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.

Richard Geist replies to comments...to March 13, 2011 post

I agree with Richard that it is imperative we recognize the patient's healthy tendrils that are often embedded in their pathology because this is really the only thing we have to work with and build upon. Focusing on pathology often feels humiliating to the patient and provides little more than intellectual insight. The issue of empathizing with oneself is also crucial, but unfortunately not written about in the literature and a therapeutic goal. Carolyn and Amy, what can I say except thank you for your kind words! And being medium is pretty good for patients. Jessica, I agree completely; working from a connectedness perspective comes with its own complications and risks and requires more of the therapist/analyst than using a "technique" that keeps us somewhat distant, but safer. But, as you say, it also requires that we are very careful that what we are doing is in the service of the patient's needs not ours. Kristine, you're probably right there will be some criticism and you're right that I was enamored with my patient, but I think in the way that parents tend to over value their kids--and feeling slightly over valued as a patient is not such a bad thing. Barbara, I hadn't thought about it that way, but of course you're right that sharing the information with her was in itself an action, in this case I think in the service of welcoming what I perceived as an emerging twinship selfobject need. But again it is important as you point out to make sure we at least think we are acting in the service of the patient's needs. Steve, those patients who resist closeness require the same empathic understanding of their overwhelming fear of being close (and often the emotional traumas that have resulted from it). If we can allow them to remain distant while understanding the necessity for it, I have found eventually they will allow themselves to come a bit more connected. Christine, I think you're right (as was Pam); there were sexual undertones, but I didn't feel they were the central theme in terms of her sense of self. If they had been, I would have responded more directly to them. Ernesto, I think you're right; affect is central to connectedness and empathy as well as selfobject function. Perhaps I took this too much for granted rather than spelling it out.

Richard Geist, Ed.D.

Richard Geist delineates Self from Ego Psychology

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

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

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

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

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

by Lycia Alexander-Guerra, MD

photo provided by John Lambert, LCSW

Experience Near

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

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

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

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

“Psychoanalytic Process”

On the afternoon of September 11, 2010, Sanford Shapiro, MD , referring to his paper “Psychoanalytic Process” explored what is mutative. Shapiro recalled that Ego psychology teaches that interpretation of defense leads to insight. But he reminded us that many experiences, trauma, disorganized attachments, chronic and severe lack of mentalization, may occur before language acquisition, leaving the experiences implicitly encoded but without connection to symbolization or language and, so, unavailable to interpretation. Many experiences are non-conscious (implicitly encoded) such that they never make it to consciousness. These experiences do not follow Freud’s model of the unconscious, that is, are not made up of what was once conscious but repressed.

Additionally, Shapiro has given up allegiance to an intrapsychic experience, recognizing that all experience is contextualized in an interpersonal world (Atwood, Orange, Stolorow).

Implicit relational knowing (Daniel Stern) is not conscious, and, therefore, not accessible to interpretation and insight. [must be enacted and made explicit.] Benjamin writes: what can’t be told must be shown. These automatic behaviors impact all subsequent relationships, including transference, throughout life.

Neuroscience now knows that our neurons are both plastic and their number is not fixed at birth. We know that the development of the brain is context dependent. This allows the possibility for the hope of changing neuronal dendritic branching and neuronal connections through psychoanalytic therapies. What this means is that new relational experiences offer options to automatically triggered relational patterns.

The analyst helps the patient develop reflective curiosity about automatic relational paradigms, often done by ‘perturbations’ (systems theory) which may disorganize a stable system and momentarily allow for the possibility to reconfigure experience in a new way. Patients can be very forgiving when we do not blame them for ruptures and we allow for repair.

Shapiro also spoke about pathological accommodation (Brandchaft). He noted that normal accommodation is a negotiation between two people such that neither feels the integrity of either individual has been compromised. He referred to Ghent’s paper on masochism, submission, and surrender, noting that surrender is not at one’s expense, but that submission is when one subverts one’s own integrity to someone else’s authority. Brandchaft agrees with Mahler’s individuation process (but disagrees about separation): parents must negotiate the child’s individuation so that the child remains safe and can be assertive. If negotiation does not occur, the child complies or is rebellious, and pays the price with isolation.

Clinically, says Shapiro, pathological accommodation is triggered by certain events and are signaled by subtle shifts in affect (not content). Shapiro says it is important to go back and see what happened immediately before the shift, inviting the patient‘s curiosity, and admitting a mistake was made by the analyst. Taking responsibility for the rupture is sometimes a new emotional response, and the patient may begin to experience that h/she does not have to go along or comply to stay connected. It is also important to take the shame out of any rupture, e.g reframing a motivational experience from aggression (about which one can be ashamed) to a survival mechanism or a way of regulating tension (about which one might feel good).

The empathic introspective mode helps a patient “feel mentalized by the analyst." This, in turn, helps the patient begin to get a sense of self. The patient finds her/himself in the therapist’s mind. Mentalization (Fonagy) elaborates the intersubjective capacity to know that another has a separate mind with differing contents. Stern says we are born with the capacity to be intersubjective; Benjamin sees it as a developmental achievement, created via the third.

“The Evolution of Contemporary Psychoanalysis”

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

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

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

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

Shapiro says his theory is simply investigation, or inquiry. He tries to avoid being loyal to a theory or technique so as to allow himself to be with the other. Shapiro follows the moment to moment affective response of the patient to his interpretations to know if he is on track.
***

In his paper, “The Evolution of Contemporary Psychoanalysis” Shapiro states that Contemporary Psychoanalysis is a two person psychology born out of the cross-fertilization between interpersonal and self psychologies. He also juxtaposed interpersonal and relational theories against Freudian, Kleinian, Ego and Self psychologies, Intersubjective, and social constructionists.

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

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

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

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

A Therapist's Use of the Self

On April 17, 2010 I attended the Tampa Bay Psychoanalytic Society’s “Day with Lauren Levine, PhD.” Dr. Levine, both a delightful person and a sensitive and talented clinician, eloquently managed to convey, both implicitly and explicitly, her relational approach to psychoanalytic psychotherapy. Weaving throughout her clinical paper the story of her patient and herself with the ideas of her teachers and mentors at the NYU Post Doc she elucidated the use of the analyst’s self to facilitate transformation in the patient. Noting from Adrienne Harris that ‘the analyst’s wounds that must serve as tools,’ Dr.Levine said, “Our own relational stories at times facilitate, and at times hinder, our capacity to engage deeply in the analytic process.”

In her paper, Dr. Levine explores the ways in which, as analysts, "transformative aspects of our personal analyses reside, often unconsciously, or preconsciously in the analyst, creating unexpected opportunities in our work with patients." She describes how a profound piece of work in her own analysis around efforts to connect with her young son "resonated in her work with a patient, enlivening and deepening the treatment." "In the process, her patient discovered new places within herself which enabled her to reach out to her teenage son in new and reparative ways."

From Dr. Levine's relational perspective, it is critical for the analyst to have the capacity, and the courage to go to those darker places within herself, and draw from that emotional reservoir in deconstructing enactments, so that the analysis is "safe, but not too safe" (Bromberg) for analyst as well as patient.

Dr. Levine used the experiences in her own analysis and with her son to open up the analytic space with her patient, seeking, as Stephanie Solow Glennon proposed, ‘to foster authenticity, aliveness, and creativity.’ Recognizing the wisdom of Emanuel Ghent’s words that each of us has ‘a deep yearning to be found and recognized,’ Dr. Levine strives to create the safety, as suggested by Adrienne Harris, necessary ‘to open access to unbearable affects.’ She strives to help her patients “begin to feel less ashamed and humiliated of those split-off, unacceptable parts of oneself.”

Darlene Ehrenberg described the ‘intimate edge’ as 'not simply at the boundary between self and other; it is also at the boundary of self-awareness…. It is a point of expanding self-discovery, at which one can become more intimate with one’s own experience through the evolving relationship with the other, and then more intimate with the other as one becomes more attuned to oneself. '

For the complete and eloquent illustration of the use of the self by Lauren Levine, see her paper "Transformative Aspects of Our Own Analyses and Their Resonance in Our Work With Our Patients” in Psychoanalytic Dialogues, 19:454–462, 2009.

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

Neuroscience in Psychoanalysis?

I think so, for to truly think and work contextually (Orange, Atwood, & Stolorow, 1997), and not diminish the experience of the inescapable embodiment of our non-corporeal being, it helps to have a working knowledge of our physiological functioning, as we tussle with the marvel that the interrelatedness of body and spirit is.

It seems that Freud was grappling with these issues for he published closely together (1893-1895) Studies in Hysteria which launched the talking cure, and The Project for a Scientific Psychology. The latter reflects Freud’s abiding interest in understanding the biological foundations of the psychological processes and phenomena with which psychoanalysis is concerned. But, as Gallese (2007b) points out, given the limited state of knowledge and technologies at the time, the Project could not be carried very far.

In his illuminating discourse on empathy last weekend, Frank Lachmann alerted us to several of its components which he calls procedural precursors and describes as nonconscious automatic processes: cross-modal transfer, vocal rhythm coordination, affective state sharing, and entering the behavioral, affective, and proprioceptive streams of another person. These processes are subsets of neurophysiological functioning and Lachmann mentioned in passing the mirror neuron system (“...everything seems to be mirror neurons these days...”).

This evoked for me the neuroscientific and psychoanalytic work of Vittorio Gallese which is summarized in a number of papers published in psychoanalytic periodicals
(2003, 2006, 2007, 2007a, 2007b, 2008, 2009, 2009a, 2009b). This body of knowledge points to the Mirror Neuron System as the network in the Central Nervous System that coordinates, mediates, Lachmann’s precursors of empathy, as well as a number of other important functions. I find the details of Gallese’s discoveries and formulations endlessly fascinating. But here (Gallese et al., 2007b) he conveys the idea pithily:


“The neural circuits activated in a person carrying out actions, expressing emotions, and experiencing sensations are activated also, automatically via a mirror neuron system, in the observer of those actions, emotions, and sensations...
this finding of shared activation suggests a functional mechanism of “embodied simulation” that consists of the automatic, unconscious, and non-inferential simulation in the observer of actions, emotions, and sensations carried out and experienced by the observed...
the shared neural activation pattern and the accompanying embodied simulation constitute a fundamental biological basis for understanding another’s mind…
The implications of this perspective for psychoanalysis are discussed, particularly regarding unconscious communication, projective identification, attunement, empathy, autism, therapeutic action, and transference-countertransference interactions.” (emphasis added).


With Orange, Atwood, and Stolorow (1997), I believe that the central domain of psychoanalytic inquiry is subjective experience and its vicissitudes, and that each psychoanalytic process is concerned with the emergence of understanding, of relatedness, of stable and positive self-experience. I am not proposing here that neural mechanisms become a central concern. I am suggesting that taking into account biological factors (the embodiment of our existence) provides a fuller context for our theorizing and for our work.

Ernesto Vasquez, MD
February 18, 2009.


Gallese V. The roots of empathy: The shared manifold hypothesis and the neural basis of intersubjectivity. Psychopatology, Vol. 36, No. 4, 171-180, 2003.
— (2006), Mirror neurons and intentional attunement: A commentary on David Olds. J Am Psychoanal Assoc, 54:46-57.
— (2007), Empathy, embodied simulation and mirroring mechanisms. Commentary on “Towards a neuroscience of empathy” by Doug Watt. Neuropsychoanalysis, 9, vol 2: 146-151.
—, Eagle M.E., and Migone P. (2007a), Intentional attunement: Mirror neurons and the neural underpinnings of interpersonal relations. J Am Psychoanal Assoc, 2007a, 55: 131-176.
— (2007b), Dai neuroni specchio alla consonanza intenzionale. Meccanismi neurofisiologici dell’intersoggettività. Rivista di Psicoanalisi, LIII, 1: 197-208.
— (2008), Empathy, embodied simulation and the brain. J Am Psychoanal Assoc, 56:769-781.
— (2009), Mirror neurons, embodied simulation, and the neural basis of social identification. Psychoanalytic Dialogues, 19:519-536.
— (2009a), We-ness. Embodied simulation and Psychoanalysis. Reply to commentaries. Psychoanalytic Dialogues, 19: 580-584.
Eagle M.E., Gallese V., Migone P. (2009b), Mirror neurons and mind; Commentary on Vivona. J Am Psychoanal Assoc, 57(3): 559-68.
Orange, D., Atwood, G., Stolorow, R. (1997), Working Intersubjectively. Contextualism in Psychoanalytic Practice. Hillsdale, NJ, The Analytic Press.

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

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

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

Narcissism Negates Subjectivity

In an early morning conversation with Daniel Shaw, LCSW, from the National Institute for the Psychotherapies (NIP), NYC, as the prelude to his presentation to the Tampa Bay Psychoanalytic Society, Inc (TBPS) on November 7, 2009 of his paper Enter Ghosts: The Loss of Intersubjectivity in Clinical Work with Adult Children of Pathological Narcissists, Shaw disclosed how he was inspired, in part, by the NY production of Eugene O’Neill’s Long Day’s Journey into Night to write about Alice and the cumulative relational trauma she suffered at the hands of her narcissistic parents. Shaw’s early training had led him to Heinz Kohut’s How Does Analysis Cure and Alice Miller’s The Drama of the Gifted Child, but he credits Alice with teaching him to ‘hang in there with’ challenging patients, and for helping him to grow as an analyst and a person. Allowing for the possibility that nobody is always right allows for growth (even in such hegemonic ideologies as classical psychoanalytic theory).

The breakdown of intersubjectivity is complementarity. Shaw expands Fairbairn’s concept of “the moral defense” to include the complementary part parents play in this relational dynamic. Recall that the moral defense, put simply, states that in order to maintain the attachment to the parents, a child of bad parents chooses to feel s/he is bad rather than acknowledge that the parents are bad. Complementary to the child, narcissistic parents see themselves as all good, perfect, and infallible, the complement to the child’s taking on the badness. As the parent disavows her/his own badness, the child is coerced into accepting the projection. The child is continually objectified, not subjectified.

Narcissism negates subjectivity. When a child is continually objectified by narcissistic parents who do not recognize the child as her/his own center of agency, the child suffers cumulative relational stress, or cumulative developmental trauma. The child grows up in a double bind, not allowed independent desire which risks abandonment and rejection, but disdained for her/his dependence, a dependence associated with shame and humiliation.

Kim Vaz, in her introduction of Shaw to TBPS, revealed his struggles with, and his compassion for, his challenging patients when she took this excerpt from another of Shaw’s papers, which received the 2001 Educator's Award for an Outstanding Scholarly Paper from NIP ( Shaw, D. (2003). On the Therapeutic Action of Analytic Love. Contemporary Psychoanalysis, 39:251-278.):

“Ari was a patient who was not easy to love, at least not at first and not for me. Ari was forty when he began to see me. His marriage was falling apart and he had been miserable for years. He felt close to becoming violent with his wife. He was burned out, always angry and always anxious, at home and at work . . . . Ari spent most of a year splenetically venting, about his wife, his son, his partners, his employees, and so forth. Feeling shut out, I often found myself shuttling between resentment, detachment, and feeling intimidated. Eventually, I understood that I was withdrawing, withholding a necessary confrontation, in retaliation for the narcissistic injury I felt about my perceived lack of effect on him. This understanding helped me to reorganize and mobilize the assertiveness I needed in order to reach Ari. One day, I finally raised my voice and said, quite loudly, ‘You know, I would like to say some things to you, but I'm afraid if you don't like what you hear, you will bite my head off, possibly literally.’
Ari looked up at me with his sharp, penetrating eyes, and I was scared. I was quite surprised and touched, though, to see Ari's eyes go moist, his face reddening. He said sadly, ‘I'm just like my father. Yes, this is what I do to everyone, my wife, my son, everyone, just like my father did.’
I said, ‘It must be awfully lonely, with everyone afraid of you like that.’ He looked up at me, silently. I added, ‘You know that song “Desperado?”’
‘Yes, I know it,’ he said, still looking intently at me.
‘You remind me of those lines, “you better let somebody love you, before it's too late.”’
Ari looked down and began to weep. I was quite moved. Right then, my very mixed feelings about Ari melted into an unexpected warmth, respect, and tenderness, and I heard myself say to myself, ‘I really love this guy.’ ”

AN INVITATION TO LOVE

James Fosshage, PhD, spent Saturday, October 10, 2009 at the Tampa Bay Psychoanalytic Society, Inc. (TBPS). A portion of the afternoon was dedicated to his paper, "Searching for Love & Expecting Rejection: Implicit & Explicit Dimensions in Cocreating Analytic Change," (2007. Psa Inquiry. 27:326-347).

Classical aspirations to neutrality, abstinence, and anonymity have been replaced with the recognition that an analyst’s subjectivity inevitably intrudes into the analytic space, making unachievable, these three traditional pillars. One might then ask about the aspect of responding to invitations to subjectivity.

Fosshage noted that when an analyst offers, in a “moment of meeting” (Boston Change Process Study Group), a genuine and authentic response to a patient’s declaration of love, instead of interpreting such declarations, a loving relationship can be co-created. A sufficiently loving relationship leads to changes in traumatic organizing patterns. Furthermore, these changes bring about a decreased activation of the old organizing patterns. Likewise, they increase a patient’s ability to move more quickly away from activated traumatic organizing patterns.

Old organizing patterns recede and are replaced in the foreground by the newer, more vitalizing, relational patterns experienced reliably in the analytic dyad, and co-created both via implicit and explicit communications. Feeling loved and respected contributes to a new feeling about self and about self-with-other. Since love is one of the feelings expectably engendered in a close, intimate relationship, though in the analytic relationship unrealizable in certain aspects (e.g. the prohibition against sexual contact), love, if not made explicit in the analytic dyad, can become tantalizingly unbearable.

Transformation then, Fosshage said, is achieved through the co-creation of new organizing relational patterns, not the least of which is co-creation of a sufficiently loving relationship.

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?"

HETEROSEXUAL MASCULINITIES

Opening the 2009-10 Program Series of Tampa Bay Psychoanalytic Society, Inc. was Bruce Reis, PhD, relational faculty at NYU Postdoctoral Program in Psychotherapy and Psychoanalysis and a contributing editor to Studies in Gender and Sexuality. His talk “Reconsidering Masculinity” aimed to dismantle the monolithic model of heterosexual masculinity and showcased his most recent book (co-edited with Robert Grossmark) Heterosexual Masculinities.

Loosening the rigid normative of heterosexual masculinity, Reis hopes to open to multiplicity the long held (Greenson, Stoller, Elise, Chodorow) conception that boys must repudiate the feminine in order to become masculine. Elise, in particular, writes about the fear of penetration and the defenses against it (the “citadel complex”), but Reis cites Kaftal’s criticism: Elise does not take into account the paradoxes of gender, as if penetration were binary and as if fear of penetration were masculine. Diamond reminds us that there is a pre-oedipal identification with both parents and that gender identification with the same sex parent is not the whole story.

If there, as infant research is beginning to elucidate, no primary fusion with the mother, then there is no need to propose that separation from the mother is the role of the father. Father need no longer be cast as “the other” parent. Father’s presence may be playful, erotic (open to delight, pleasure, excitement, indulgence), and nurturing, making it unnecessary to conceive that boys must repudiate the nurturing mother. In other words, as Person writes, there is a plurality of masculinities.

COMPARATIVE INTERSUBJECTIVITY

Tampa Bay Welcomes Back Bruce Reis, PhD

Dr. Bruce Reis, a guest in February 2009 of the Tampa Bay Institute for Psychoanalytic Studies, Inc at their Trauma Workshop Healing Haunted Lives, returned to Tampa to speak on Saturday, September 12, 2009 this time at the Tampa Bay Psychoanalytic Society, Inc. In his first morning presentation, Dr. Reis spoke on Comparative Intersubjectivity, highlighting Recognition, the Subject, and definitions of Intersubjectivity.

Jessica Benjamin reminds us that recognition is not, as some Interpersonal authors misconstrue, knowing the personality or preferences of the other, but rather is the recognition of the other as a separate center of consciousness, with her/his own desire and initiative, and as a subject ‘like me.’ She notes that mutual recognition is an ideal and that in reality there exists a constant tension between the need to assert one’s self (one’s own desire) and the need to be recognized (in relationship with an equal other subject). Reis notes this is a tumultuous tension, never easily achieved, and is constantly re-lost, just as Hegel noted that recognition is an ideal condition.

Philosophers have written of intersubjectivity for two centuries. Hegel saw life as subjects at war with each other, a ‘me’ versus ‘the world,’ or a life-death struggle between two hypothetical individuals where each’s desire (to omnipotently have her/his desire fulfilled) comes into conflict with the other (who has own desire). Hegel proposed possible outcomes: One vanquishes/kills the other, but this victory is pyrrhic as the other is then unable to meet the individual’s needs for recognition; One enslaves the other, but then the master cannot achieve true recognition when that recognition from the other (slave) is discounted; or, thirdly, and ideally, there is mutual recognition between two equal subjects.

Benjamin, relying on infant research, feminist theory, and the Frankfurt school, tempers Hegelian ideas with those of Winnicott. While both Hegel and Freud intimated that an infant does not want to recognize the other!, Winnicott thought infants do have a desire to know the other. Benjamin holds these antithetical ideas in dialectic tension: we want both to know and want to destroy the other. Reis points out how interpretations (e.g. ‘It is clear to me that you feel about me the way you felt about your mother’) can dominate the other.

Thomas Ogden also interprets Hegel and Winnicott, but comes to a different intersubjective theory. Like Winnicott he sees the subject (of the analyst or patient, or, of mother or infant) both as created and as already in existence to be discovered. Influenced by the British Middle School of Object Relations, he postulates “the analytic third,” not a concretized person, but a process, a dialectic tension between the Unconscious of the patient and the Unconscious of the analyst, a third created by both. This is a type of Relational co-created process where the patient’s material is partially structured by the analyst’s Unconscious. Whereas Wilfred Bion saw the analyst’s reverie as an objective, scientific tool which allowed the analyst to experience the patient’s Unconscious, Ogden sees reverie as a more personal experience for the analyst, presumably a mutual influnce.

Postmodern psychoanalysis, then, has moved from drive theory to object-relating, from getting to understand the patient-other to experiencing the distinct otherness of the patient.

While Benjamin writes of intersubjectivity as a developmental achievement (albeit one in constant struggle) the Boston Change Process Study Group (BCPSG) says intersubjectivity exists from the beginning of life. Infant research shows that infants are not in an autistic shell (Freud) nor in need of separation (Mahler), but that infants see themselves as separate from mother [primary intersubjectivity]. Benjamin sees this as a precursor to intersubjectivity, that the mother may be seen by the infant as separate, but not yet seen as a subject with her own consciousness and desire [secondary intersubjectivity, and where, e.g. one knows the mind of the other through a third].

For the BCPSG, then, there is no need to destroy the object (Winnicott) in order to see her, when she survives destruction, as separate. Subjects already exist! And there is not the Hegelian tension, not a tension between recognition and destruction between mother and infant. Instead, infants are observed to want to share the good company of others, and when infants and attuned mothers ‘fit’ there is mutual accommodation between the two. The BCPSG then has a different starting point than Freud or Object Relations, with a conception of mind not from inner (intrapsychic) experience, but from in-the-body behavioral interactions; nor from brain (neuronal level) function, but from function of embodiment where brain is in body and body is in a social world.

Stolorow, Atwood, Orange, et al, have a different perspective of intersubjectivity, based, in part, on phenomenology, hermeneutics, and Heidegger, where intersubjectivity is not a developmental achievement, but the ever present condition that allows experience to exist at all. They take a clinical approach similar to that of Self psychologists: empathic immersion where confrontation of the patient’s experience is eschewed. There is not a fight to the death, but instead a focus, like Kohut, on the developmental needs of the patient. The patient is the authority. This approach is different from Relational schools, where authority is deconstructed, and where the patient’s experience is not privileged over the analyst’s. In fact, one could wonder how privileging the patients experience, instead of holding it in dialectical tension with the analyst’s, is really intersubjective at all. Reis says Bion presciently answered this when Bion did not assume what was going on in the patient’s mind, but neither did he assume that the patient knew more than the analyst.

OLD SCHOOL ACCENT ON THE NEW: Tampa Bay Psychoanalytic Society Hosts Robert Michels, MD

In an early morning conversation with Tampa colleagues, Robert Michels, MD described transference as an accent. Like a language learned early in life that will always color future learned languages, transference will color all interpersonal relationships. Current relationships are always influenced by early relationships. While accents enrich experience, hopefully there will be enough learned phonemes for there to be flexibility.

Both in early conversation and in his morning presentation, Michels gave an historical approach to the competition of orthodoxies. He noted how difficult it was last century for analysts to liberate themselves from Freudian ideas and Freud's mythos. He noted, as well, the major shift from attention to (unconcious and repressed) content, managing both the transference and the resistance, to attention to process and the way one chooses not to reveal content; a shift from defense analysis to character analysis.

In the 21st century, with the popularity of the Relational approach and with the recognition of the negative effects (such as narcissistic injury), of austerity, clinicians now think of themselves, not as 'expert,' but as collaborative colleagues with patients. Today, clinicians are less committed to one theory, and, instead, pluralism (in theory) exists. Analysts are less authoritarian, and less able to sit comfortably assured that their theory or technique or shibbolith is the one. Michels advocated having as many tools as possible, and then skillfully using the one applicable to the moment.

Michels is a brilliant mind, facile enough to have his finger on the pulse of changing theory and technique. Ironically (or maybe not), the presentation, as one attendee noted, was an enactment of the difficulty in giving up what was learned early in career (ego psychology) in order to flexibly apply or adapt to the new. Michels thick 'accent' on contempoary theory was noticeable, but the morning was none the less accessible and enjoyable.