Saturday, March 6, 2010

Teicholz is Terrific!

Convergences In Psychoanalytic Theories
Noting the far reaching impact of constant and immediate mutual influence (as documented in infant research) on the therapeutic endeavor, Judith Teicholz, Ed.D., urged clinicians in a most collegial, small discussion group (hosted by the Tampa Bay Psychoanalytic Society, Inc. on March 6, 2010) to consider the humbling discovery that we impact patients more than we imagined and at a pace greater than imagined. This occurs outside of conscious awareness, and it is from this constant mutual influence that the structure of the self emerges. Beebe’s infant research films show that it is steady, attuned responsiveness that is ideal, and also what is continually disrupted and repaired. Being in a relationship with someone-- who is genuinely trying, over and over and over, to understand you, while simultaneously creating a new and evolving narrative -- is at the heart of therapy. In comparing theoretical positions, Teicholz recommended that our theoretical intentions be held in tension with openness to the patient’s experience.

“An Improvisational Attitude”
In her morning presentation Teicholz discussed the dialectic between safety/ trust, play, and self. Winnicott wrote that only in play can an individual be creative, and, furthermore, only creativity allows the emergence (‘discovery’ was his word) of the Self. Teicholz sees spontaneous play between patient and analyst as a royal road to self and other. Collaboration is a unique expression of an intersubjective field, belonging neither to one or the other alone, but a third created, and it requires both participants to be open to the self and to the other. Teicholz, too, sees (dyadic) play as a creative process, and necessary for a cohesive sense of self. Improvisation, a form of play, as with actors, requires taking what the other puts forth and using it, and that an improvisational attitude engenders play. The cue from an other, within relentless, bi-directional , mutual regulation, can go to places undreamed of by its initiator. Empathy too requires imagination, and Teicholz says empathy signals a willingness to play. Mutual empathy builds a relational bond, and both feel safer. Likewise, safety co-created facilitates the space for play.

Play and improvisation, then, are growth promoting. Improvisation, with its spontaneity and make believe [unquestioned as per Winnicott], in therapy is the impromptu (unplanned and unintended) provision of whatever is needed at a given moment. This is not a gratification of instinctual drive, but a necessary provision to enhance the cohesion of self and other, and to facilitate the psychoanalytic process. Improvisation is a subjective form of engagement which can open a third position in a dyadic stalemate (Ringstrom). The back and forth play in service of the patient, while strengthening the dyadic bond, expands the sense of self and one’s consciousness, creating new meanings and and facilitating growth, joy, interest, and curiosity.

Tronick writes that the human mind strives toward coherence and complexity. Two or more together create complexity, and coherence emerges when complex meanings come into place (as within the therapeutic dyad). Tronick says that to create new meaning, one must give up (or reconfigure) the old [or, maybe, hold old and new in tension?] and accept the chaos of the dyadic expansion, including via play, of the self. Teicholz adds that improvisation moves us toward the goal of creating new meanings and greater complexity, thereby enhancing cohesion of the self.

Sometimes improvisation includes mimicry in an exaggerated form, as when the mother echoes the baby’s movements, voice, or state, but in a slightly altered form, creating both the experience of being understood as well as of otherness (Fonagy et al). Because humans have the capacity to continually adapt to significant others, improvisation can dislodge (violate expectations: Lachmann) entrenched experience. But play alone is not mutative; it must be relevant, affectively salient, and occur within a ‘good enough’ dyadic experience, where one, and the other, is known in a new light. Play can reorganize experience [relational paradigms, emotional convictions, organizing principles] and enlarge the repertoire. Tropp et al write that the goal of therapy is to produce change powerful enough in one context to produce alterations in other contexts. While insight might lead to behavioral change, Lyons-Ruth and Tropp note the reverse is also true, that altering behavior [through, e.g., implicit relational knowing and through improvisation] can lead to insight.

“Dancing on the Edge”—the Forward and Trailing Edge
As if her earlier presentation were not replete enough with beautiful clinical examples, Teicholz spent the afternoon in a small group setting discussing in detail a clinical example to illustrate how important it is for the therapist to hear the patient’s point of view and to somehow make sense of it in order to understand what the patient is trying to do. The forward edge (Kohut, Tolpin) or leading edge is a striving toward cohesion and health or psychic growth, and in the transference the patient looks to the analyst for what is missing. Tolpin called the forward edge ‘the repetition compulsion of health.’ The trailing edge, on the other hand, speaks to the regressive pull of instinctual life, of what is repetitive and defensive.

While Freud may have emphasized what was pathological (trailing) about defenses, Kohut reminded us what is purposeful (forward) and protective about them. While all behaviors, including within transference-countertransference dyads, have an element of the forward and trailing, it is sometimes difficult to recognize the forward edge. Deeply hidden are the tentative outgrowths of hope for relational experience. For example, while verbal attacks on the analyst may also include a defense against intimacy, they paradoxically invite engagement. When the analyst survives (Winnicott) attacks, that is, neither retaliates nor withdraws, but keeps alive interest in the patient’s experience (a kind of ‘primary maternal preoccupation’), the forward edge of the hope for shared connection and attachment is illuminated. In the search within the dyad for the forward edge, it is incumbent upon the analyst to place the patient’s painful experience in the context of the analyst’s failure (wearing the attributions-Lichtenberg). When the analyst evokes both the here and now, and the past, increased recognition by the patient of the delineation of inner and outer, new and old, may result.

A remarkable day
was spent with Judith Teicholz, Ed.D. Not since Carla Leone visited Tampa in March 2009 has a speaker’s explicit talk been so in consonant with her/his demeanor. What was communicated implicitly by Teicholz did not contradict her papers. She demonstrated in attitude and behavior exactly what was meant by her words. How very important this is when we consider implicit relational knowing and how so much is communicated without words. [In fact, what I often think “creepy” about a person is when the implicit and explicit do not ‘match up’ (Upshaw).] Just as ongoing mutual influence transcends any particular theory, so Teicholz is transcendent in her integration. No wonder, with her ability to synthesize and utilize, as called for by the moment, varying theoretical positions, Teicholz’ has been the perfect choice to pull things together at the end of large conferences.

Lycia Alexander-Guerra, MD

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