More about the co-creation of transference

In teaching and learning more about the co-creation of ‘transference’ in our Intro to Psychoanalytic Concepts I course, we used papers by Fosshage and by Slochower to further our discussion. While Fosshage helped the class rethink anonymity and abstinence from a more contemporary view, and nicely explicated a more contemporary idea of transference as an organizing activity from the classical displacement model of transference, the candidates and I agreed that the distinction between pathological and non-pathological forms of transference may not add to our clinical experience. Regardless of its form, we agreed that transference is always co-created.

A lovely example came, again, from a candidate. The candidate described that her patient had insulted her, the analyst’s, competence, then the patient additionally complained that the analyst was a ‘blank screen.’ The candidate-analyst found it “harder to hear” that she was viewed by her patient as not so human (capable of feeling) than to hear she was not so skilled as a therapist. The candidate then explained to her peers [who had heretofore failed to see the co-creation of the patient’s latter comment] how she, the therapist, had “refused the discomfort” of the insult to her competence and so had remained unmoved. “I did not feel my anger” so “my answer was not human.” The patient, having expected hurt or anger, or some response, and having read -right brain to right brain-  the therapist’s dissociation from uncomfortable human feeling, then complained about the ‘blank screen.’  

This segued nicely into Slochower’s paper where we see Slochower on the cusp of struggling to recognize her own contribution to the patient’s ‘hateful’ness, and struggling to ‘wear the attributions’ of incompetence, manipulativeness, and greed as she negotiates with her patient an attempt at a mutual understanding. A second candidate noted aloud how Slochower’s interrogation of ‘Why would I want to do that?” nonetheless leads to a deeper revelation about the patient’s fears: “Obviously, to get as much money from me as possible.” Slochower gives us an illustrative case example of just how very hard it is for analysts to see our own contribution and acknowledge it to patients and, thus, validate the patients’ experience of us. This is one way our patients are our best supervisors.

Fosshage, J.L. (1994). Toward Reconceptualising Transference: Theoretical and Clinical Considerations. Int. J. Psycho-Anal., 75:265-280.

Slochower, J. (1992). A Hateful Borderline Patient and the Holding Environment. Contemp. Psychoanal., 28:72-88.

When transference stinks

What we learn first stays with us the longest. 

In beginning a new cycle of first year courses this semester, TBIPS, in its Intro to Psa Concepts I, starts with a contemporary point of view. Asking candidates and students to think about what are some possible components of a psychoanalytic process, someone includes ‘transference.’ We have read for today’s class a paper by Lew Aron and one by Irwin Hoffman.

A psychoanalytic candidate expresses scepticism about the relational concept of mutual influence in the transference: ‘Doesn’t the patient bring things in her head that have been there before she ever met you?’ Of course the patient brings things that had nothing to do with the therapist, but what emerges with the therapist is constitutive of being with the therapist. The candidate gives an example: ‘I open the door to a first time patient and she says, “your building smells.” How could that not have come from her alone?’ I am curious. The candidate says this particular patient had had a traumatic past and had been physically disfigured-- her face, her gait-- in a fire. I inquire: what was his experience at the moment he opened the door to this patient whose face had been thus scarred. The candidate said that the film The Exorcist had come to his mind, her face horrifying, terrible.

Since microexpressions can be non-consciously communicated, right brain to right brain, and since horror can look like disgust, and disgust akin to bad smells, was it possible that this new patient recognized her new therapist’s look of disgust and her right brain registered it as ‘something stinks around here’? Maybe. The patient did not return after the initial consultation. What might have happened had the therapist spoken aloud to the trauma this patient endured as evident from her facial scars and, more important, had inquired about what it was like to see the initial shock of them on his face?

The class is inordinately grateful for this candidate’s example which helped us illustrate a more contemporary view-- that of mutual influence-- of transference. His example speaks to the readings:

From Aron:

“The analytic situation is constituted by the mutual regulation of communication between patient and analyst in which both patient and analyst affect and are affected by each other. The relationship is mutual but asymmetrical.”

“the patient’s experience of the analyst’s subjectivity needs to be made conscious”

“It is often useful to ask patients directly what they have noticed about the analyst, what they think the analyst is feeling or doing, what they think is going on in the analyst, or with what conflict they feel the analyst is struggling.”       

“The exploration of the patient's experience of the analyst’s subjectivity represents only one aspect of the analysis of transference.”  

From Hoffman:

“For Langs what is wrong with the classical position is that it overestimates the prevalence of relatively pure, uncontaminated transference.”

“the implications of the patient's ability to interpret the analyst's manifest behavior as betraying latent countertransference.”

Aron, L. (1991). The Patient's Experience of the Analyst's Subjectivity. Psychoanal. Dial., 1(1):29-51.

Hoffman, I.Z. (1983). The Patient as Interpreter of the Analyst's Experience. Contemp. Psychoanal., 19:389-422.

Requesting more Swift progress

I may not be very familiar with the music of Taylor Swift but I have, of course, heard of her stature in the music industry when she stood up for music artists’ income by pulling her music off Spotify (a streaming music service) in 2014. Now, in a victory that affects many more women and men, she is standing up “for...anyone who feels silenced by sexual assault.” On Monday (8-14-17), Swift won a victory [She was awarded what she asked for, a symbolic $1.] against a former DJ who blamed Swift for his firing when she accused him of groping her at a pre-concert photo shoot.

Our profession knows only too well the devastating effects on sexual assault survivors. Now, if only the U.S. President would stand up against bigotry and hatred. Many of us were more than chagrined at his waffling about such hatred evidenced last week in Charlottesville,VA with the death of Heather Heyer and injury to others. I do know one lyric attributed to Swift, “Haters gonna hate.” Unfortunately, many cannot “shake it off” and the consequences of hate also need to be given a voice. A voice is another important, empowering benefit of therapy.

More about narrative, or narrating one’s story

American writer Richard Ford, who has recently written Between Them -- the memoir of his parents’ (Parker and Edna) life and love-- shared with PBS Newshour’s IMHO (In My Humble Opinion) on May 19, 2017 some of the reasons one writes a memoir:

“To render testimony

To bear witness

To make sense of a recollected life...

Substantiate ourselves to ourselves…

To utter what must not be erased…”

and because “I missed them” and some longings are “acted upon even long after it might be

supposed that enough time has passed for longing to subside.”

Furthermore, “Age is a winnowing process and sometimes what gets sifted out as we seek to know the important consequence of lives are the actual lives themselves.”  About his parents’ lives, he recognized that though “as most parents are, [they were] all but unnoticeable in the world’s disinterested eye,” they were of importance to him because of the love and relationship they shared with him. [I am reminded of the iconic play “Our Town” (1938) by Thornton Wilder where the ordinary town of Grover’s Corners and the ordinary lives of its citizens are made extraordinary by the relationships people share.] He said of them: “Being their son seemed a privilege, and almost mysteriously, they opened for me a world of immense possibility.”

Perhaps in response to the current political climate, he added, “In a world cloaked in supposition and opinion and misdirection and often in outright untruth, things do actually happen. My parents’ lives did take place.”

Some of Ford's reasons for writing this memoir speak to our work (witnessing, remembering and making sense, even instantiating authentic beings through actual experience). When we listen with reverence and love to the stories of the lives of our patients, we validate the importance of their memories, their feelings and their lives. For as Ford noted from Saint Augustine ‘Memory is a faculty of the soul.’

More on storytelling narrative, and on how to do so, literally, or literary

A lot has been written in contemporary psychoanalysis about the need to free ourselves from strict theory and technique in favor of the process of the moment to moment experience of two people intimately engaged in the collaborative construction of relationship and of meaning, primarily for the patient’s benefit. I was pleasantly struck to find the same ideas about uncertainty, spontaneity, surprise, and surrender in the process of one author’s writing.

Listen to what George Saunders, author of the critically acclaimed and New York Times best-selling novel Lincoln in the Bardo (2017), tells Jeffrey Brown on the Newshour Bookshelf (March 28, 2017) about the process of writing: “The holiest state is to be a little confused by what you are doing and you are guided by the energy that the story is actually giving you as it is revised. That’s kind of tricky because it means you have to abandon your ideas about organization or thematics and really submit [surrender] to the story… and hopefully it will result in some new mode of beauty.”

I thought it aptly put. (He is a wordsmith after all.)

By the way, Saunders additionally said in the same interview that he was inspired by Lincoln who had somehow been able to “transform... sorrow into a kind of expanding empathy for everybody” and whose “response to fear or hardship was expansiveness instead of shrinkage.” Were that we all were so heroic.

The search for happiness, I mean, meaning.

Emily Esfahani Smith, author of “The Power of Meaning” reported in a PBS Newshour IMHO (In my humble opinion) segment on Mar 10, 2017 that psychologists have counterintuitively concluded that the chasing after happiness can leave people unhappy and lonely. It is instead the search for meaning and trying to figure out how to make our lives count which bring happiness. She cites the epic of Gilgamesh, one of the oldest known literary works (Mesopotamian, ~ 2500 BC), and sees in it the hero’s search for how to live knowing that he will die. Smith says his quest remains urgent.

Social scientists say meaning is found when we connect and contribute to something beyond ourselves, such as to family, work, nature, or god. Smith cites three conditions found in people who say they have meaningful lives: 1) They believe their lives matter; 2) They have a sense of purpose;  and 3) They think their lives are coherent and make sense. Storytelling itself gives meaning, she says, and offers clarity.

I am reminded of the work we psychoanalysts do, a connection which brings personal meaning to our lives, but also affords to our clients both a search for meaning and an attempt at a coherent story.  We know that a coherent narrative in Mary Main’s Adult Attachment Interview predicts secure attachment.  We know, too, that an important job in parenting is to convey to a child that she or he matters, has a right to exist, and is connected to something bigger (the family). Tomorrow, were he alive today, would be my father’s 96th birthday. I wanted to give a grateful shout out to my father for having always conveyed meaning to our lives by his love and dedication to his family (he was a great listener and storyteller himself) and to his work (he was a writer who showed joy and meaning could exist in one’s professional life), and by seeing his joy burgeon as he aged (through his interaction with his grandchildren).

Meaning through connection and narrative? Our profession was made for it.

Container Function

Bion conceived of the analyst as a ‘container’ of projected parts of the other-- as mother is for infant-- particularly of intense, negative affects. The extruded parts and affects of the other are what is ‘contained.’ Analyst (as with mother) is not merely a receptive container, but a welcoming and validating one, and, moreover, accepts and modifies them (a part of the alpha function), but does not necessarily interpret them. The ‘container’ ideally dampens these overwhelming affects so that they are eventually amenable to regulation and self-reflection.

Thus, through projective identification (projection and response to what is projected) the analyst has come to know unwanted affects and painful relational patterns, and furthermore attempts to ‘digest’ them and re-present them in a more ‘palatable’ form. We might note the similarity to making use, after the fact, of enactments which bring to light nonconsciously encoded patterns of ‘how to be” in relationship-- except that enactments are made use of by both analyst and patient who intersubjectively process shared experience and co-create any meaning making. An example might be mutual recognition containing aggression because complementarity is no longer at work.

Spezzano adds a felicitous element to Bion’s ambiguous term ‘container’ when he intimates it is: to be held in the mind and meaning system of the other as a protection against psychic homelessness, meaninglessness and chaos. Putting parts of the self in the other may then be an attempt to create holding of the self in the analyst’s mind. In the analyst’s mind, there can be an increased opportunity to co-create context for them, and an increased capacity to safely play with these projected parts, as was the case with a young man-- an avid user of ‘spice’ or K2, but no longer a user of heroin -- who let me feel all the sadness, himself long indifferent (numb) to the pain experienced by the little boy whose mother had left him and his father when he was but six years old (he never saw her again). Tears could stream down his face when I described the plight of an abandoned six year old, but that boy’s sadness was not his own. Through approaching the loss and confusion of a child through the little boy I held in mind, my patient could begin to approach what might have been his own experience.

Lullaby

    Clinicians just starting out often worry about saying the ‘right’ thing to a patient. I often tell supervisees that people come to us not for answers, and not necessarily for words, but for “something more,” such as a longing to be recognized, to have someone take an interest in their inner lives. As humans, we usually have an interest in others, and as therapists, a deep interest in others and in their inner lives. We have a desire to know more, and we make an effort not to impinge with our curiosity, to have a benevolent curiosity if you will. So far so good.

     People also come to us needing to be held in mind. Just as caregivers grow the brains of their infants by gazing at them, by enjoying them, by remembering and imagining what it was like to be such a baby with an inner life and with experiences, so the holding a patient in mind (even outside of the session) comes to us as we reflect on and imagine the past, present, and future experiences of our patients. The caregivers’ interest grows the baby’s inner life: the baby experiences itself as ‘I am interesting. I am important. I have a right to be here. I exist.’ 
Sometimes our patients need such things from us: to be held in mind, to be enjoyed, to hold our interest, to have their feelings “marked” (in the same direction of the affect, without being identical). These experiences are part of “implicit relational knowing” and do not require words to effect reconfigurations in brain anatomy and brain chemistry. 

Sometimes our most sorrowful of patients have missed out on some necessary pre-verbal experiences: of being gazed at, nursed, rocked, sung to, of being held in the caregiver’s arms, and being held in mind. Ogden called this very important fundamental stage of sensory experience the autistic-contiguous position. It is the foundation or sensory ‘floor’ upon which subsequent experience is integrated and organized.  

    I recall a 15 year old boy with a horrible history of abandonment, neglect and physical and sexual abuse, often in foster care, who was court ordered to see me after punching his father. (His father had called the police.)  The boy arrived for the first appointment very angry. He crossed his arms, declared emphatically that he was not going to talk to me, and promptly fell asleep on the couch for the entire session. 
Perhaps I had the autistic-contiguous position in mind. Perhaps I was thinking about this boy’s childhood (some of it previously revealed to me by his father when the father had made the appointment) and thus was imagining that this boy had probably never been held in the mind of a caregiver, never been held in a caregiver’s arms and been rocked and sung to, never had consistent opportunities for mutual regulation of distressing affects. But, whatever the 'reason,' I began to sing him a lullaby as he slept there immobile. When the session was over, he lept off the couch. He returned the following week and each week thereafter, and talked and told me his sorrows. (He even hoped to continue long past the six months ordered by the court.)

Ogden, TH. (1989) The Primitive Edge of Experience. Northvale, NJ: Jason Aronson.

Intersubjectivity and China

In psychoanalysis we talk a lot about intersubjectivity, seeing the other, the different other, as “an equivalent center of being” (Benjamin), the recognizing of difference. In the USA, with travel bans and threats to build walls between countries, we lament the negation of the other, the falling to one side of a polarity, failing to sustain the tension between differing subjectivities.

In 2010 I congratulated the talented Chinese therapist I supervised, for the Nobel Peace Prize had been bestowed on her fellow countryman Liu Xiaobo. She had not heard. 

Censorship was only one area against which human rights activist Liu struggled. He authored books on democracy and human rights.  Liu, imprisoned after co-authoring in 2008 ‘Charter 08’ -- a petition-manifesto signed by hundreds which criticized Chinese government and called for political reform -- was not allowed to receive the Prize in person. He died today, disallowed from receiving treatment outside of China for liver cancer. He is the first Nobel laureate to die in detention in almost eighty years. Liu had been previously imprisoned for over a decade after taking part in the 1989 Tiananmen Square protest, where students faced down tanks. He had been an activist for human rights in China since then.

Black Girl Interrupted, Black Girls’ Internalization

Internalization alludes to aspects of the other, including those projected, which can become part of the self, encoded experientially and procedurally in the brain, as do interactions or way of interacting with the other. What the other feels about the self, what is implicitly communicated, also becomes part of the sense of self, whether positive or negative feelings. It is the feeling (affect) more than the action that is encoded. Whether the self can come to expect soothing or neglect is also internalized. This procedural knowledge is carried forth into later life.

Black girls age 5-9 years are seen as older than their years, called ‘adultification,’ according to a recently published study by Jamilia J Blake, PhD, Associate Professor of Educational Psychology at Texas A&M University and Rebecca Epstein, Executive Director of Georgetown Law’s Center on Poverty and Inequality. Blake and Epstein found that black girls are seen by the school and juvenile justice systems as more adult and less innocent than their white peers. They are perceived as needing less protection and less comfort and nurturing, and were found to be punished more harshly than white peers, e.g. five times more likely than white girls and twice as likely as white boys to be suspended from school. Teachers were more likely to call the police on black girls and prosecutors less likely to drop cases against them than white girls. While a previous study by a separate research team [Perry] had shown a similar ‘adultification’ of black boys from about age ten years, black girls showed a higher disportionate rate of disciplinary action than even black boys, thought due to ‘gender transgressions’ (violating norms of femininity).

What adults project onto children affects the way children see themselves. So, what happens when children are seen as less innocent and more adult like (whether ‘adultified’ or parentified)? are punished more harshly? and given less nurturing? Do they grow up perceiving themselves to be ‘bad’ and unworthy of their longings for [inter]dependency, comfort, and help? Do they feel undeserving of tender caring and instead are the caregivers, or, worse, so bereft of receiving care that their subsequent and understandable resentment and anger lead to lashing out, even becoming the delinquents others expected all along?