Deconstructing what we read

Nothing pleases an instructor more than when students learn to read and think critically. How pleased was I then when the first year class at TBIPS was able to take the clinical vignette from an assigned journal article, deconstruct the reported interaction, and come up with additional points of view.

In the assigned artice, the author began with some background: a young woman of a withdrawn, depressed mother and a hostile, accusatory father was described as being opaque to others, unable to be vulnerable and emotionally intimate with others, operating from a paranoid-schizoid position, distrustful of men, found it difficult to bond with women, and experienced interpretations as intrusive and insulting. The analyst complained that his attempts at empathy were rebuffed.

Then followed from the author/analyst a brief portion of process notes:

The patient was indignant about a male colleague who had made advances; the male analyst responded by giving an explanation for the colleague’s behavior. [The class easily recognized the analyst as defending the other’s, not the patient’s, point of view, in essence an attack on the patient’s reality. ] The patient responds derisively, accusing the male analyst of being like all those other men who think they can say or do anything with women.

The patient continues, talking about being professionally excluded by an Old Boys’ Club at work. The analyst, attempting empathy, lands on interpreting her feeling alone, without female colleagues. The patient says she thinks the analyst really think she is a bitch and she accuses her analyst of phony empathy. [The analyst does not consider here his own contribution to his patient’s rebuff, that perhaps the patient perceives accurately what is in her analyst’s heart. The analyst, after all, had only moments before attacked her point of view.]

The patient then complains about her very bad day and asks her analyst if he has ever had such a day. The analyst asks for her thoughts. [Here the analyst is the opaque one, being with his patient exactly what he, in his description of her, accused her of being, and he is likewise being unknown to her, just as her depressed mother had been. Is this an enactment?, the class asks.] The patient then insults the analyst, accusing him of being uncaring and, as a man, without compassion.

Vignettes from the literature and from our own clinical experiences are often used in classes to improve our skills. And where the medium is the message, we deconstruct who we are alongside what we say and think, leaning in the direction of hope, empathic attunement, and opening the third space. Next time I will post on how the Intro. class used Winnicott.

Richard Geist delineates Self from Ego Psychology

One of the most celebrated authors read at the Tampa Bay Institute for Psychoanalytic Studies, Inc.’s Self Psychology Study Group, Richard A. Geist, Ed.D., may also possibly become one of the most celebrated speakers at the Tampa Bay Psychoanalytic Society where, on March 12, 2011, he read two of his papers. The seamless way Geist was able to weave audience questions and comments throughout the presentation of his elegant clinical papers provided implicit knowing about the way he works. As such, at almost no time in the presentation did we feel read to [for some, being read to in a professional forum may call to mind the classical approach of the analyst as ‘the one who knows’, imparting knowledge to the analysand, the experience as wooden as the blank and ‘neutral’ analyst]. Instead, his presentation was immensely collaborative, much as contemporary clinical work aspires to be.

Geist said that an analysis which is mutually empathic will more easily evoke healthy transferences (consequently, allow more easily for a patient to feel understood), and it is through the analyst’s willingness to allow her/his boundaries to become permeable, facilitating the felt presence of each in the other’s life with interpenetrating subjectivities, that mutual empathy is fostered. The analyst’s responsiveness, with its components of empathy [I noted how Geist’s child training at Boston Children’s Hospital, where in Behavioral Pediatrics one learns to stay close to the experience of the child, fits well with Self Psychology’s staying empathically close to the patients’ experience], selfobject transference, and subjectivity contributing to connectedness, are all experienced by the patient as part of self.

Elaborating on the analytic attitude, which is accepting, understanding, and responsive emotionally, Geist noted that the analytic attitude is always in service of maintaining a cohesive sense of self and toward connectedness. An analytic attitude is also protective of the patient. Geist, in utilizing the concept of protection (much like many of us might refer to safety) expanded our understanding of how the protecting selfobject transference safeguards the ‘tendril’ of growth (Tolpin’s ‘leading edge’) and protects from affect overload. The creating of a sense of safety and trust is aided by permeable boundaries and empathic immersion. Drawing from Kohut, Geist offered that we think of ourselves not as the object of a patient’s anger, but instead as the subject of the patient’s feelings, remaining empathically immersed and asking ourselves what it must be like for the patient to feel a particular way in the therapy.

Delineating Ego psychology from Self, Geist noted that Ego psychology is designed to dissect the self, while Self psychology is designed to put the self back together. The Self psychologist responds to the whole self in its contextual ambience, and, unlike the Ego psychologist, does not focus on a particular defense or a particular affect found at any given moment. Self psychology sees transference as always in the direction of health, not as a distortion (as per Ego psychologists), and, as such, do not conceptualize in terms of ‘negative transference.’ Self psychology heeds research that shows a child develops optimally in an environment of responsiveness, and is therefore, unlike Ego psychology, not built on a frustration model. Interpretations were perhaps one of the most delineating concepts of the day: Interpretations, though but one aspect of what helps patients get better, are designed to welcome the patient’s fantasies as attempts at healing, and they emerge from connectedness within the clinical situation, not from theory. Interpretation is always in service of what the patient needs in order to maintain sense of self and always in the service of expanding permeable boundaries for interpenetrating subjectivities.

If there could be a disappointment to his visit, it would be the ‘bait and switch’ of the advertised paper to be presented (Geist, R.A. (2009). Empathy, Connectedness, and the Evolution of Boundaries in Self Psychological Treatment. Int. J. Psychoanal. Self Psychol., 4:165-180) [and the most provocative of any I have ever read], but this was aptly relieved by the reading instead of his soon to be published paper: Our Private Theory of Change_Connectedness and the Analyst's Attitude. I also highly recommend his paper: Geist, R.A. (2008). Connectedness, Permeable Boundaries, and the Development of the Self: Therapeutic Implications. Int. J. Psychoanal. Self Psychol., 3:129-152.

by Lycia Alexander-Guerra, MD

photo provided by John Lambert, LCSW

Experience Near

On Saturday afternoon, January 15, 2011, Alan Kindler held an interactive workshop at Memorial Hospital with the Tampa Bay Psychoanalytic Society, Inc on staying close to what the patient was experiencing and reporting. [This was a lot harder than one would think, especially for experienced clinicians who may have found it hard to divest themselves from their theories and interpretations and simply reflect back what was heard instead of adding our own speculations.]

In an attempt to have workshop participants practice getting closer to the patient’s experience, Kindler used video clips of actors playing patients and asked audience participants to use empathic observation to access the specific feelings and experience (and the relationship between the two) of ‘patients’, and to make tentative (open to objections and corrections by the patient) responses to their subjective feelings in the context of what the ‘patients’ were relating. Kindler recommended really knowing the details of conscious experience before moving to the unconscious, fully aware that which details come to the foreground of the therapist’s attention are contingent upon the subjectivity of the therapist. Experience-near data, the details of the patient’s experience, passes by so quickly that much is missed in the listening.

Kindler used the following definition of empathy: a mode of observation and listening in which the therapist strives to apprehend the patient’s subjective experience, as reported by the patient in the present about the past. Empathic understanding is the recognition of the details of the patient’s experience at any moment within its context. Empathic understanding requires attention to detail and a life time of practice. [E.Vasquez noted that understanding may be the core of therapeutic action. W.Player noted that empathic understanding might be oxymoronic, since attunement is more implicit than cognitive, to which Kindler suggested empathic resonance.]

Kindler described the components of subjective experience, where affect is central and contextualized, which may include thoughts, fantasies, acts, intentions, memories, images, assumptions, and beliefs. Because affects are central components of the patient’s subjective experience, their accurate recognition is the essential first step. Kindler suggested that clinicians hone the nuanced language of affect to find the right word to help the patient give a name to the affective experience.

“The Evolution of Contemporary Psychoanalysis”

On Sept 11, 2010 the Tampa Bay Psychoanalytic Society, Inc hosted Sanford Shapiro, MD referred to his paper on “The Evolution of Contemporary Psychoanalysis—A Fifty Year Perspective.” Author of Talking to Patients, a self psychological view of creative intuition and analytic discipline, (Jason Aronson) the revised edition 2008, includes implicit memory and relational psychoanalytic thinking. Referring to Victoria Hamilton’s The Analyst’s PreConscious , Shapiro noted that theory helps us stay calm in face of patient assaults and added: Do not underestimate the ability to stay calm.

Shapiro, approaches each session ‘without memory or desire’ (Bion)and asks himself: how is this patient planning to use me at this moment? He notes how patients test us. The initial test is about safety. Patients expect from us what they got from their parents (the transference test). This is sometimes evident when the patient, turning passive into active, attacks e.g. our competence. Just ‘survive’ (Winnicott); surviving (without retaliation or withdrawal) the test is passing the test. Weiss noted that analysts confirm or disconfirm patients’ beliefs; when we respond in new way, we may disconfirm their beliefs.

Using empathic introspection, we need to ask ourselves: How are the patients to feel good about themselves if we are always pointing out their shortcomings? Sometimes patients comply with our theories to avoid further hurtful interpretations.

Reenactments or enactments were classically thought to be disruptions. Donnel Stern (relational) believes they are necessary before they can be made explicit and then interpreted. Frank Lachmann (self) calls them ‘rupture and repair’ . This contemporary psychoanalytic acceptance of enactments has allowed analysts to ‘come out of the closet’ into the public forum about their private theories.

Shapiro says his theory is simply investigation, or inquiry. He tries to avoid being loyal to a theory or technique so as to allow himself to be with the other. Shapiro follows the moment to moment affective response of the patient to his interpretations to know if he is on track.
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In his paper, “The Evolution of Contemporary Psychoanalysis” Shapiro states that Contemporary Psychoanalysis is a two person psychology born out of the cross-fertilization between interpersonal and self psychologies. He also juxtaposed interpersonal and relational theories against Freudian, Kleinian, Ego and Self psychologies, Intersubjective, and social constructionists.

Shapiro, a student of Sterba, interpreted Sterba’s “The Fate of the Ego in Psychoanalysis” (1934)as a pioneering relational perspective because Sterba describes dissociation as the split between observing ego and experiencing ego, the former which allies itself with the analyst’s ego. But the analyst is an active participant, not an objective observer.

Shapiro explored contributions from Winnicott, Kohut, and Intersubjectivity which he had found personally useful in his professional helping of patients. For example, seeing things from the perspective of the patient (empathy) helps the patient to feel understood, more confident, and opens up explorations with lessened shame or guilt; or focusing on the impact the analyst has on the patient before interpreting transference distortions. From relational (Mitchell) was added the focus on the patient’s impact on the analyst. Because patients can sense analysts’ reactions, sometimes acknowledging what the patient already knows in self disclosure can be useful.

Shapiro changed his view of resistance. Classically, resistance was seen as arising from instinctual wishes from within the patient. Ego psychologists interpret this resistance and other defenses. But intersubjectivists [like Benjamin] view resistance as also, in part, the patient’s fear of the therapist’s response. In a two person model, we are interested, then, in exploring as well what contribution the therapist may have made to the patient’s fear. Shapiro’s clinical example illustrated staying with the patient’s perspective instead of confronting the distortion. [He did this by what sounded like ‘wearing the attributions of the patient’ ala Lichtenberg.]

Shapiro also changed his views on motivations. Likewise, he re-examined his belief in his analytic authority and expertise and became more of a facilitator, helping others overcome obstacles to resume their growth and development. He recognized that sometimes the relationship itself, and implicit communication, is mutative, and that interpretations were not always necessary. In his technique, Shapiro draws on the empathic-introspective mode from Self Psychology and the impact the patient and he have on each other from relational theory.