On therapeutic action - From emotional availability to psychoanalytic compassion.

In addition to Orange’s (1995) initial view of empathy as emotional availability, Lachmann’s discourse on empathy (February 13th, Tampa) also brought to mind this treasure she gave us in 2006: an elaboration of emotional availability as psychoanalytic compassion. Although it is best to study this essay in its entirety, for brevity I will review here only the section on ‘Compassion as Emotional Understanding’. In footnote 4, Orange explains: “I think of empathy as a larger capacity to understand another's emotional experience from within an intersubjective field (Orange, 1995). Compassion, in my view, is that part of empathy that makes me willing and able to descend into and to explore the Dantean realms of suffering with the other.” Deriving from the Latin patior (to suffer, undergo), patient, as a designation, is not pejorative, for “a patient is one who suffers, one who bears what feels unbearable. Compassion, then, is a suffering with, a bearing together.”

Orange notes that the capacity to share the suffering of another “can gradually restore the shattered, alien-feeling, frozen, lost, dehumanized other a sense of belonging to the human community,” and therefore, along with others, Orange “would restore the concept [of compassion] itself to a central role in the “therapeutic action” discourse. In this paper, however, she focuses “on the attitude and capacity that the analyst brings to the psychoanalytic engagement.”

Not technique, and even less a rule of technique, compassion is, instead, both process and attitude. As process, compassion approximates Gadamer’s (1975) dialogic process of “undergoing the situation with the other” and arriving at an understanding, which is something Orange (1995) elucidates as emotional understanding. “Together we make sense of the patient's emotional predicament within the relational system that we experience together, and gradually this shared world changes by means of a personal reorganization of experience (of both participants)” (emphasis added).

Something that, at times, may not seem gentle or nice, and may occasionally even challenge, contradict, or introduce alternative perspectives, “[a] compassionate attitude... enables hitherto unknown and impossible forms of experiencing. Implicit and explicit forms of participation in the patient’s suffering create a world of compassion that introduces new experiential possibilities” (emphasis added). Ah, therapeutic action, how analysis cures, rendered less elusive, less mysterious!

But that is not all. “This participation, however, is a way of being-with, not a formula for doing psychoanalysis. Where there was indifference, humiliation, rejection, shattering loss, and the like, compassionate psychoanalytic understanding does not simply replace or heal by intentionally providing new experience. Instead, when the analyst treats a person as endlessly worth understanding and his or her suffering as worth feeling-together, this attitude of compassion implicitly affirms the human worth of the patient. Instead of being preoccupied with the question of the patient's recognition of the analyst as a subject, the psychoanalytic relationship accords to the patient, often for the first time, the dignity of being treated as the subject of one's own experience (the reciprocity may come later).”

And what about interpretation? “Because of their previous experience in life and in treatment, patients most often come to us expecting to be classified, judged, treated with rigidity, or exploited. If, however, we are not too intent on naming pathologies and defenses or with being right, but instead relentlessly seek to understand and accompany the sufferer, an implicitly interpretive system emerges. For me, close and compassionate listening is itself an important form of interpretation, dissolving the interpretation-gratification duality, and fully deserves to be considered psychoanalytic. It says to the analysand: "You are worth hearing and understanding." ” (emphasis added).

Orange then adds detail. “This listening involves attention to the ways the patient's experiential world has created suffering for the patient as well as for others in the patient's life. Without leaving the patient's side or becoming judgmental, we can understand how one could come to be so hurtful to oneself and to others. We can understand the simultaneous two-sided experience, so often dissociated, of being both hurt and hurtful. Recognizing context and complexity [the two preceding sections of the essay] prevents reduction and judgmental attitudes and enables compassionate understanding. ”

To make the concept of psychoanalytic compassion more complete, Orange offers the notion of accompanying the other. “In recent years I have become more aware of the importance of simple accompanying that some would contrast with proper "analytic" work and might disparage as "supportive" psychotherapy. Whether my patient suffers from an incurable, painful, and debilitating disease or from terminal cancer or lost a family member in the World Trade Center tragedy, I must not look for ways to see my patient as causing or even contributing to her own suffering; if I did so, I would be joining those who tell her just to accept it or get over it. There is no way to fix the situation or to "cure" the patient, so I must accept my own powerlessness to help. I must simply stay close to her experience, sorrowing and grieving and raging with my patient, even if this means that my practice feels very heavy to me. Even when the story is very complex -and it always is - a willingness to walk together into the deepest circles of the patient's experiential hell characterizes the attitude of compassion ... that the process of psychoanalytic compassion requires.”

Orange summarizes this way: “The interpretive gesture of reaching out to embrace the patient in a sustained, even relentless, struggle to find an understanding is what I mean by psychoanalytic compassion...[it is] an implicitly interpretive process of giving lived meaning and dignity to a shattered person's life by enabling integration of the pain as opposed to dissociation or fragmentation. A compassionate attitude says to every patient: your suffering is human suffering, and when the bell tolls for you, it also tolls for me.”

Orange, D. (1995), Emotional Understanding: Studies in Psychoanalytic Epistemology. New York: Guilford Press.
Orange, D. (2006), For Whom the Bell Tolls-Context, Complexity, and Compassion in Psychoanalysis. International Journal of Psychoanalytic Self Psychology, 1 (1):5-21.
Gadamer, H. (1975), Truth and Method. New York: Crossroads, 1991.

Ernesto Vasquez, MD
February 17, 2010.

[Donna Orange will speak in Tampa April, 2011]