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.

Repulsion in the analyst

In the afternoon session of “A Day with Bruce Herzog” on January 14, 2012, Dr. Herzog presented to the Tampa Bay Psychoanalytic Society, Inc.: Repulsion in the Analyst and its Impact on Empathic Capacity, a paper that is remarkable for Herzog's willingness to discuss something many therapists are loathe to admit. His candor about times when he was disgusted or disdainful and how he traversed these therapeutic impasses was compelling.

Herzog believes “For an adequate therapeutic process to occur there must be islands of empathic contact, which requires some matching of relational premises [1] between the analyst and patient.” and that “greatest empathic connection takes place when the relational premises of patient and therapist are best aligned. [I think of how much easier it is to love a friend than an enemy.]

Patients may come to us expecting rejection or disdain while simultaneously hoping for something different. There are other times when revulsion is in accordance with the patient’s point of view [empathy?], and serves to collude with a patient so that neither discusses something they find unacceptable. Herzog encourages us: “As long as there are enough instances where there is a concordance of relational premises and behaviors in the dyad, sufficient areas of contact for a ‘good enough’ empathic connection can be established.” He emboldens us: “The therapist first needs to know that empathizing with the patient will not harm him [him the therapist].”

While this may be so, it is, of course, I think, incumbent upon the analyst to seek, to struggle, assiduously if need be, to find the point of view of the other. Sometimes there seems to be no common ground, sometimes empathy fails us, and we are left then to negotiate explicitly a way to be together without common ground. Sometimes this negotiation can only come to the table through the other side of an enactment.


[1]“ ‘Relational premises’ refer to the many innate relational assumptions that are applied by an individual to interpersonal circumstances. These assumptions amount to belief systems that we hold about the functioning of, and our place within, relationships. We often assume that others share our relational premises; this is not always the case and can be a cause of considerable conflict…”

A Conversation With Bruce Herzog: Relational Templates

When the Tampa Bay Psychoanalytic Society, Inc offers a day-long program with a guest psychoanalyst, one of my favorite parts of the day is the early morning, intimate, small group “Conversation” with the expert speaker. On January 14, 2012, Bruce Herzog discussed his very accessible ideas about relational templates.

Repeated behavior becomes a relational template, and becomes procedural. He defines relational template as “an internalized relational pattern that has been learned through repeated exposure and applied to interpersonal circumstances throughout life”[1] and may be “activated” by specific, contextually-driven interactions. (Unlike Stolorow’s ‘invariant organizing principles’ which implies cognitive, relational templates are behavioral. Herzog‘s “relational expectancies” are more akin to the former. A relational expectancy includes an automaticity that assumes a relationship to be a certain way.)

Multiple templates exist, each with its own variable unconscious, and are hierarchical, the most frequently activated ones being the most accessible. He notes “a stockpile of templates waiting to be mobilized when needed”[2] The analyst can track shifts in relational states (often accompanied by a shift in affect), e.g. when a negative transference appears. Clinically, the analytic relationship offers the opportunity to encode new ways of being in relationship, new templates. For example, when a patient, long holding the expectancy to be ignored or misunderstood, finds that the analyst does not meet her/his expectation, a new template is encoded and now joins the repertoire of multiple relational templates. Herzog notes that each of us has the capacity throughout life to continue to grow and change when our expectations are confounded in this way.

Herzog prefers the term ‘template’ for its simplicity; Preferring ‘relational template’ to the unwieldy 'projective identification,' Herzog nonetheless notes that Klein described something useful to the clinician. For example, where Kleinian analysts might say a patient had projected disavowed sadism into the analyst and so now the analyst is feeling angry at the patient, Herzog would say simply that a sadomasochistic template has been activated.

Like an attuned parent who gives words to experience, thereby adding to the child’s comfort, mastery, or joy, Herzog says “naming and explaining” helps a patient. But, he notes, it is not simply content which is mutative, but that we bother to say something at all, for, along with tone, prosody, etc, this is also a procedural interpretation, the non-symbolic part of the verbal interpretation. [See his 2001 paper]

Patients may activate templates in the therapist just as analysts’ behaviors also activate patients’ templates. The therapist has certain capacities (e.g. what s/he can give) while the patient has certain capacities too (e.g. what s/he can take). In template theory, provision might balance expectation; it is as if the analyst is saying, ‘Even though you ask something of me in a way that makes me want to withdraw from you, I know you need it and so I will provide it.’ Having in the past been accused of being a ‘provision-ist,’ Herzog retorts that the accuser might be a ‘frustration-ist’ and recalls how Kohut advocated “optimal frustration” and Bacall, “optimal responsiveness.”[3]

Herzog finds that perhaps his foremost goal in treatment is to enjoy his work, which means enjoying his patient, which means the patient, perhaps for the first time, is enjoyed (thereby creating a new relational template). Herzog also reminds us that each therapist must ‘survive’ (in Winnicottian terms). He also seeks to find something he can love in every patient. [It is perhaps these final sentiments with which I most agree.]






[3] Bacal and Herzog (2000). Optimal Responsiveness and the Use of Specificity Theory
in Clinical Practice, Presented at the 23rd Annual International Conference on The
Psychology of The Self, Chicago, Ill.

Herzog, B. (2001). Procedural Interpretation and Insight: The Art of Working Between
the Lines in the Non-Verbal Realm. Presented at the 24th Annual International
Conference on The Psychology of The Self, San Francisco, Ca.

[1,2] Herzog, B. (2004). Reconsidering the Unconscious: Shifting Relational States,
Activators, and the Variable Unconscious. Presented at the 27th Annual
International Conference on The Psychology of The Self, San Diego, Ca.

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.

Richard Geist delineates Self from Ego Psychology

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

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

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

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

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

by Lycia Alexander-Guerra, MD

photo provided by John Lambert, LCSW

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.

Experience Near

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

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

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

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

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

Frank Lachmann: Principles of Salience; Empathy and Affect; Expectations: met, surpassed, violated.

Three Principles of Salience
In his early morning presentation on Saturday, February 13, 2010 to the Tampa Bay Psychoanalytic Society, Inc, Dr. Lachmann encouraged attendees to include an awareness of the leading edge of a patient’s strivings, and not to overemphasize the trailing edge. For example, a patient’s competitiveness with the therapist may be an advance for the patient, a moving beyond what he/she could previously achieve [previously may have been unable to assert her/himself]. This new striving needs to be recognized as growth, and not merely be interpreted as a wish to usurp (Oedipal) or steal from the analyst the interpretations. Lachmann also distinguished between the Self Psychological approach:‘I learned from the patient…’; and other approaches: ‘I pointed out to the patient… [which, I think, speaks to co-creation and a collaborative effort, as distinguished from the one who knows, the omniscient analyst].

To provide the underpinnings for what we may find useful clinically/ how transformation comes about,Lachmann (and B.Beebee) in their book "Infant Research and Adult Treatment" elaborated three principles of salience, developed from infant research: 1) an infant builds its psychic structure (representations; organizing principles, RIGs) through its ongoing experiences of regulation, both self regulations and interactive regulations. For the latter, day to day activities between infant and mother build up what to expect from the particular dyad. The accrual of these built up experiences, which are mutually influenced by each partner in the dyad, is a dialectic of ever changing, moment by moment, influence on the self and other. [You can never stand in the same river twice.] In the clinical setting, session to session activities, such as greetings and parting rituals [or how either approach or withdraw from certain topics], also build up representations of interactions which become generalized (Dan Stern’s RIGs). Important, in addition to interpretation, are these built up expectations. 2) disruptions inevitably occur, when , e.g., mother is over or under responsive to the infant, and repairs must then follow to reestablish regulation. In the clinical situation, ruptures (e.g. the end of the session) do not require apology but, instead, ruptures in dialogue are to be investigated. 3) Heightened affective moments (from Fred Pine), whether due to joy or trauma, have a more powerful organizing effect than the mere passage of the time they take to occur would warrant. [similar to “attractor states” in systems theory, per one attendee]. The three principles of salience are clinically useful to think about in session: e.g. what produced the disruption? How might it be explored? What was a heightened affective moment? A clinical example was used to illustrate this.
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Empathy and Affect

In his later morning presentation, Lachmann talked about empathy and affect. Empathy, “vicarious introspection" [Kohut] or ‘feeling oneself into the subjective experience of another,’ is advocated from the very beginning of treatment. (Later, citing Robert McKee, lecturer on structure of film narrative, McKee says that -- a “like me” experience from the viewer, a resonance with the character who must have a shred of humanity, a moment of recognition, is required to maintain the audience’s emotional involvement).

Lachmann countered critics who erroneously characterize Self psychology as using empathy as the only way that an analyst conveys information or effects transformation. Empathy, Lachmann says, is necessary but not sufficient. Differing from Kohut, Lachmann stated that it is not the transformation of archaic narcissism (which needs mirroring and idealizing transferences) into mature narcissism (empathy, humor, creativity, recognition of transience, wisdom), but, rather, it is affect and only affect which is transformed in therapy, and done so only as a result of affective engagement. It is not defenses, self states, or ego organization, but affect, which is transformed.

Kohut did not spell out how transformation is brought about. Using the three principles of salience, Lachmann says transformation is bi-directional, impacting both therapist and patient, and co-created (the analyst may have empathy, but the patient must be ready to be empathized with), and embedded in the therapeutic process, ongoing throughout the therapy. It is through ongoing regulation, rupture and repair, and heightened affective moments that transformation takes place. [of Lachmann’s 2007, Transforming Narcissism: Reflections on Empathy, Humor, and Expectations the following is written: “He asserts that empathy, humor, and creativity are not the goals or end products of transformations, but are an intrinsic part of the ongoing therapist-patient dialogue throughout treatment. The transformative process is bidirectional, impacting both patient and therapist, and their affect undergoes transformation - for example from detached to intimate - and narcissism or self-states are transformed secondarily as a consequence of the affective interactions. Meeting or violating expectations of emotional responsivity provides a major pathway for transformation of affect.”]

Precursors to empathy are procedural and non-conscious, but none the less lead to an understanding of the patient’s subjective experience. They indicate the capacity for later empathy and accessibility to our inner states, and include: cross modal transfer (e.g. where one hears the words, but imagines/sees the scene) . This precursor is present from birth, as illustrated in neonates who imitate sticking out the tongue (what has been seen is transfer to body movement), or in infant’s ability to attend to a ball (smooth or nubbed) previously felt, but not seen; state sharing (different from projective identification, as state sharing is bi-directional and co-created, and as it is a natural occurrence and not necessarily defensive); and entering in to the behavioral stream of another (one may change posture or vocal tone to be commensurate with the other’s). Resonance does not have to be exact to be effective. [In fact, the analyst, being close enough to be reminiscent of an old object—transference, but also different enough to be new object and to allow for the possibility of a new experience—new relational paradigm or new organizing principle, is therapeutic.]

In ongoing regulation, patient and therapist negotiate closeness/distance, intimacy, and attachment via their posture, body movements, vocal tones, and rhythms, all which lead to transient shifts in the affective states of both partners. Each self transforms, each changes, leading to something unique and new. Tronick’s “still face”(of previously responsive and engaged mother) paradigm was used for illustration, in which violation of expectations leads to distress, disengagement, and withdrawal in infants.
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Expectations: met, surpassed, violated.
In the afternoon, Lachmann discussed infant research further, and later dissected the reports on the school shooter Kip Kinkel, who first murdered his parents before killing classmates. Lachmann, noting Edward Tronick’s and Dan Stern’s works on the violations of expectations of affective responsivity (and Andre Green’s paper on the ‘dead mother’), reminded us that infants meet/imitate affective states of the mother to be in connection with her and not merely as a defense against loss.

Violations, when repeated, can become strain trauma, and early trauma of chaos, unpredictability, abuse, and other indiscriminate behavior, may leave a person vulnerable to feeling unsafe with others or when alone, and handicap the capacity for reciprocity in relationships. Such a person may lack resources to right self esteem when narcissistically injured and therefore erupt with rage, and may have learned, early on, to violate (invading privacy—as in obscene phone calls; assault; rape) the expectations of others. But joyful violations (irony, humor, creativity, and well-timed surprise-- about three seconds for infants)may be welcome. On the other hand, expectations too closely met, as when mother echoes infant’s distress without some irony or modification, may increase the infant’s terror or anxiety. One may have expectation of welcome or rejection, invasion or intimacy.

Therapeutic action may confirm (meet) or contradict (violate) expectations. Lachmann asks: What is the nature of the different experience that the analyst effects with the patient?, and, What specifically is the effect of this differing experience on the patient?, for a different experience in itself is not sufficient to promote change.

Lycia Alexander-Guerra, MD
photos by John Lambert, LCSW

'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

MODES OF LISTENING

The early morning “Conversation with James Fosshage” which began "A Day with James Fosshage, PhD" October 10, 2009, at the Tampa Bay Psychoanalytic Society, Inc. (TBPS) previewed some of Fosshage's ideas about implicit and explicit communication, learning, and knowing, and their applicability to the clinical situation.

Cognitive Psychology’s learning theories about implicit procedural (riding a bike, playing tennis) processing was expanded to the relational sphere, implicit relational knowing, by the Boston Change Process Study Group (BCPSG), which includes Lyons-Ruth and (Daniel) Stern. While appreciating that the BCPSG is beginning to rethink privileging the implicit over the explicit for what is mutative, Fosshage emphasizes the interaction between both, and sees the implicit emotional context and the explicit verbal as powerfully mutative, words having to be backed by the emotional processing. This idea sparked TBPS member, William Upshaw, MD, to state that being [perceived as] genuine [occurs] when the implicit and explicit are matched.

Fosshage described three modes of listening: Kohut’s empathic mode of listening from within the patient’s perspective; other-centered listening which encompasses what it feels like for the analyst to be in relationship with the patient (e.g. the analyst finds herself experiencing listening to the patient as delightful or loathsome); and listening from the analyst’s self perspective, where the analyst’s subjectivity enters.

Of interest, too, was Fosshage’s description of a comprehensive interpretation. Rather than including elements attributed to the id, ego, and superego, or even to past, current, and transferential aspects, Fosshage stated that a comprehensive interpretation would include empathic listening, other-centered listening, and the analyst’s self perspective. Contrasting himself to the interpersonalists, who privilege making explicit how it feels to be with the patient, Fosshage said he starts with empathic listening and takes cues from the patient as to whether increased expression of the subjectivity of the analyst is invited (e.g. a patient might ask, “Are you angry with me?’).

Later in the day, Fosshage discusses invitations to subjectivity that have to do with love, and how he responds to such invitations, such as when a patient states "I love you," or asks "Do you find me sexually attractive?"

It's Not Incompatible After All!
Using Theoretical Differences

A Commentary on Susan Sands' article, "Self Psychology and Projective Identification - Whither Shall They Meet?"

By Jacqueline Roller, PsyD


Susan Sands identified herself as a relational clinician whose work is grounded in self psychology. I was impressed with her ability to examine how self psychology may fall short of understanding some patients. I had been drawn to self psychology because it purports an empathic immersion with the patient. I previously understood this empathic stance as one of the most mutative elements of analysis. Her article made a sound argument that the empathic immersion is with the patient’s ego (concordant identification). Sands cautioned that self psychology is at risk of missing an important aspect of the patient’s internal world, namely the internalized objects (complementary identification). This article challenged me to re-examine my previous theoretical stance in order to more fully understand the patient.

Sands argued that the analyst may miss the countertransference in the empathic immersion. The analyst may be blinded from recognizing when the identification is with the patient’s internal objects (complementary identification) rather than the patient’s ego (concordant identification). The article emphasized that patients have a desire to be fully understood; including their disavowed affective experiences. Sands contends that empathic immersion promotes understanding only one aspect of the identification.

After consideration of the article, I continue to believe empathic immersion is a helpful tool for concordant identification with the patient. With this immersion I can gain greater understanding of the patient’s ego. However, I am left without an understanding of the patient’s internalized objects, namely complementary identification. This article challenges me to receive the patient’s experience of disavowed affect in order for complementary identification to occur. I believe projective identification is a useful tool for receiving the experience. The transformative element will occur when I can receive the projection, contain the experience, survive it, and then offer something different to the patient. The article builds a strong case for using the empathic immersion of self psychology while maintaining an open container for receiving the projection. If I offer a space that allows for both concordant and complementary identification there is a greater chance that the treatment will be mutative.

References
Sands, S.H. (1997). Self Psychology and Projective Identification—Whither Shall They Meet? A Reply to the Editors (1995). Psychoanal. Dial., 7:651-668


Jacqueline Roller, PsyD attends the New Directions program in psychoanalytic writing at the Washington Center for Psychoanalysis in Washington D.C. and is in private practice in Sarasota, Florida.

What are the curative factors in recovery from mental illness?

Link to a very interesting article in the Washington Post on Feb. 10, by Charles Barber, a mental health worker at Yale:

http://www.washingtonpost.com/wp-dyn/content/article/2008/02/08/AR2008020803272.html?hpid=opinionsbox1

Barber describes his own journey to recovery from an incapacitating mental condition, and draws some observations from his own experience and from research into the conditions that facilitate recovery. He speaks against the "medical model" of attempting to alleviate symptoms through the use of drugs, and instead focuses on the healing effects of "social context." He notes that outcomes from even such severe mental illnesses as schizophrenia are better in developing countries, where "patients get more support from family and society." His is an argument against pharmacotherapy and "therapist as expert," and instead, an argument for immersion in a supportive social mileau.

Barber does not use the language of self psychology or relational analytic theory but, using these schools of thought as lenses, what he says becomes readily explainable. A self psychologist would recognize all of the curative factors Barber lists as sustaining selfobject relationships that lead to restoration of cohesion to the disequilibrated self. What Barber describes as curative is the restoration of the "selfobject mileau."

Near the end of his article, Barber states that "Listening to patients [the curative factor] cuts against the establishment grain." Here, he speaks of what Kohut and others have termed "empathic immersion" in the patient's experiential world. (Cf. also Donna Orange et al.)

How would other schools of psychoanalytic thought explain what Barber describes in his article? Post your thoughts, reactions, and other musings on how best to explain the important observations about what constitute the curative factors that Barber describes.

Note that Barber has a newly-published book in which he elaborates on these ideas.