Using Winnicott, Part II

In Playing and Reality (1971) Chapter 4: Creative Activity and the Search for the Self, Winnicott hopes to illustrate how, if the analyst would sometimes just get out of the way, the patient will come into a sense of self in her/his “search for the self.” In his clinical example, Case In Illustration (pp. 56-64), he allows a three hour session with a patient because she needs a lot of time to come into being, as it were. He believes he is allowing the patient freedom from his intrusions, impingements, derailments, [and cleverness] by his protracted silence. [Indeed, the patient may have felt Winnicott to have been palpably present by his demeanor, benevolent attitude, ability to hold her in his mind, etc., but the reader does not have this benefit.]

Upon rereading this case with the first year class at the Tampa Bay Institute for Psychoanalytic Studies, Inc, I was struck by the patient’s many attempts to feel Winnicott more significantly engaged with her. She says: “I’m loathe to come into this room…I feel of no consequence.” Winnicott adds that she cites “Odd details of my dealing with her, implying that she is of no consequence.” She states “I don’t matter.”

When the patient eventually speaks of positive feelings and activities, Winnicott takes this as evidence of her be[com]ing real as if this naturally unfolded by her creative play, alone in the presence of the other. What Winnicott does not acknowledge here is that this ‘positiveness of being’ followed both his interpretation (indicating he understood how withering and deadening it is when there is no one to give back to her her experience; no mutuality, as it were) and his responsiveness that she drink up the milk he had made available there for his patients.

Having reported more of her feelings and activities, she then asks, “Where are you? Why am I alone so?...Why don’t I matter anymore?” And, after talking about her birthday experiences, the patient says, “I feel as if I have wasted this session. I feel as though I came to meet somebody and they didn’t come.” [Here I think the patient is talking about Winnicott’s absence, as he tries to stay out of her way, from being in the space with her.] Winnicott speaks, reflects back, and the patient says, “I get a feeling sometimes that I was born.” [I take this as further confirmation that it is Winnicott’s participation which enlivens the patient.] Winnicott reflects for her what she may have always felt: that others were not glad that she was born, that they did not enjoy her. She confirms this with: “what is so awful is existence that is negatived” [negated]. She continues and asks [hopefully], “…is there a little soul waiting to pop into a body?”

Winnicott emphasizes, from the patient’s dream: “I might find a me—get in touch with a me,” that the patient is “trying to show you me” for the first two hours of the session. Winnicott writes: “The searching can come only from desultory formless functioning, or perhaps from rudimentary playing, as if in a neutral zone.” Yet I could not help noticing that the patient was only enlivened, came into being, when Winnicott spoke to her in such a way as to communicate his understanding of her, thereby giving her evidence of his having been listening attentively, and had done so because she was significant to him. Perhaps his patient felt his silence as an indication that she was insignificant to him.

In class, I was equally struck by one first year student who could so adeptly feel her way into Winnicott’s position, illuminating to the class a different point of view from mine, and imagine that his patient, having perhaps had demanding, intrusive parents, who forced compliance of her being to theirs (that she please them, say what they wanted to hear), would very much need an analyst who stayed out of the way, letting the patient say what she wanted, or say nothing at all, indicating she would not have to please the analyst. [Still, I thought, when Winnicott was pleased to let the patient give an interpretation that he would have made himself, that the patient was indeed saying something she thought he might want to hear, and doing so perhaps to keep him engaged with her.]

Had Winnicott lived today, would he now drop the ‘the’ of “the self” and characterize self as a more fluid, emerging entity? More importantly, would he have transformed his theory to view interaction through a slightly more contemporary lens, a lens which recognizes the need for all of us, including patients, to be seen, to have an effect, to feel significant to someone, even to one’s analyst, to recognize that we all need, at times, the presence of an effected other to come into being? Or would silence, as an indictor of respect for the patient's creativity and being alone in the presence of the other, still loom so large with a patient so desperate to feel significant to her analyst?

Deconstructing what we read

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

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

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

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

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

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

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

Mitchell's Developmental Tilt

This semester the TBIPS first year class is reading Mitchell’s Object Relations Theories and the Developmental Tilt. In it, Mitchell asks (doubts) whether so many diverse theories can go under one theory called Object Relations. But, more importantly, he notes that many Object Relations theorists maintain allegiance to the Freudian drive-conflict model (whose sine qua non of neurosis according to Freud is the Oedipus complex) by simply placing relational issues developmentally earlier than the oedipal stage. He asks, is Object Relations just an extension of drive theory? Or is it altogether new, substituting drive discharge as motivation and the structural theory (ego, id, superego) of mind with object-seeking as motivation and with relational configurations, “relations with others, past and present, real and imaginary” (mental representations of part/whole objects, in Object Relational terminology, and how they interact with each other) as the makeup of the mind?

Mitchell sees assimilation of Object Relations theory into drive theory as mixing apples and oranges. He says that assimilating Object Relations, through what he calls the” developmental tilt,” into drive theory risks designating lifelong needs of relationship as pathology:

“these innovations have been introduced into psychoanalytic theory via the developmental tilt; consequently, the dynamic issues they depict tend to get characterized as infantile, pre-oedipal, immature, and their persistence in later life is often regarded as a residue of infantilism, rather than as an expression of human relational needs extending throughout the life cycle.”

Mitchell believes contrivances such as regarding “relational issues as prior to drive issues”, were required by ego psychologists (who privilege drive and defense, ie the structural conflict model) in order to assimilate Object Relations. Mitchell does not conceive that relational issues “emerge sequentially over the course of early infancy, becoming progressively resolved” but says they instead persist throughout life.

Furthermore, the developmental tilt risks, Mitchell contends, infantilizing patients by casting the analytic relationship in an infant-mother dyad:

“…instead of conceptualizing these dimensions of the analytic relationship as providing the patient with a richer, more complex, more adult kind of intimacy that his previous psychopathology allowed him to experience, the developmental tilt leads to a view of these dimensions essentially as developmental remediations…”

Consequently, spontaneous gestures as evidence of new relationship (such as Balint’s somersaulting patient) are viewed not as a ‘forward edge’ [Tolpin], but as a regression to the old and are pathologized: their “evidence later in life is regarded as a regressive residue of very early disturbance.” When Object Relations theory is “positioned via classical theory” through the developmental tilt, psychoanalytic “interaction is collapsed into mother-infant terms.” Similarly “the need for tenderness throughout life”… is collapsed “into the infant's need for tenderness from the mother … depicted as regressive, unresolved residues from earliest childhood” [and] “depicted as [the] …only developmental forum in which such needs make sense.”

Mitchell agrees with contemporary theorists on the importance of the real relationship, as well as of what is new:

“the analytic relationship has been understood as more and more of a real and new relationship than previously. For Freud, the relationship with the analyst was a re-creation of past relationships, a new version struck from the original "stereotype plate" (Freud, 1912). The here-and-now relationship was crucial, but as a replication, as a vehicle for the recovery of memories, the filling in of amnesias, which cured the patient. Contemporary views of the analytic relationship tend to put more emphasis on what is new in the analytic relationship. The past is still important, but as a vehicle for understanding the meaning of the present relationship with the analyst, and it is in the working through of that relationship that cure resides.”

I find I agree with Mitchell’s ideas, especially the need for relationship and tenderness being lifelong (just as Kohut posited a lifelong requirement for self object experiences) and can dust off my previously long constrained (anonymous, abstinent) self to participate with my patients in the therapeutic endeavor toward new experience co-creating new ‘templates [Herzog].’

Mitchell, S.A. (1984). Object Relations Theories and the Developmental Tilt. Contemp. Psychoanal., 20:473-499.

Projective Identification

Recently, at TBIPS’ Relational Study Group, a paper we were discussing brought up projective identification, a concept that has baffled clinicians for decades. I would like to share my thoughts on projective identification. When Melanie Klein coined the term, it was to describe an intrapsychic phenomenon: how the unwanted parts of the self (often aggression or helplessness) were projected into the other, and were then seen as under the control of the self, and, consequently, so too was the other seen as under the control of the self. Note that s/he who did the projecting was also doing the identifying with the unwanted part.

Projective identification became redefined as a phenomenon between two people: what was projected by the self was identified with by the other such that the other began to behave commensurate with the projection. E.g. a patient projects sadistic impulses into the therapist and the therapist inadvertently becomes sadistic, or feels sadistic. The self could behave in such a way as to make the other feel what it felt like to be the one doing the projecting. Projective identification, then, began to include the countertransferential use of the projection giving the therapist information about the patient’s experience.

Even when projective identification is seen as emanating from the paranoid position, it nonetheless is an attempt to communicate how one is feeling, as well as a wish to be understood. Because patients are sometimes bereft that the therapist will ever know what it feels like for the patient to experience such rage or helplessness or envy or despair, they are nonetheless sometimes fortunate enough to utilize projective identification to help move the therapist’s understanding along. Otherwise, patients might feel untenably isolated and unconnected to us. Despite how uncomfortable (causing the therapist to disparage the defense and pathologize the projecting patient) it may be to be in the throws of the experience, if not bound by the projection, the therapist might sometimes have the wherewithal to inquire whether the patient has somehow managed to come upon a way to aid the therapist to better know what the patient’s experience felt like by inadvertently helping the therapist to feel that way too.

Since its original definition was conceived within a one-person psychology, contemporary Relational theorists, if they use the term at all, have further redefined projective identification. Relational theory questions the unidirectionality of projective identification. It does not conceive the projection to originate entirely from the patient’s psyche but instead recognizes how unlikely the therapist would be to ‘identify’ with a ‘projection’ were it not to resonate with something already within the experience of the therapist. The therapist, too, contributes to what is projected in addition to resonating with the projection.

I like to say that it is one thing to wear the attributions of a patient and explore what, for both the patient and oneself, it would be like to do so, but it is something else to be what the patient attributes to us. I suggest to less experienced colleagues that we be brave about discussing patients’ (e.g. aggressive) feelings toward us. When patients have ‘split’ us into the bad or hateful object, it sometimes helps restore personal equanimity to consider how and why it became necessary for the patient to operate, at this moment, from the paranoid position. Harder is to consider how we might have inadvertently contributed to this shift.