a focus on the patient's relational patterns as they are expressed in the transference, and by giving feedback on how they are affecting the analyst.
Self psychologists also work in the here-and-now, but with exploration of the analyst's contribution to the patient's experience more than the patient's effect on the analyst (Teicholz, 2002). For instance, given a patient's negative reaction to what the analyst thought was a minor schedule change, an interpersonal analyst might say: "When you complain about such minor changes in our schedule, I start to feel constrained." The analyst might add a comment connecting his own countertransference to feelings that others in the patient's life might experience in interaction with the patient. By giving feedback to the patient about certain aspects of the transference-countertransference experience, the interpersonal analyst hopes to help the patient become more aware of, and perhaps achieve some mastery over, the kinds of interactions that may be factors in the failure of the patient's extratransference relationships.
While self psychologists have a similar interest in helping the patient attain more sustaining relationships in the extratransference world, they aim first to change the patient's self-state or regulation of affect; they believe that this change will, in turn, lead to change in the interpersonal realm. The focus is on the patient's feelings more than on behavior, and on what the analyst has done – or is still doing – to evoke an upsurge in the patient's anxious demands (Teicholz, accepted).
By acknowledging our own contributions to our patients' difficulties in the nalytic relationship, we help them make sense of their current feelings and help them gain access to earlier versions of similar affective experience (Kohut, 1984). Before our patients can take responsibility for their own feelings in relation to us, we must take responsibility for our real contributions to those feelings (Loewald, 1979). Clinically, expanding on Renik's (1998) suggestion that we "get real", I would place the "realness" of the analyst's effect on the patient on a par with the patient's effect on the analyst. In Renik's case vignettes he provides material illustrating primarily how the analyst conveys the patient's effect on the analyst.
In a recent paper that place the analyst's "moral responsibility" at the center of the analytic relationship, Benjamin (2004) refers to the analyst's struggle actually to feel her own contribution to a pateint's suffering – however unwittingly that contribution has been made – and to convey this ownership to the patient. Benjamin provides rich clinical material and, with depth and complexity, elaborates the analyst's subjectivity in these struggles. But with regard to the analyst's actions, she seems to echo Kohut's (1959, 1971, 977, 1982, 1984) earlier clinical recommendations that the analyst acknowledge his contribution to the patient's experience, especially when things have gone awry. Such sequences constitute the cycle of disruption and repair so central to self-psychological cure. Lichtenberg, Lachmann, and Fosshage (1996) also tell us that the analyst should try on, and wear, the patient's attributes, no matter how alien they at first may seem.
Clinical Vignette #3, Derek
In this vignette, I suggest how multifaceted are the aspects of self that a given patient can evoke in an analyst; how varied are the qualities of engagement that can emerge over the course of a single treatment; and how many are the viewpoints from which we may try to make sense of the same analytic material. This is a piece of work from early in my career with Derek, a man who had attained both an M.B.A. and a Law degree and was a young executive with a large, multinational corporation. His treatment lasted only three years, until a promotion required that he move to Europe. He has sent me a note at Christmas from time to time since terminating, and from these I learn that a year after moving to Europe he married and began a family. He reports that he has continued to thrive in both his personal and his professional life.
From the start of therapy, Derek was bright and likable but concrete in his mental functioning. In the moment I am describing, we are two years into his twice-a-week treatment. He is 32, single, and has just invited me to come for a day-trip on his sailboat. At the time, I am his 44-year-oId therapist - the age difference I interpret to have significance for him later in the treatment.
In his first session, Derek had announced that he knew all about transference and thought it only fair to warn me that there would be none of it in his treatment. He also said that he really could not tell me why he was seeking help, nor say anything about his childhood - I responded that if by "no transference" he meant at he had made a decision not to have any feeling toward me, then I could only imagine that he must have had a pretty bad time of it the last time he had felt something for somebody. He said, "Probably," but continued to be mum about his life, past and present.
In his second session, he requested a time change from the weekday afternoon appointments we had agreed on in our previous meeting. He asked if I had any late evening or weekend hours. The reason he wanted the change, he said, was that he felt fine on weekday afternoons-it was in the evenings and on weekends that he felt low. He also complained about feeling cooped up in my office and asked if we could meet outside-perhaps go for walks in the Common. I said that as much as I would like to meet at his preferred times and places, I did not have late evening or weekend hours. I told him that I also needed to make sure that we met at a time and place without too many outside distractions, where I could at least try to concentrate on our shared task. He did not answer, so I asked if he felt bad that our arrangements were more in accordance with my needs than with his. He said this was so, but offered nothing further.
For most of the first year of treatment, Derek arrived 10 minutes late for every appointment. And as he was leaving each session he mumbled something about not being sure if he would be back for the next meeting. Eventually I asked if our meetings were uncomfortable for him, and he said they were not. Later I asked whether his lateness and his doubts about continuing-might reflect an understandable an understandable wish on his part to have our meetings a little bit more on his terms. He smiled and said nothing.
Derek and I soon struck up a reserved but playful tone in our interactions. He still said very little about himself, but I felt he was testing my trustworthiness. After three months he finally spoke of his childhood, and of the problems for which he was seeking help. These included chronic depression, suicidal ideation, insomnia, excessive alcohol and marijuana use in his own estimation, sexual impotence, and a self-despised ritual that involved finding women who were willing to be tied up and spanked before engaging in sexual intercourse with him-the only way he could achieve potency in the presence of a woman.
Although he was a tall, nice-looking man, Derek said he had been a late bloomer, small for his age until his senior year of high school. He had been athletic but too small to get on teams, and he had been bullied by the other children. Ignoring Derek's entreaties to go with him, his father left the family when he was 5. So Derek was left with his mother, who beat him regularly for minor infractions, sometimes for literally having a hair out of place, or for walking on the newly washed kitchen floor before it had dried. He had one older sister, who tattled on him all the time and then watched as Derek's mother struck his bare buttocks repeatedly with a belt. Derek survived the pain and humiliation of these episodes through a fierce determination to show no feeling.
Regarding his sexual rituals, Derek said that not only did he despise his willing accomplices, but afterward he was infused with such shame and self-loathing that he felt suicidal, usually drinking and smoking himself into oblivion. Meanwhile he avoided any woman he actually liked and admired because he knew he would be sexually impotent without the tying-up and spanking rituals.
In spite of the intensity of his self-loathing, Derek seemed often to have a sly smile on his face when he was describing his tying-up and spanking episodes. I once asked-with what I hoped was a distinct lightness of tone-if by his descriptions. Derek always burst out laughing at such questions. I said that probably anyone who had grown up with his mother and sister might get satisfaction from making other people uncomfortable now and then.
During his second year of treatment, Derek, on his own initiative, struggled to give up the spanking rituals and for .the first time he began dating a woman he liked and admired. But the new relationship went up in smoke after the third date because he found himself feeling overwhelmingly critical of his new girlfriend. He recalled that, when he was in high school, his mother had been brutally negative about the first few girlfriends he had made the mistake of bringing home. Now, tuning in to the tiniest flaws of face and body, he himself became intensely critical of the women he went out with.
Notwithstanding this bleak picture, Derek had many means of distracting himself. Among these was his love of sailing. He bought a new sailboat and soon announced he would take the summer off to sail. He added, with the familiar smile, that he was sure his trip would be therapeutic. At my suggestion, we negotiated a shorter break for him: six weeks of treatment-free sailing, instead of the 12 he had proposed.
But right after this vacation, Derek stopped paying my bills. He said he could not pay because he had bought too much high-tech equipment for his boat – again the sly smile. I smiled too but wondered (aloud) if his not having the money to pay me might also fit with his wish to get even with me for having cut short his intended three-month hiatus. As always, Derek laughed when I spoke of his apparently aggressive motivations in our relationship. I thought that the joke in this case might have gone something like this, although neither of us said it: "You can interpret all you like, Dr. Judy - in fact, you've got my number. But I still have you over a barrel, because I took my six, week vacation and now I'm not paying Your bill." Instead of interpreting further, I suggested that we work out a schedule of payments for his therapy so that he would not add to his debt, and he started making the agreed upon payments.
It was at this point that he began dating a woman about 12 years his senior-also the age difference between Derek and me, although we had never discussed it. Very soon, every physical flaw of this 45, year-old woman became the focus of Derek's therapy sessions. The two were spending considerable time on his sailboat together and had embarked on a sexual relationship, with Derek's hypercriticality apparently having replaced the earlier tying-up and spanking rituals. Again I linked the hypercriticality to his mother's early criticism of him and to her criticism of his high school girlfriends. But after a month or two the relationship with the older woman fizzled, and there was a brief lull in Derek's dating life. It was then that he invited me out on his boat.
Instead of giving him the party line about analytic boundaries, I kidded Derek about whether he wanted me out there on his boat so he could scrutinize and amplify my flaws, as he had scrutinized and amplified those of his latest girlfriend. At this comment, Derek once again laughed heartily. It was funny, I think, because I was implicitly revealing my vulnerability to exposure at the same time as I was commenting on his mildly sadistic intentions in our relationship. We might say it was an intersubjective interpretation, hypothesizing motives for both of us. Right after this session, Derek suddenly paid off his remaining debt to me in one payment, His lateness, and his parting remarks about not coming back for his next session, had by now also disappeared.
I had waited nearly two years before commenting more directly on what I felt at one level was an ongoing sadomasochistic enactment between us, however mild and playful. Metaphorically, we might say, I had gone along with Derek's tying-up ritual. I had tolerated his lateness, his ambivalence about the treatment, his long vacations, and his postponed payments. But we might also say that, metaphorically I had insisted on tying most of the knots myself, very loosely; and that I periodically untied the knots with my interpretations, so that both of us felt freer. (I think that his laughter, each time I pointed to his aggression toward me, might have at least in part reflected his relief that I was not stuck in a masochistic position, in relation to him.)
Whether it was articulated or not, I think that our ongoing enactment presented Derek with multiple opportunities for procedural learning (Stern et al" 1998), especially the experience of a new kind of relationship in which he could safely play: that is, where his hair could get messed and he could mess up the clean kitchen floor, so to speak, without my punishing him. No one got hurt because I took good care of myself and the treatment frame while keeping an eye on his analytic goals.
By the end of his second year in treatment, Derek had discontinued the tying-up and spanking rituals entirely, and for the first time in his life was able to achieve potency with a woman he liked and admired. He was no longer depressed or suicidal. His alcohol and marijuana use had greatly diminished, and he reported sleeping well. Although, of course, he had to go through a trial-and-error process of several additional relationships before finding a woman with whom he could achieve a more lasting intimacy, he finally made an attachment that stuck. As he became increasingly confident in this new relationship, he shyly expressed his gratitude to me for the help he had gotten from our work together.
It was soon after these developments that Derek was promoted: in his job, requiring his move to a European city. He became engaged to be married, and his fiancée moved with him. He writes that he is continuing to do well, in both work and family life.
COMMENT ON CLINICAL VIGNETTE #3
I think that my work with Derek manifested activities and qualities of engagement that cut across the recommendations of several mal or analytic paradigms and that the tone and tenor or our relationship was clearly a joint creation, absolutely unique to this particular treatment. I felt throughout the treatment that my usual ways of working were challenged and that I had to stretch myself emotionally, especially to find or sustain an empathic position in relation to his sadistic tendencies.
I introduced Derek to the idea that his transference feelings and behavior might make sense if we considered them in light of my-impact on him, as well as in light of specific aspects of his early experience. And after he began telling me about his childhood-that he was basically rejected and abandoned by his father, assaulted by his mother, and betrayed and humiliated by his sister-I repeatedly linked his current self, loathing, his fear of intimacy, his feelings of impotence, and his sadism toward women to these earlier relationships. Especially because of Derek's near' suicidal shame, I tried to make these links in a way that conveyed my genuine feeling that his current problems were very understandable in the aftermath of his specific early experiences and that I saw his suffering – even the suffering he inflicted on others – as an indication of our shared humanity.
I also suggested meanings and motivations for Derek's behavior; in other words I made interpretations, including interpretations of his aggressive and sexual behavior. But I tried to formulate my interpretations in ways that gave voice to my understanding and acceptance of his feelings and behaviors. For instance, I let him know that, although I registered his seemingly aggressive moves against me, I also saw them as expressive of a healthy reactive aversion (Lichtenberg, 1989; Lachmann, 2000) both to his parents and to his sister's earlier aggressions against him and to what he experienced as my aggressions against him now. The latter might have included (in his experience) my insistence on holding our meetings at a time and place of my convenience; my failure to go sailing with him; and my interpreting what I imagined to be the hidden purposes and meanings of his behavior.
Meanwhile, as I earned Derek's trust, I felt that I could take more interpersonal risks without fearing a catastrophic disruption of the relationship. So by the time Derek asked me out on his sailboat I felt I could let him know, at least indirectly, that I could identify with the older woman he had been dating and could imagine her discomfort at having been negatively scrutinized by him. We can see this as interpersonal feedback because I was making reference to how it felt to be the "other" in a relationship with him. Of course, I was also sharing an aspect of my countertransference experience with him. But at the same time, I was revealing that I could identify with Derek himself as the young child of his negatively scrutinizing mother. Thus my so-called interpersonal feedback was simultaneously a self-revelation and an implicit statement of empathic understanding concerning multiple levels of Derek's experience, then and now.
Furthermore, by choosing not even to mention to Derek that therapists just plain don't go out on sailboats with their patients – something he knew every bit as well as I did – I entered into far more personal play with him about his invitation. I think that by doing this I somehow put the two of us on a more level playing field. So another way of thinking about our interaction is that with his invitation he had squiggled something on the metaphorical paper between us and that I, in turn, had squiggled something back (Winnicott, 1971).
Throughout the treatment we also engaged in enactments of the very relational patterns we were discussing. And, although I did my part spontaneously, I kept monitoring and thinking about my participation, post hoc. The renewed permission I kept there would have been not treatment at all if I had not somehow joined Derek in some aspects of his mischief and sorrow.
I am sure there are additional ways that we could characterize my interactions with Derek. For instance, no doubt my approach moved constantly back and forth between perspectives within and outside his experience, as suggested by Fosshage (1995). And I would guess that I responded to the full range of human motivations that have been outlined by Lichtenberg (1989), as they took turns ascending in my own and Derek's experience and psychic functioning.
Some Summarizing Comments
Although Kohut (1982, 1984) saw empathy as a potential bond between two people, he also proposed that we use empathy as a mode of observation (Kohut, 1959) or as a guide to action (Kohut, 1982). With empathy as a guide, we have a wide range of choices of psychic content, mode of interaction, and quality of engagement (Teicholz, 1995, 1996, 1998, 1999, 2000, 2001, 2002, accepted). An ongoing emphasis on the open-ended field of analytic interactions can be found in Bacal's (1985, 1998; Bacal and Herzog, 2003) concepts of "optimal responsiveness" and "specificity". This refusal to narrow the analyst's options is also a constant in the writings of Stolorow et al. (1987) and of Lachmann and Beebe (1996b). It receives further endorsement from Lachmann's (2000) creative use of humor and from Ringstrom's (2001) and Kindler's (2003) emphasis on improvisation.
All these theorists – while seeing empathic immersion as the initial step and background constant of the analytic relationship – portray an analyst who is willing to engage in the richest and broadest array of human interactions. I would say that they all use empathy as a guide, rather than viewing it as just one among many qualities of engagement. With empathy as a guide, the field of action and the quality of engagement are left open for the patient's and the analyst's coconstruction. What I take further from these theories is that, if an analysis remains open to new experience, then at some point the analyst's theoretical starting point is likely to be subverted or transformed by the uniqueness of personality in patient and analyst and by the unpredictability of how they will interact and improvise on the patient's behalf at different points in the treatment.