Useful Relational Intersubjective Inferences

Having recently attended a conference where the speaker read a paper which leaned heavily toward inferring, from the psychoanalytic situation, particularly the narrative, infantile drives and fantasies, I was much relieved to find myself once again in the Tampa Bay Institute’s Study Groups and classes discussing inferences from infant research and attachment theory. Specifically discussed was the 1999 paper The Two-Person Unconscious: Intersubjective Dialogue, Enactive Relational Representation, and the Emergence of New Forms of Relational Organization by Karlen Lyons-Ruth.

Lyons-Ruth reminds us that meaning systems are organized by more than the symbolic (words and images): “meaning systems are organized to include implicit or procedural forms of knowing.” As such, a primary engine of change is “new enactive ‘procedures for being with’ [which] destabilize existing enactive organization…” Moreover, “procedural forms of representation are not infantile” for “development does not proceed only or primarily by moving from procedural coding to symbolic coding.” She states that “‘internalization’ is occurring at a presymbolic level...[thus] representation [is] not of words or images, but …of enactive relational procedures…”

One such procedure is parent-infant dialogue and, when flexible and collaborative “is about getting to know another’s mind…” A coherent, open dialogue requires openness of the parent, not in the form of “unmonitored parental self-disclosure, but by parental ‘openness’ to the state of mind of the child...” [And] “intersubjective recognition in development requires close attention to the child’s initiatives in interaction…” Likewise, the parent seeks “active negotiation and repairing of miscues, misunderstandings, and conflicts of interest;” It is from these ideas of Lyons-Ruth and others that clinicians infer the importance in the analyst-analysand dialogue the need for flexible and collaborative openness to the state of mind of the other, with attention to initiatives of the other, and a responsibility to seek repair of ruptures.

Mutual Recognition in a Fly Bottle

The Tampa Bay Institute for Psychoanalytic Studies, Inc boasts two Study Groups, each every other week, one on Relational Psychology, alternating Fridays with Self Psychology. For several years now I have been looking for places where the two psychologies happily marry. In the past month our discussion groups have seen the rocky courtship of Self and Relational psychology in the papers found in 2010 IJPSelfPsychology by Donna Orange with commentaries by Jessica Benjamin, Philip Ringstrom, and Malcolm Slavin.

It was Orange in Recognition as: Intersubjective Vulnerability in the Psychoanalytic Dialogue who first seems to misrecognize recognition by characterizing the relational usage of the term to mean “demand”ing that the patient deal with the subjectivity of the analyst. She writes that most of her patients who “come from families where they were excessively required to validate the parent’s experience...become adults excessively attuned to the needs of others...The last thing these patients need…is an analyst who is preoccupied with a therapeutic agenda to get patients to recognize her as a subject.” [I am under the impression that most relational therapists would see the capacity for intersubjectivity (to recognize an Other as a subject) as a result of treatment, not a requirement for treatment, and that Orange has overstated her characterization.] Orange goes on to advocate for the use of empathy [called mutual attunement these days by Self psychologists trying to find their way to a two-person psychology] to find our way into the patient’s predicament (Wittgenstein’s fly bottle) and to stay close to the patient’s experience in order to help the patient find a way out. Orange utilizes “close emotional attunement” to access the patient’s emotional experience “through verbal and nonverbal conversation where we establish and identify together the nature and rules of a particular language game [Wittgenstein]…” [what, I think, relational therapist would call negotiation] .

I was very pleased with Orange’s response to Ringstrom, Benjamin, and Slavin, for she humbly admits to her misrecognition. While I agree that the psychoanalytic endeavor strives to hoId the patient asymmetrically central, I still do not understand Orange’s Levinasian inclination to put herself below, instead of on par, with the patient. (She intimates throughout her writings that this is a personal relational template for her.) I also wonder why, when using Winnicottian ideas so often, Orange would place “destruction” outside her language game (perhaps she wants to safe guard from confusion her own term “world-collapsing”). And, moreover, why not become familiar with the language games of other schools, holding more lightly the theories of her own camp, and "stretching" toward pluralism?

Benjamin, I think, writes with a greater clarity than Orange, perhaps unencumbered with arabesques of philosophical side leaps, and explicates the usefulness of an analyst with her own subjectivity who “assumes a reality independent of the patient’s worrisome anxieties about having to be a caretaker for the analyst…[T]he analyst, being a subject in her own right, means she is the one who can take care of herself and regulate herself…” The patient is not re-traumatized by the “demand” to take care of and regulate, as the patient once did for the parent, the analyst.

Ringstrom wonders if Orange does not idealize [perhaps holding less than lightly] empathy (in much the same way classical analysts idealized anonymity, abstinence, and neutrality) because, when empathy fails, as it inevitably will, Orange does not offer alternative ways in, and out of, the fly bottle. Ringstrom offers an alternative: enactment. “Enactments allow access to self-states that are typically coded in implicit procedural memory…” Orange eschews Hegel [also a misrecognition, or being willfully obtuse, or merely a failure to enter Hegel’s language game?]: “…we should give up the search for the Hegelian self-conscious subject, with its implied demand for the other to re-cognize and create it.” And she eschews use of the term dialectic, preferring the term dialogic. Ringstrom, I think, describes a lovely dialectic that even intersubjective self psychologistslike Orange might recognize when he, using Benjamin’s inevitable negation, writes “assertions of self that take the other for granted (negation) often result in ruptures that force awareness (recognition) and often precipitate repair (mutual recognition).”

It is Slavin who stands easiest in the spaces between Self and Relational psychologies, balancing the tension between the two as he gives in his clinical example an elegant use of his subjectivity to meet the patient in her experiential world. His vignette describes how, in admitting his disinclination to be with the suffering of his patient, he paradoxically reaches the patient. Orange added her own vignette of a time when she, too, self disclosed her own failure to go into the fly bottle with her patient. She says about this disclosure, “I had given her what she needed to recognize me so that I could recognize her…” This, I think, is where Orange marries the relational subjectivity with self psychology’s empathy (neither the exclusive purview of the other, though often mischaracterized as if it were, as Orange did) and recognized that sometimes empathy allows us, consciously or unconsciously, to recognize that what the suffering other needs from us in this moment is our subjectivity.





Orange, D.M. (2010). Recognition as: Intersubjective Vulnerability in the Psyc... Int. J. Psychoanal. Self Psychol., 5:227-243.
Benjamin, J. (2010). Can We Recognize Each Other? Response to Donna Orange. Int. J. Psychoanal. Self Psychol., 5:244-256.
Ringstrom, P.A. (2010). Commentary on Donna Orange's, “Recognition as: Intersubjective Vulnerability in the Psychoanalytic Dialogue”
Int. J. Psychoanal. Self Psychol., 5:257-273.
Slavin, M.O. (2010). On Recognizing the Psychoanalytic Perspective of the Other... Int. J. Psychoanal. Self Psychol., 5:274-292.
Orange, D.M (2010). Revisiting Mutual Recognition: Responding to Ringstrom, B... Int. J. Psychoanal. Self Psychol., 5:293-306.

Self and Relational Psychologies Face-off

Soon after Labor Day each year, The Tampa Bay Institute for Psychoanalytic Studies, Inc (T-BIPS) recommences its two (Self and Relational) Study Groups. On Friday, September 16, the TBIPS Self Psychology Study Group read the 2005 paper by Israeli analyst David G. Kitron The Unacknowledged Knowledge and the Need for a Sanity-Confirming Selfobject. It made for a lively discussion about whether or not an analyst could actually “temporarily” or “partially” “suspend his or her own subjective experience.” Self psychologists and the Stolorow et al Intersubjectivists tend to intimate that we can. Relational Intersubjectivists claim this is not possible.

No doubt that our profession aims at being helpful to our patients, which means being toward a focus, even with our own subjective experience, on the patient’s experience. Kitron aptly commends Ghent’s (1990) surrender over submission. He also reminds us that survivors of childhood trauma have had their reality-testing attacked, what he calls a failure of a sanity confirming self object. I applaud when he writes, “It is the therapist’s duty…to search for any mistake he might have made.” Not to do so would attack again the patient’s reality-testing (gas lighting) and re-traumatize. The analyst’s mistake, if denied by the analyst, becomes part of the “unacknowledged knowledge.”

Where Kitron and Relational thinkers may diverge is when does the therapist deem that “a side-by-side coexistence of two subjectivities is gradually made possible.” Kitron says “the therapist has to ‘step aside’ and suspend his subjectivity temporarily” until the patient has developed the capacity for intersubjectivity [mentalization, Fonagy would contend, is a component of this capacity]. I tend from the very beginning to lean toward the “hold in tension” philosophy. What I mean is that I do not want to obfuscate the part of the patient that is inevitably aware of my subjectivity [as even psychotic patients are] even while, because the patient has had the repeated experience of attack on her/his reality testing, the patient finds any other’s subjectivity unwelcome, even noxious or traumatic. To “suspend” my subjectivity might then be a mere reversal of where one “dominates and paralyzes the other.” I try, then, to hold my subjectivity in tension with the need of the patient to have her/his subjectivity exalted.

Orange on Levinas

Donna Orange, in her visit on April 9, 2011 to the Tampa Bay Psychoanalytic Society, spent most of the day discussing her take on the philosophy of Emanuelis Levinas (a student of the Talmud and a contemporary constructivist and phenomenologist , he believed in a hermeneutics of lived experience) who wrote about the "wisdom of love" (as opposed to the ‘love of wisdom’). Levinas believed that ethical responsibility is integral to the encounter with the Other, [and consequently, to intersubjectivity], a responsibility that is constitutive to our own being and interiority, that is, that subjectivity is formed, in part, through the encounter with the other. In this privileged encounter with the other, one feels both the relatedness with and the alterity of the other. Unlike what Self Psychology would purport about the confrontation with otherness, Levinas wrote: "The Other precisely reveals himself in his alterity not in a shock negating the I, but as the primordial phenomenon of gentleness."

In discussing Levinasian ethics, in particular Levinas’ idea of transcendence and the belief that one instantly recognizes the transcendence of the Other, Orange emphasized putting the other above oneself. As Orange’s form of intersubjectivity, like that of Stolorow’s/Atwood’s, with its influence from Self Psychology wherein the focus on the analyst's subjectivity is as a source of understanding, and where the need of the patient for the analyst as a selfobject is paramount, it came as no surprise that Orange would be enamored of this facet of Levinasian ethics. In fact, for me, her heavy emphasis was seen as a justification for empathic immersion and for the analyst to function predominantly as a selfobject experience for the patient.

While I agree that placing the suffering other above oneself (who would not open the door for someone struggling with crutches to get through it?) is, for those not so preoccupied with themselves as to be aware of their surroundings, a natural response, I think it is a hard philosophy to adopt when the other is not a suffering other. Orange, taking from Levinas his holding the other above self, even being responsible for the sins of others [here I am reminded both of Christ dying for the sinners’ sins and of the self blame of victims; Levinas, as a Lithuanian Jew, had survived the Holocaust but his family, sadly, did not] advocates a philosophy beyond ‘love thy neighbor as thy self’ to “love thy neighbor more than thy self.”

More than one audience member asked: how does one avoid masochism in this philosophy? Her advice to read Emmanuel Ghent’s 1990 paper on Masochism, Submission, Surrender did not suffice to further the dialogue (though his brilliant paper does). Had Orange made explicit the inference to the clinical applicability of Levinasian ethics, given that the patient is seen as the suffering other, then the attendees might have better embraced the philosophy Orange touted. Had clinical examples been supplied to illustrate the practical application of such ethics, then the audience would have been won over by her scholarly explication of Levinas’ ideas of transcendence.

Ghent, E. (1990). Masochism, Submission, Surrender—Masochism as a Perversion of Surrender. Contemp. Psychoanal., 26:108-136.

More about Listening

How we organize what we hear and observe is influenced by our own subjectivity, our experiences, and our theories. Because no theory holds the ‘truth,’ we must hold our theories lightly, recognizing that each person’s reality is perspectival, and recognizing that the meaning of the material need not be fit into the procrustean bed of a theory. As I listen and muse on what is going on in the therapeutic dyad, I often think I am like a juggler, with many plates in the air at once. I must simultaneously consider whether or not I hear at this moment a familiar sigh or theme from the patient; whether or not the present narrative or relational paradigm harkens back to the patient’s childhood events; what, if any, are the transference counter-transference implications; what happened in this past moment or last session or over the months or years of analysis that contributed to this coming up or happening now; and so on; all the while being open to the unknown and to surprise in a free floating reverie with evenly hovering attention!

Listening is dialectical (you can never stand in the same river twice), which means patient and therapist influence each other and neither is ever the same again. Listening is intersubjective, containing within it both the listening and the being listened to. Listening allows space for creativity (Winnicott) and for the, as yet, unformulated and unspoken. It is a gift we give our patients, interested in every word and gesture. It is a gift our patients give us, along with the privilege of their trust. When we listen, we do not seek to confront or contradict the patient, though we may sparingly ask for clarification. Many people have never experienced such genuine attentiveness from another.

As communication is both explicit (with words and common gestures) and implicit (perhaps what Freud referred to as unconscious to unconscious communication) we must listen as well with our perceptions and unconscious perceptions. We attend to the texture of feeling and gestural communication and not just to words or content or to conscious understanding and insight. We become comfortable, not impatient, with silences when the patient may need to be with some caring other without the pressure to produce or perform. Each therapist will have a unique interest in this or that part of a story, evoking a resonance with something in the therapist’s personal history. Each therapist must find her/his own way of expressing, in a way contributory towards patient growth, what has meaningfully affected us.

Is Mutual Recognition a Foil to Empathy?

I have long struggled with attempts to integrate theories from Self Psychology with those of the varying ideas about Intersubjectivity. Self Psychology emphasizes the receiving of empathy (by patient from analyst, or, developmentally, by child from caregiver) and not the development, as Klein noted and Winnicott elaborated, of the capacity for concern, or empathy, for the other. Benjamin writes about intersubjectivity (in part, the capacity to relate subject to subject) as a developmental achievement. She also notes that it is the “mother’s recognition [that] is the basis for the baby’s sense of agency.”

Orange expands on the idea of recognition: “What we acknowledge, in relation to the other, is not primarily the other’s identity or status, but rather our own intersubjective vulnerability.” Using language (semantics) and taking literally the etymological roots of re-cognition (‘to know again’), Orange refers to Benjamin’s use of Hegel’s anerkennung, which Orange says lacks the ‘again’ and, therefore, refers to acknowledgement or appreciation and acceptance. While Benjamin emphasizes the joy of mutual recognition, Orange, expanding again, quotes the philosopher Hans-Georg Gadamer “The joy of recognition is rather the joy of knowing more than is already familiar.” Since recognition is “profoundly lopsided for a long time” Orange advocates that we do not “underestimate…trauma” [the noting by Orange of Winnicott’s being-with the patient in the co-created space (a transitional, or third, space) reminds me of the emphasis placed by relational theorist Bruce Reis on being with a patient whose traumatic experiences might be without words] of our patients, and that we not impose our own “agenda” (to be recognized as subjects) on patients. Orange “place[s] the primary responsibility for attunement and responsiveness on the analyst”.

Orange writes, “Perhaps we should give up the search for the Hegelian self-conscious subject, with the implied demand for the other to re-cognize and create it.” Orange intimates that other (not Self psychology) theorists expect the patient to meet equally the needs of the therapist. This mischaracterizes, I think, relational intersubjective emphasis. Orange is coming to Tampa Bay tomorrow (April 9) and I am eager to hear more about her foils (other theories of intersubjectivity) and how one might enter into dialogue with them.

Benjamin, J. (1990). An Outline of Intersubjectivity: The Development of Recognition. Psychoanal. Psychol., 7S:33-46.

Orange, D. (2008). Recognition As: Intersubjective Vulnerability in the Psychoanalytic Dialogue. Inter.J.of Psychoanal.Self Psychol., 3: 178-194.

Subjectivity, self-disclosure, and an ideal

It is now well articulated that our own subjectivity greatly influences, both explicitly and implicitly, the work co-created by us and our patients. Whereas Freud thought abstinence, neutrality, and anonymity were part of the ideal stance, contemporary thinkers know these to be not only impossible but sometimes unhelpful, even detrimental, to the therapeutic process. Aron (1991), and Hoffman(1983) write that the patient's experience of the analyst's subjectivity needs to be made conscious, that is, it is sometimes okay to ask patients what they notice about us and our reactions, perhaps particularly when we have feelings we hope we have kept hidden from the patient. Patient reaction to our subjectivity is only one aspect of the transference, but was, traditionally, a neglected area of exploration. (Remember that what patients notice about us may also be defended against by patients.) Just as patients can not entirely know themselves, neither are we the authority on the accuracy of our patients' perceptions of us. Patients learn about themselves from us, so we, too, learn, often uncomfortably, about ourselves from patients. Bion thought that the more real the analyst, the more the analyst can be in tune with the patient’s reality.

Still we strive to be careful not to impinge on the psychoanalytic process by excessive self-revelation. I like to think that self disclosure pertains to allowing into the process what is going on with me in the therapeutic relationship, not about what goes on with me in my private life. Semrad quipped that psychotherapy is a mess trying to help a bigger mess, his way, I think, of saying that you do not have to be a perfect person to be a good therapist. Because self-revelation by the therapist is ongoing and inevitable, we (through our deportment, dress, attitude, etc) cannot help but to reveal our imperfections. They may impinge upon the patient less when we find in our personal lives gratification in love, work, and play, separate from what gratification we un/consciously hope for from patients.

When considering our own subjectivity (point of view, beliefs, opinions, goals, desires, etc.), we might examine our own motivations for having chosen the mental health profession as well as our fantasies about how we might help others, and ourselves, by having so chosen. Philosophically, do we have hope for ourselves (and do we hope to facilitate hope in others) for a life experienced with fullness and passion, for both joys and sorrows, and to experience life, not in isolation, but in authentic connection with others? Is ardor for life a personal value? An ideal stance then might better be suited by being open and curious, and brave toward newness, uncertainty, and psychological intimacy.


Aron, L. (1991). The Patient's Experience of the Analyst's Subjectivity. Psychoanal. Dial., 1:29-51
Hoffman, I.Z. (1983). The Patient as Interpreter of the Analyst's Experience. Contemp. Psychoanal., 19:389-422.

Valentine’s Day Thoughts

Having had the good fortune to hear Malcom O. Slavin, PhD speak on Saturday, February, 12, 2011 to the Tampa Bay Psychoanalytic Society, Inc., I came away with some thoughts on love previously relatively unconsidered. In particular, Slavin’s ideas on “adaptive probing” (probing, for example, to access and share an unarticulated fear of annihilation and death consequent to the existential awareness of our finitude and of our human need to make meaning), it occurred to me that the proclivity to probe others comes to the fore in love relations as well. The assertion of self interest through probing to know oneself better by better knowing the other is neither solely selfish nor aggressive. Indeed, it reciprocally requires of the beloved a capacity to allow awareness of the less accessible multiplicity of selves in order for the lover, too, to be able to face (though now, not alone) heretofore inaccessible sides of the self. Patient and therapist, too, cooperatively allow such access, beneficial to both.

In the clinical situation, this intersubjective, mutual probing requires that the therapist not hide behind ritual or role. Can the therapist and patient hold the tension created by emerging multiple selves? Can lover and beloved? Love is both selfish and altruistic. Love is the selfish quest for wholeness, through help from the other, the accessing of parts of one’s self by probing to know the multiple selves of the other. It is altruistic in its very probing, aiding, too, the other to know her/his own multiplicity better. Altruism (putting aside temporarily one’s own agenda or perspective) can deepen our sense of our selves in a way that can be powerfully creative and enlivening. In contemporary psychoanalysis, Relational theorists have, likewise, deepened the meaning of empathy into a two person experience with their recognition that otherness stimulates and nourishes growth of the Self.

Interrelatedness is necessarily reciprocal, and generates a tension between self and other. Just as light and dark require the other to define the one, poles of the dialectic necessitate the other, so each needs otherness and the other to better know the self. In the mutual sharing of both the hope to make meaning and the despair of mortality, what (content) is said is not particularly salient. Rather it is the connection to, and articulation of, the conflictisg needs between therapist and patient, or lover and beloved, that frees both to access a greater diversity in the experience of self. We aid patients in their accessing a more varied experience of themselves by opening our selves to broader and more spontaneous experience. So, too, do lovers mutually struggle to find one’s own subjectivity, and struggle with the subjectivity of the other.

Winnicott, though, reminds us that there is also always a private self that remains incommunicado. A lover, then, must tolerate the unknowableness of the other’s core self while simultaneously reaching towards knowing. Slavin, in his deeply philosophical probing of human experience, posits the evolutionarily adaptive function that this core self guarantees: a safe guarding of ourselves and our own interests when we simultaneously seek, sometimes through accommodation, surrender, or altruism and love, the enriched experience of self and other. Without this ever present tension between self and other, Slavin noted, human evolution would not have been possible, as we would, instead, be like ants, bees, or wasps, in a totalitarian utopian vision where individual needs and separateness disappear. Humans, in loving, find ways of negotiating each other’s differing realities and seek to accommodate without over accommodating. It is not a bad trade off.

Lycia Alexander-Guerra, MD

Psychoanalytic Training Changed My Life, Really

Psychoanalytic training in the USA requires experience as an analysand, in addition to the clinical training as an analyst being supervised by more experienced analysts, as well as the didactic courses. Embarking on the journey to become a psychoanalyst required for me a radical shift from my medical training. As a physician and psychiatrist, I learned to be a diagnostician, pharmacologist, and advice-giver. Being a psychoanalyst requires a different perspective. Modifying the medical ‘fix it’ model, I had to emphasize collaboration with, instead of imparting knowledge to or directing, a patient. Symptoms and complaints take on additional communication about symbolic meaning and relationship. (Experience in interpreting poetry, literature, and film for their many levels of symbolic meaning gave me a good start for thinking about the many levels of connotative meaning, beyond the denotative, of a patient’s narrative.)

There are many theories about what is helpful to psychoanalytic psychotherapy patients. Theories of psychoanalysis and psychoanalytic psychotherapy have evolved for more than a century since Freud first introduced his ideas, and they continue to evolve, so we hold onto theories lightly. We still utilize some of the traditional Freudian principles, e.g. one of the cornerstones of psychoanalysis remains the acknowledgement of the Unconscious (or Unconsciouses) , though defining it, and ideas about accessing it, have undergone modification. The other aspect agreed upon is that the relationship is important.

While there is some research about what is mutative, it is relatively sparse. Various schools of psychoanalysis privilege different aspects. Structural/Ego analysts, for example, might aim to foster the more frequent use of more mature, adaptive defenses, or to ‘discover’, with the patient, unconscious conflict. Object Relations analysts might strive to keep pace with what part –object is manifest in the patient or analyst at any moment and to help the patient integrate her/his sense of self/others. Relational analysts might utilize what is going on within the therapeutic dyad to co-construct a narrative that helps patients connect more with themselves and with others. Self psychology recognizes the importance of empathy and attunement, and of the analyst serving as a selfobject experience for the patient so that the arrested psyche can recommence its development. The Intersubjective School might stress mutual recognition that fosters reciprocity and greater interpersonal satisfaction.

All authors and clinicians have their own biases about theories. From difference we enrich our repertoire and experience. Supervision and peer supervision is invaluable, as is sharing the conversational ‘space’ and embracing difference of opinions. While reading papers and texts may initially aid confidence, nothing can substitute for experience. Not only did psychoanalytic training improve my capacity to be open to and understand patients, benefitting treatment outcomes, but it allowed the building of a full and satisfying practice. One of the aspects of practicing psychoanalysis which makes it so delightful to me is that, if we are open to the present moment, we get better and better at it, day by day, minute by minute.

An Analytic Attitude

As I come off a three week break from facilitating classes at the Tampa Bay Institute for Psychoanalytic Studies, Inc., I think again about how experienced psychoanalytic clinicians might share an analytic attitude with students, avid to experience a deeper relationship and understanding with those who seek them out for help. While an analytic attitude comes with inclination and experience, fostered by training and our own analyses, and while there is no agreement on theory, analysts share the common attitude of endeavoring to understand the intrapsychic and interpersonal life of the patient, to hold the needs of the patient within a frame, and to foster the growth and development of the patient toward a more meaningful and enriched, diverse life. We behave ethically. We behave with restraint. We work to be aware of the influence we have on patients by being self-reflective. We bear, sometimes with our patients, sometimes alone, unbearable affects, tensions, paradox, and uncertainty.

Perhaps I would benefit most from a New Year's resolution to give up control, to 'let go.' Most people, including therapists, particularly those with medical training, have the urge to assert control and avoid vulnerabilities and insufficiencies. Giving up the illusion of control, however scary, and being open to the experience of therapy and its co-creativity, allows transformative possibilities, and leads us and our patients away from self-alienation. Control does not constitute nor uplift the self.

A psychoanalytic attitude is the openness to experience the emotional ‘truth’ of the other’s, as well as our own, subjectivity. It is an ardent experiencing, appreciating experience in its own right, alongside insight, toward the true self; to value not only knowing but being toward the true self. This philosophical attitude decenters insight’s privileged place and makes room for relationship and for being with. Decreasing the patient’s isolation can lessen suffering. Psychotherapy is a sacred experience, under-taken, like faith, with one’s whole being, giving oneself over to the possibility of being in communion, if only rarely and momentarily, with another. Each member of the dyad ideally participates with openness and intensity as we make meaning of ourselves and our lives through revelation and through impact on each other.

Bion advocated an openness to the patient within the bounds of our ethics, always mustering up our respect, decency, and wisdom. When analyzing, open inquiry is preferable to knowledge. Bion advised that we approach each session ‘without memory or desire,’ that we be open to the new possibilities co-created when the therapist does not insist on knowing or on helping, but instead leaves space for a path that is always evolving, unpredictable and unique. When we, with an open heart, do not expect patients to give up their troubles, another serendipitous effect may include the lessening of those very symptoms.

I ask myself, "Can I recognize without flinching another’s subjectivity, or, when I inevitably flinch, can I acknowledge with the patient my discomfort in a way that negotiates a new closeness with, and understanding of, the patient? Can I model that there is no thing too untenable to hear, or to bear feeling, in the company of another? Can I survive the untenable without retaliation (withdrawal, humiliation, breaches of empathy) and hold in tension (not ‘either/or’ but ‘both’) uncertainty with knowing?"

Lycia Alexander-Guerra, MD

Affect and Emotional Life

“Psychoanalysis is emotional medicine for emotional ills.” (Orange, 1995). “Ideas, insights, interpretations, and other cognitive approaches may support emotional healing, but they do not provide it… only if the analyst can find room in inside herself or himself for THIS patient is there any hope.” (emphasis added).
Accordingly, Orange outlines an intersubjective theory of affect and emotional life. She emphasizes three features of emotional life. First, the complexity of emotional life. “Emotional life, an irreducibly complex process, requires an epistemology that resists the urge to oversimplify. Relational history makes understanding emotional life an intricate task. We continually organize and reorganize [experience] in layers of meaning.

Therefore, “[w]hen we attempt to extract an “affect’ from the continuity and complexity of any emotional life, and use that affect to explain something, we make two mistakes. First, we abstract and extract what is inextricable. Second, we may violate the integrity of the person’s experience. Although some of this violence is unavoidable, patients often point it out to us. When we attempt to help a patient articulate a feeling, we often hear: “But that is not all,” or “It’s more than that,” or “It keeps changing.”

Orange points out that one “effect of the psychoanalytic tendency to speak of single emotions has been the focus on ambivalence and its acceptance as a model of mental health. In this view we are always torn between love and hatred, conceived as two basic and simple affects. We must feel both toward the same person at the same time. On the contrary, I see emotional life as originally complex. It makes more sense to wonder how it disintegrated, how it became oversimplified. How did the responses in a given family bring a child to feel that loving a parent was incompatible with anger, or disappointment, or interest in something else besides the parent? How did the child develop the conviction that feeling itself was dangerous to significant ties?”

In addition to isolating some emotions from the whole of emotional life, another difficulty is that “[m]any emotions, like shame and dread, are themselves internally layered. Shame involves self-hatred in the face of explicit or implicit other’s perceived or expected disapproval. It is complex, often multiply layered, and usually continuous with moments of more intense pain. People often say, “I’m ashamed that I’m ashamed about this.” (I plan to consider of shame as part of the experience of emotional trauma in a subsequent post which I suggest to read in the context of the present one.)

“A second essential feature of emotional life,” Orange continues, “is its relational character. Emotions are responses to relational events or needs, and emotional expression is an attempt to connect, or to regulate connection, with another. The social smile of infants is a social smile. Smiling and crying are methods of “object seeking” (Fairbairn, 1952). Any thoroughly relational theory of human nature or psychoanalysis must treat emotional life in that context. Emotional experience begins, continues, and heals in specific intersubjective contexts. When emotional experience is presented as independent of context – psychiatry speaks of “inappropriate affect,” for example – this may mislead us into thinking of emotion as a mere internal signal. Instead, from the perspective of intersubjective theory, we see the emotional expression of the moment as formed by relational history and as evoked or triggered by the intersubjective fields of the present. Its reference to the future often consists in the expectation that the relational experience of the future will resemble that of the past, but it includes an anxious hope that someone will respond differently.” (emphasis added).

Third, “[n]ot only complex and relational, emotional life is emotional. This apparent tautology is important only because both psychiatric and psychoanalytic languages have attempted to describe and work with emotion as if it were a cognition or an instinctual derivative. In either case it is viewed as residing in the individual. On the contrary, I see emotion as a primarily noncognitive and nonverbal relational response. It can be linked to cognitions and schemata, but it has its own reality.”

Recognizing that intersubjectivity theory had a cognitive cast, Orange (1995) began, and has continued, ((Orange et al (1997), Stolorow et al (2202)), to point out that the principal components of subjectivity, the organizing principles, “often unconscious, are the emotional conclusions [or emotional convictions] a person has drawn from lifelong experience of the emotional environment, especially the complex mutual connections with early caregivers. Until these principles become available for conscious reflection, and until new emotional experience leads a person to envision and expect new forms of emotional connection, these old inferences will thematize the sense of self. This sense of self includes convictions about the relational consequences of possible forms of being. A person may feel, for example, that any form of self articulation or differentiation will invite ridicule or sarcasm.” (emphasis added).

Arising as “emotional inferences a child draws from intersubjective experience in the family of origin… [t]hese principles [or convictions] may concern relatedness, as in “I must adapt to others’ needs (moods, expectations, and so on) if I am to retain significant emotional ties. They may also consist in a fundamental sense of self, still intersubjectively configured: “I will never amount to anything,” I am always a burden,” “I am worthless and god for nothing…” More often, these principles are emotional inferences drawn as the child attempts to organize some sense of self out of chaotic, traumatic, or more subtly confusing early and later relational experience.”

Orange (1995) concludes “[i]f emotional life is truly complex, relational and “emotional,” then certain clinical consequences follow. One is that our patient’s “Yes, but…” may not be defensive but instead may be a plea for a fuller understanding of “complex mental states”(Kohut, 1959). If we believe that emotion really differs from cognition, then we will distinguish emotion and cognition in talking with patients and support a respect for the contribution of each to a whole human life. We will show regard for a “sense of things”- ours or the patient’s – whether or not this sense is verbalizable. In a Winnicottian spirit, we will make more room in many psychoanalytic treatments for art, music, and poetry as a means of creating a shared emotional life. We will also have less need to reduce these “forms of feeling” Hobson, (1985)to any form of cognition or insight.” (emphasis added).
Ernesto Vasquez, April 6, 2010

Orange, D. (1995), Emotional Understanding: Studies in Psychoanalytic Epistemology. New York: Guilford Press.
Orange, D., Atwood, G., & Stolorow, R. (1997), Working Intersubjectively. Contextualism in Psychoanalytic Practice. Hillsdale, NJ: The Analytic Press.
Stolorow, R., Atwood, G., and Orange, D. (2002), Worlds of Experience. Interweaving philosophical and clinical dimensions in psychoanalysis. New York: Basic Books.

Today’s Easter Sunday marks the forty-second anniversary of the assassination of Dr. Martin Luther King, Jr.

King, the Moses of black Americans, though never to see it himself, was to deliver his people to the Promised Land, a promise of freedom afforded under the protection of the U.S. Constitution. His assassination marked, to the utmost, the failure of recognition of the other as a separate center of subjectivity (Benjamin), just as white Americans for centuries had failed to see black Americans as subjects, treating them instead as objects, property, inferiors, where different than meant less than, as if there were no self that survives the destruction of otherness, as if we could not be enriched by different perspectives and points of view. Were it that this split complementarity of otherness could instead be the source of newness and creativity to be savored as an enriching newness that lifts us up out of the ashes and dust of conformity, complacency, and deadness of the soul. Is this not the resurrection that we all may celebrate?

Assurance to those who bring difference (of opinion)

I would like to assure Robert Stolorow that there was no "cruelty and viciousness" and no attacks on Stolorow's personhood in the presentation in Tampa on March 21, 2010 by Philip Ringstrom. Instead, Ringstrom questioned ideas and pointed out, as he saw them, contradictions, or perhaps simply described an evolution of ideas. He also contrasted how other theorists might use terms and apply theories clinically. The recent post, without the original offending document, makes its contents hearsay.

While we are all grateful to the contributions of Stolorow in his describing the phenomenology of trauma, and we heartedly regret any suffering he endures, we also struggle to hold in tension ideas that contradict his in our attempts to practice perspectival realism, to give all self states a voice, and to consider the subjectivity and 'truth' of a myriad of ideas.

Is Stolorow's Intersubjectivity Intersubjective? Philip Ringstrom in Tampa Bay

Philip Ringstrom delighted the intimate group -- particularly students in attendance from the Tampa Bay Institute of Psychoanalytic Studies, Inc (T-BIPS) who are learning to think critically-- with his critique of Stolorow, Atwood, and Orange’s Worlds of Experience (2002) on Sunday, March 21, 2010 at the Tampa Bay Psychoanalytic Society, Inc. (TBPS). An interesting juxtaposition for Tampa Bay, as Stolorow had recently (Jan 2010) discussed his work in Tampa, this book was currently being read at T-BIPS. Ringstrom also contrasted these authors, who write as if with one voice, to Relational authors who, celebrating difference, write in separate voices.

Stolorow, et al had a theory of intersubjectivity which posited that it was not trauma per se which proved traumatic but instead the absence of attuned responsiveness, along with feeling shamed for one’s reactions to trauma, which proved traumatic. Ringstrom claims that Stolorow, as a result of experiencing his own personal trauma and finding no comfort in the attuned responses from others, had a crisis of theory: Stolorow distinguished attunement not supplied with attunement not felt. Ringstrom thinks Stolorow has a hidden moral agenda, when, after turning to philosophy, particularly Heidegger, Trauma and Human Existence(2007) splits the world into those who have been traumatized, their absolutisms shattered (brothers and sisters in darkness) and therefore, consequently, the only ones awakened to authenticity, and those who have not been traumatized and therefore continue to live in delusion. Stolorow finds the two incommensurable.

Ringstrom finds this incommensurability at odds with intersubjectivity, for intersubjectivity, per Stolorow et al, says all is contextualized. Likewise, if Stolorow et al had previously seen as normal delusions which are protective after the shattering of absolutisms, how now, when these delusions are shattered, do traumatized people become the only ones who are normal/authentic? And if only those who are traumatized can supply, in a kind of twinship, attunement to other victims of trauma, Relational theorists might ask how then does Stolorow’s intersubjectivity confront difference? While Stolorow sees twinship as a consequence of trauma, Ringstrom asks what becomes of Kohut’s idea that there exists an innate longing for twinship? (He refers us to Ilene Philipson’s Pathologizing Twinship.) Ringstrom adds that twinship is also a cult dynamic, splitting ‘us’ and ‘them,’ and sees the us/them mentality as a failure (see Benjamin’s work) of intersubjectivity.

Instead, Ringstrom considers a part of what is traumatic to include the unimaginable. In Heidegger’s being toward death, there is an awareness of death, and the question is whether, at the end of one’s life, one has lived an authentic life or not. Ringstrom referred to the paradox eloquently described by Irwin Hoffmann: that death is both a necessary boundary to ascribe meaning to life and renders life meaningless. Ringstrom cautions against confusing this death anxiety with death trauma. The audience, too, noted the difficulty of taking personal experience and generalizing it to a theory.

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

Academy Awards 2010

Daunted by the Academy’s nomination this year of ten films for the honor of Best Picture, some that I might still choose to never see, I will not be blogging about the nominees this season [despite my great love for the Coen Brothers and for Tarantino] in this category, save one, Up in the Air. I will also say something about A Single Man, of which I think the Academy mistakenly failed to include as a nominee for Best Picture, along with their oversight of Julianne Moore for Best Supporting Actress.


When one in the psychoanalytic field thinks of trauma and loss, one thinks of the idea of a relational home which serves to mitigate both. Shelley Doctors notes that Relational therapists are attuned to how two together interact, what is uniquely co-created from this interaction, and, yes, what meaning is made of it. Being in relationship with another can facilitate the capacity of being with; being with our painful feelings, and, as Doctors, adds, the perception of the other as receptive creates an atmosphere “in which experience may be known and shared;” what Hazel Ipp says permits “ a sense of release, revitalization, and enhanced connection.” Robert Stolorow also intimates the importance of a relational home when he writes that “Painful emotional experiences become enduringly traumatic in the absence of an intersubjective context within which they can be held and integrated.”

Up in the Air (directed by the very adroit Jason Reitman of Juno and inspired by the novel by Walter Kirn) is about a hired gun (George Clooney), who performs the dirty work [no, this is not Michael Clayton again] as the firing agent for companies which, though downsizing, want to avoid breaking the heart-breaking news to their soon to be former employees. Ryan Bingham (Clooney) is connected to no one, has no significant other, and has little contact with his family of origin. Nonetheless, he almost blithely dispenses advice and encouragement, and solves problems on a need to need basis. Many of those devastated by job loss in this film are portrayed by people who are not actors but who have lost, in their real lives, their jobs. It is somewhat precious that they now get to respond to their, albeit fictional, hang men. What is most striking about these real people are their explanations, at the end of the film, about what kept them going despite the loss of a huge part of their days and identities: unequivocally it is their loved ones, their relational homes. This is in vivid contrast to Bingham, and to George Falconer ( A Single Man).


In A Single Man (adapted from Christopher Isherwood’s novel and boasts fashion designer Tom Ford as first time director), Falconer (Colin Firth) has lost a sixteen year emotional home when his lover was killed in a car crash. The victim’s family, eschewing its son’s homosexuality, did not even allow Falconer to attend the funeral of his beloved. And, because this is 1962,because Falconer is a teacher (professor at a California college), or perhaps just English, he must keep his homosexuality a secret, both falconer and captive falcon. This culturally and self imposed isolation leaves him consequently having no one, save Julianne Moore, with whom to share his loss. There is no relational home which might serve to mitigate overwhelming grief.

While Up in the Air aptly captures the cold starkness of hotel rooms (even those upgraded for the million, or ten, mile club) befitting of a man unconnected, A Single Man has the beautiful cinematography of a period piece (1962! with JFK and finned cars), sometimes shot in black and white, sometimes in dreamscape. Is it strange that I found both movies so uplifting? Bingham, for his temerity and generosity despite having no current connections? and Falconer for his ability to see beauty moment by moment despite, perhaps because of, a great loss?

Lycia Alexander-Guerra, MD

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]

Empathy as a human attribute, a sensibility

In her post of February 15th, Lycia Alexander-Guerra gives us a cogent summary of Frank Lachmann’s
formulations of empathy at the Society’s day-long meeting on Saturday February 13th, 2010. I would like to focus here on one particular aspect of Lachmann’s presentation.

Although in the morning session Lachmann said that “[e]mpathy, like any skill, can be acquired and enhanced
by training and learning,” in the afternoon session, I believe he modeled empathy as a quality of the person, a human attribute, a disposition, an inclination, an attitude, a capacity, a sensibility, a way of being-in-the-world.

For, in the course of our dialogue, something quite remarkable emerged very naturally from within Lachmann,
imperceptibly at first - a delicacy, a caring, a respect, almost a reverence for the human condition as he shared
his understanding of the adolescent who had murdered his parents and about the Tramp’s plight in Charlie
Chaplin’s film ‘City Lights. ’ Then, by the inflection in his voice, his stance, and nearly transcendent facial
expression, Lachmann seemed to be saying appreciatively “behold the patient,” that is, the one who suffers.
We were so fortunate, I believe, to witness the emergence of an analyst’s spirit, of his capacity for empathy, an
ability cultivated over time and in many ways, rather than something (a skill) one can simply go out and get. This
was for me an experience full of wonder, and a richly evocative one at that.

It brought to mind the notion of emotional availability, Donna Orange’s (1995) synonym for empathy. She
describes psychoanalysis as conversation, “as patient and analyst making sense together, reaching an emotional
understanding.” Further, she proposes that “the only sort of understanding that can heal emotional wounds is
emotional understanding.” And argues that “each person’s perspective is inevitably partial and that a more
adequate view of anything requires dialogue. In such conversation we attempt to reach, practically speaking, a
good-enough understanding of whatever is under discussion. In psychoanalysis, where the subject matter is a
person’s emotional life, understanding that heals requires a mutually experienced emotional connection between
patient and analyst.”

Orange suggests that among the conditions and attitudes that support good-enough emotional understanding,
“[o]ne requirement is the emotional availability of particular analyst for a healing connection with the particular
person who comes for therapy or analysis. This implies the willingness and the ability of the therapist to p rovide
for that person a developmental second chance at a rich and integrated emotional life.” Orange continues, “Psychoanalytic understanding is knowledge gained from inside the intersubjective field formed by the intersection of two differently organized subjectivities. In dialogue, both participants attempt to expand
their original subjective perspectives to take in, comprehend, and understand more of the other’s experience.
We do this. . .b y placing ourselves, as consistently as we can, in the other’s shoes, both cognitively and
emotionally. We understand by participating in the emotional experience, in the being, of the other.” (emphasis
added).

A relational mode of knowing emotional reality, empathy not only emerges from personal relation but it creates
the other as a subject, since “subjectivity becomes real only when two subjectivities meet in a personal relation.
Only in such a relation can we empathically know - not just know about - one another.” Orange later concludes, “[a]n analyst must be Gadamer’s “person with understanding,” able and willing to enter the patient’s suffering and share the painful history, able and willing to “undergo the situation” with the other. I will call this combination of capacity and willingness “emotional availability.” Only when it is present can patient and analyst make sense of what seems senseless...”

In sum, “[e]mpathy is emotional knowledge gained by participation in a shared reality. It is knowledge arising
from attunement...Empathic response comes from attunement to this shared reality, and must take the form at
a frequency an d in a mode (auditory or visual, for example) that the receiver can comprehend. An empathic
environment ...is one in which each person can feel like a Thou, a respected and admired partner in a
conversation... Thus, empathy, including empathic response, is a necessary condition for understanding.”
Emotional availability thus understood is a general disposition, a readiness to respond. “This readiness to offer
our emotional expressions - verbal, semiverbal, or nonverbal - is a crucial component of the conversation that
creates psychoanalytic understanding. We offer our emotional expressions, not as substitute for those of the
patient, but as pump-priming, or facilitating, responses, our participation in the analytic squiggle game...often our attempts will be inaccurate, but in the atmosphere of emotional safety provided by this very responsiveness,
many patients can use what we offer as a kind of catalyst for their own emotional expression. We show by those
attempts that we are trying to understand, that we can imagine the patient to be having some emotional
response, and that various - and perhaps less-than-elegant - expressions of emotion are more than acceptable
to us. These attempts are trial balloons...and they convey to the patient that guessing is just fine. Together we
are attempting to find an understanding.”

- Orange, D. M. Emotional Understanding. Studies in Psychoanalytic Epistemology. New York, New York,
Guilford, 1995.

Ernesto Vasquez, MD
February 16, 2010

'Being Toward Death'

The Self Psychology Study Group of the Tampa Bay Institute for Psychoanalytic Studies, Inc. had its usual 'waging of dialogue' when it discussed, yesterday, the final chapters in Robert Stolorow's book "Trauma and Human Existence." Stolorow emphasized two points: that emotional life is context embedded; and that emotional trauma is constitutive of human existence. In the discussion, Peter Rudnytsky highlighted "the tension between a 'relational' view of trauma, which emphasizes the context-dependency that makes some experiences traumatic but not others, and an 'ontological' view, which posits that there is something inherently traumatic in human existence and our 'being-toward' death." Peter noted that "Stolorow says something close to this in his last chapter," and also noted that he wished [Stolorow] had brought it out in the previous chapter, where Peter thought that Stolorow's "presentation of Heidegger accepted too uncritically the premise that death is an essentially non-relational phenomenon."


Because of the finitude of human existence and the finitude of emotional connections with others, I thought Stolorow intimates that we should 'be with' each other in grief: he writes: we are "deeply connected with one another in virtue of our common[italics, his] finitude," that is, we have a "kinship-in-finitude,' or what Vogel called "brothers and sisters in the same dark"[ness].

I think many of us know this to be so. After 9/11, we, for a moment, thought we might be just a little kinder to one another, for life is precarious as well as precious. We were shaken from our everyday denial of (a turning away from?) death. And in moments of crisis, trauma, or loss, it is the lucky who find a "relational home" with family and friends. Stolorow writes, "Loss can be an emotional trauma for which it is especially difficult to find a relational home." William Upshaw pointed out yesterday how the psychotherapeutic relationship allows a relational home -- for sorrow and grief and loss, and for authenticity.

Stolorow's phrase "authentic being toward death" led me to consider that authenticity is a dialogue, a dialectic if you will, and that one cannot be authentic 'toward death' without also being so toward life, holding in tension this unpredictable but certain looming reality of death alongside the reaching for, the deeply living of, life. Stolorow quotes Critchley: "death and finitude are fundamentally relational." For me, when I contemplate my own death, I think of how it will affect those loved ones left behind, and I assure them now that my life is, has been, full, and so they need not worry on my account. As for those I have loved and lost, while part of me is diminished, that loss is held in tension with the gratitude of what that love brought to my life.

Lycia Alexander-Guerra

A Day with Stolorow, Part II

In the afternoon of Saturday, January 9, 2010, Robert Stolorow, PhD spoke to the Tampa Bay Psychoanalytic Society, Inc on “Contextual and Existential Dimensions of Trauma,” allowing us to experience why he is sometimes called ‘the prince of darkness.’ In his talk, Stolorow noted the contextuality and embeddedness of emotional life, and of emotional trauma, in particular.

A child requires affective attunement from another to assist in tolerance of emotion. Affect tolerance, then, is a property of a relational system. In fact, intolerance of an affect state or of a trauma is unrelated to the quantity or intensity of that affect or trauma, but instead it is the absence of emotional attunement that renders affects or traumas unassimilatable.

Painful emotional experience becomes enduringly traumatic in the absence of emotional attunement, i.e. trauma is context sensitive. Death, and finitude (our limitations), are constitutively relational. It is “the incomparable power of understanding” (George Atwood) that mitigates the finitude of relationality.

Existentially, trauma shatters absolutisms and exposes the fragility of illusions of invulnerability with which we move through the world. Unassimilated trauma leads one to feel dreadful alienation and estrangement and exposes us to the randomness and unpredictability of life. Stolorow expands what Heidegger wrote about the authentic being toward death by adding being toward loss.

He noted that, while trauma produces feelings, there also exist feelings about these trauma-induced feelings. Clinically, it is the secondary feelings that often must be explored first, as patients may feel shame about exposing the trauma-induced feelings. Retraumatization may occur when an experience closely replicates the original trauma; when it confirms the organizing principles established by the traumatic experience; or when there is loss of the bond that served to counteract the trauma.

Lycia Alexander-Guerra, MD

photo by John Lambert, LCSW