A Contemporary Look at Conflict

I am always delighted when I read how contemporary relational thinkers reconfigure century old tenets in psychoanalysis. Adrienne Harris does just that with conflict in her 2005 paper Conflict in Relational Treatments (PsaQ 74:267-293). Though finding her paper somewhat confounding, the TBIPS Relational Study Group delightedly discussed the elaborations of conflicts in human experience which Harris considers. She elaborates on conflicts between the needs of self and others (interpersonal conflicts), between two unconsciouses (intersubjective conflicts), and conflicts between self states, in addition to the traditionally understood conflicts between wishes and between wishes and their prohibitions. Along with conflicts between ego-id-superego, additional intrapsychic conflicts exist between the multiple selves of one person and the multiple unconsciouses found within these multiple selves. Disavowed or dissociated parts of self may then never come into the treatment with the selves states of a particular analyst. Conflicts for the analyst, too, include the conflict between sticking to the rules of training and being spontaneous; the conflict of desiring the imposition on the patient of the normative and the hope for the patient to have freedom from these constraints. Speech, too, provides for conflict, for example, between what is said and how it is said, between content and tone/prosody, or content and intention. For both participants there is the pull between the wish to change and the wish to stay the same. There are the interpersonal and intersubjective conflicts between analyst’s and analysand’s agendas, both overt and covert, and also those between the unconscious(es) of the analysand and the analyst. Consider then the multiplicity of the analyst’s selves and those of the analysand in their innumerable combinations! I often think that the analyst must juggle a huge number of balls in the air-- while walking a tightrope. Harris made me consider adding to that number.

Intergenerational Transmission of Trauma

Doris Brothers, author of The Shattered Self, spoke in Tampa March 10, 2012 on trauma,and briefly alluded to intergenerational transmission of trauma. I would like to elaborate on some of the neurobiological mechanisms that might illuminate how intergenerational transmission of trauma occurs. To that end, I utilize Alan Schore’s Advances in Neuropsychoanalysis, Attachment Theory, and Trauma Research: Implications for Self Psychology.(2002). Psychoanal. Inq., 22:433-484.


As we are aware from infant research and neurobiology, an infant requires the presence of an attuned other for its optimal development and to optimally organize its experience. Winnicott said there is no such thing as a baby, that is, there is a mutual (interdependence) influence (regulation) between infant and mother in which the two function as a unit, including unconscious communications that serve to develop the brain of the infant. [This bulwarks the relational theories which take psychoanalysis from a one-person (intrapsychic) to a two person (intersubjective) psychology.] The 'good enough' caregiver helps the infant maintain its homeostatic equilibrium and facilitates the emerging self. Instead of the Cartesian mind-body duality (or of self from the environment) regulation of physiological functions builds the brain (the mind, the self) in particular ways.

A mother who may herself utilize dissociation as a result of her own childhood trauma, or due to depression, may be unavailable to regulate her infant. The 'good enough' caregiver helps the immature (as yet unformed neuronal connections, and unmyelinated peripheral nerves) infant regulate through her gaze, soothing voice, etc). Ruptures in regulation affect the infant’s homeostasis, and negatively affect attachment. They may even threaten the infant’s survival. Additionally, the infant is unable to acquire experience for self regulation and restoration of its equilibrium. In an attempt to restore homeostasis, the infant must divert energy away from needed growth, development, and learning (sometimes leading to failure to thrive, to lower IQ, and lower socio-emotional learning). Because brain growth is experience-dependent, experience with dysregulation negatively impacts the developing brain, the self, and the sense of self in relation with others, particularly during the brain’s growth spurt in the first three years of life. It can lead to later psychopathology, e.g. affect dysregulation commonly found in certain psychiatric disorders.

The right hemisphere, larger in the first two years, and, more than the left, processes and stores early infant experiences. Resonant attachment experiences involve “synchronized and ordered directed flows of energy” in the primary caregiver’s brain and the infant’s brain. The right hemisphere, more than the left, also has extensive connections with the limbic system. The limbic system is the emotional processing center which helps to guide emotional expression and behavior and organize new, procedural learning. The right brain is central to “integrating and assigning emotional-motivational significance to cognitive impressions” and “the association of emotion with ideas.” The right brain, with its connections to the right prefrontal cortex, allows the sense of self continuous through time. The right hemisphere, with its bodily connections, analyzes signals from the body, and helps regulate appropriate survival mechanisms, through the autonomic nervous system (ANS)which, in turn, help maintain a cohesive sense of self.

An infant responds to traumatic chronic misattunement by hyperarousal or by dissociation. When attuned response is not forthcoming, a distressed infant initially increases its attempts (e.g. by crying) to engage the mother. Should this fail, the infant, hopeless to effect the other, conserves energy, and seems to implode, go limp, itself dissociate, becoming helpless. The ANS lends a physiological explanation for hyperarousal and subsequent hypoarousal. The sympathetic and parasympathetic systems work to maintain homeostasis. The sympathetic ANS prepares the body for fight-flight (increased heart rate, increase blood flow to the skeletal muscles, etc); and the parasympathetic, responding to elevations in stress-induced cortisol, is energy-conserving (going quiet, staring off in space, and becoming limp).

As Winnicott noted, “ If maternal care is not good enough, then the infant does not really come into existence, since there is no continuity in being; instead, the personality becomes built on the basis of reactions to environmental impingement.”
We know that dissociation affects one’s sense of subjectivity. A mother, or grandmother, who has suffered herself with unresolved trauma conveys her terror and dissociation to her infant via infant matching of the mother’s right corticolimbic firing patterns, inadvertently transmitting to the next generation her, or her mother’s, experience of trauma. Mother’s “regulatory strategy of dissociation is inscribed into the infant's right brain implict-procedural memory system.”

Maltreatment in childhood, then, is a growth-inhibiting environment for the developing brain and results in “structural defects of cortical-subcortical circuits of the right brain, the locus of the corporeal-emotional self.” “[D]issociation is associated with a deficiency of the right brain” and “early relational trauma is particularly expressed in right hemisphere deficits”. The untoward consequences include disorders in attachments, regulation of affect, and subjectivity and sense of self, with threats to going-on-being.

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?

Using Winnicott, Part I

I find no writer more felicitous to read than Winnicott. Immensely prolific, it is as if he is speaking to me spontaneously about things about which he is passionate. He is relatively jargon free, and he relatively rarely refers to other authors. His many ideas are original and profound. My favorite two Winnicottian concepts, because I find them so clinically useful, are survival and transitional space.

In The Use of the Object... (1971, Playing and Reality) Winnicott refers to the necessity of the mother surviving (that is, neither retaliating nor withdrawing) the attacks of the infant if the infant is to see her as an external subject outside his omnipotent control, thereby allowing the infant both a capacity for concern as well as a mitigation of guilt about his aggression. Likewise, in the psychoanalytic situation, the analyst surviving the analysand’s attacks (of the analyst, of the process, and of hope itself) is necessary.

In Transitional Objects and Trsansitional Phenomena (1951) Winnicott notes that a good enough mother never falls to one side of the question of whether the infant created the transitional object or found it external to himself. So, too, he intimates that the good enough analyst does not close the transitional space by imposing the analyst’s reality on the creations and observations of the patient. It is into this transitional space that play is sometimes invited, a play with words, though much like the squiggle game, to imagine together what if.., what would it be like if… and sometimes to enjoy wistfully together what has come into being through pretend.

My great admiration for Winnicott and the enormity of usefulness I have derived from his ideas made my criticism of Chap 4: Playing: Creative Activity and the Search for the Self in Playing and Reality (1971) when re-reading it with students in the TBIPS Development Course, a bit of a surprise to me. I will post next time on the use the class made of his Case Illustration.

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.

Useful Relational Intersubjective Inferences

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

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

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

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.

Mutual Recognition in a Fly Bottle

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

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

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

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

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

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





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

Herzog and Shifting Relational States

On the morning of January 14, 2012, Dr. Bruce Herzog presented to the Tampa Bay Psychoanalytic Society, Inc his 2004 paper Reconsidering the Unconscious: Shifting Relational States, Activators, and the Variable Unconscious. “The unconscious is not a fixed structure, … thus what is conscious in one state of mind can become an unconscious entity in another… When an event is encoded into memory, it occurs within the specific relational state that is active at the time. …Hence, what I am conscious of at any particular moment has much to do with the relational state that I am in.” [When I read this paper a few years ago, these statements of Herzog’s were a kind of eureka moment for me: what he wrote had made profound sense (with a forehead slapping “Of course!’) and yet I had not heard it articulated that way before.]

Herzog continues: “… each relational state has its own particular consciousness and unconsciousness. …In any individual, the unconscious is in no way fixed, but is rather a continually changing phenomenon. I have chosen to name this the variable unconscious. … The notion of a variable unconscious proposes that people, when shifting from state to state, have a level of awareness and unawareness that shifts along with them. The unconscious is no longer considered a fixed phenomenon, but is something that moves and adjusts according to what state one is in. A shift to a new relational state can grant access to certain affects, memories, and relational behaviors that may have been previously unconscious [inaccessible].” Herzog calls his concept of shifting relational states, activators and the variable unconscious: template theory.

Herzog gracefully utilizes both traditional interpretation and relational theory: “…it is not only an interpretation’s content, but … the act of interpreting [italics added] can trigger a shift to a new state that can give rise to a different awareness.” [Here I like the integration of interpretation itself, its content making conscious what was heretofore unconscious, with the act itself having meaning separate from the meaning of the content. This deconstructs somewhat the privilege heretofore given to narrative interpretation, and insight, as a mutative power.] One aim of psychoanalytic treatment has always been to increase the capacity for self reflection, in Herzog’s terms, to activate a reflective state and increase the frequency of its activation. In treatment this can allow access to previously disavowed self states or to newly co-created (in therapy) self states.

I particularly liked finding new ways to consider transference, repression, interpretation, and the goals of treatment: “The transference might be seen as the activation of a particular relational state, and the interpretation could be seen as a means to help the patient organize the procedural (non-verbal) elements of the [that] state into symbolic thought (Herzog 2001; see previous post). The entire process serves to improve the reflective capacity of the individual, by allowing the current relational state to be consciously apprehended, understood, and modified - from within an overriding reflective state established in the analysis.” And where “repression comes in the form of disavowal of certain relational states …
What’s reported to the analyst is limited to what can be accessed in the state the patient is in when seeing the analyst.”

Herzog concludes: …”my patients [are] shifting through relational states, moving between the various possibilities within their relational repertoire, and having each state of mind containing its own unconscious elements… Pathology in the individual comprises rigid denial of the existence of parts of the self, whereas emotional health involves a general awareness of all parts of the self and controlled, flexible movement between them. …The analytic dyad’s growth-promoting behavior and ability to comment on the relational changes that are being fostered will lead to the development of a new repertoire of more functional relational behaviors, and a capacity to recognize and access them.”

I thoroughly enjoyed my day with Bruce Herzog, a presenter who embodies what he says, thereby providing the best educational experience: when procedural learning accompanies the symbolic or spoken lesson. I did regret that Dr. Herzog often chose to put aside for the day, leaving unexplored, the contribution the analyst makes to a shift in a relational template, and thereby, momentarily, eschewing elaboration of a two-person psychology.

Repulsion in the analyst

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

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

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

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


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

A Conversation With Bruce Herzog: Relational Templates

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

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

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

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

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

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

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






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

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

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

Self and Relational Psychologies Face-off

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

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

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

"In your eyes", infatuation, or the spark of maternal love?

"Love...
I get so lost sometimes
Days pass
And this emptiness fills my heart
When I want to run away
I drive off in my car
But whichever way I go
I come back to the place you are
All my instincts
They return
The grand façade
So soon will burn
Without a noise
Without my pride
I reach out from the inside
In your eyes
The light, the heat
In your eyes
I am complete
In your eyes
I see the doorway
To a thousand churches
In your eyes
The resolution
In your eyes
Of all the fruitless searches
Oh, I see the light and the heat
In your eyes
Oh, I want to be that complete
I want to touch the light
The heat I see in your eyes"
-- Peter Gabriel, "In Your Eyes"

Is this song not just infatuation run amok? Seeing everything we've ever wanted to see in another woman's eyes? Don't we someday realize these are the eyes of a fallible human? What woman could possibly live up to such a standard?

But let's think about this from a more primal point of view:
Does not the infant get so excited to see the "light and the heat" in his mother's eyes? Is this not what he seeks? The attention he adores, the loving gaze of his mother’s eyes? Does he not often go hungry wondering if the universe will ever answer his calls? To the infant, the mother is the universe, the mother is his universe. And what could be more amazing than to gaze into the eyes of that universe staring right back at you? Especially after a long night of hunger you have no way of knowing will ever end?

As adults, I think many of us go out in the world looking for this gaze, as it was lost or withheld from us somewhere along the way. We seek the magical maternal gaze in the eyes of a significant other. The gaze that meant all was good; hunger would end; warmth would come. The adult seeks the infant’s "catch" of what for it is permanent bliss. Some of us are searching more badly than others, because that maternal gaze was not so forthcoming, the universe not so friendly.

By Tim LaDuca




Lycia Alexander-Guerra adds:

This post is very timely for the TBIPS Relational Study Group which this week reads: You Are Requested to Close the Eyes (2004) Psa Dial, 14:349-371, in which Bruce Reis critiques the Freudian, Lacanian, and Kohutian concepts of mirroring as unidirectional and failing to take into account the intersubjective experience in which “to see is to see oneself being seen by an other.” Reis contrasts these to Winnicott’s concept of mirroring which moves beyond subject-object complementarity to “communion with otherness,” ‘a two-way process in which self-enrichment alternates with the discovery of meaning in the world of seen things.’

Freud saw the visual as psychopathology (e.g. scopophilia, exhibitionism, the over excitation of the child who views the primal scene, even the blind Oedipus). Freud’s own discomfort in being looked at may have contributed to advocating the anonymous, blank screen (opaque mirror) in addition to use of the couch. Lacan proposed that the infant was alienated from its self when first recognizing itself in totality in a mirror, and doomed to “confuse the external image of herself with the images of other subjects” (Reis). Antipodal to Lacan, is Kohut’s theory that through the visual, mirroring by the mother for an infant “seeking witness for its experienced grandeur and perfection” (Reis), the infant develops its cohesive, nuclear self. Still, the mother is experienced as an object, need fulfilling though she may be.

Reis addresses “the difference between object and other,” a salient component of relational psychoanalysis. As Benjamin notes, development is facilitated by the inclusion of the not-me inherent in intersubjectivity. Reis writes of “a relationally embedded self that recognizes itself as another for another and is obliged to acknowledge that there are other perspectives.”

From infant research, Reis tells us that interpersonal matching parses (quoting Meltzoff and Moore) ‘interactions in terms of relationships rather than particular behaviors.’ Mirror neurons not only help with imitation of actions, but understanding of them. Infant research (Stern; Beebe) also reveals “that split-second responsivity occurs in facial-visual interactions between mothers and infants. Each partner influences the other moment to moment…” and, also, “there remains an irreducible otherness to the other, a strangeness that is there from the first look….” For Winnicott and Reis, this difference in the form of the other contributes to and is constitutive of selfhood. “Seeing and being seen are inextricably bound together because, for an infant to see, it must be visible for an other.”

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.

Valentine’s Day Thoughts

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

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

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

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

Lycia Alexander-Guerra, MD

The Psychotherapeutic Relationship

The therapeutic process is not only about what is intrapsychic (the content of the mind, and the unconscious); it is also an interactive, bidirectional, and co-created engagement between therapist and patient. Regardless of any particular theories one utilizes, fostering from the very outset a mutually respectful relationship with the patient is paramount. Understanding diagnoses will not be helpful if the patient does not come back. To that end, the patient must, from the beginning, implicitly understand that you are trustworthy, respectful, and caring. Sometimes it is helpful to acknowledge with open inquiry the interpersonal experience. Collusion with patients’ illusions, without inquiry, may serve to increase the patient’s anxiety, hopelessness, and self-alienation.

Hoffman (1983) and Aron (1991) recognize that, while the relationship is mutual (both make contributions and affect one another), it is also asymmetrical. Relationships, including those between therapist and patient, are constituted by mutual regulation. We affect and are affected by each other, and, when this is not the case, one or both can feel ineffectual, unrecognized, even helpless. We aspire to mutual recognition. While we want the patient to journey her or his own path, we do not aspire to foster an autonomy that threatens the patient with isolation. When we do not demand pathological accommodation, or when we offer being alone in the presence of the other, it may be the patient’s first, or a rare, experience of autonomy without risk of loss of connection.

In seeking to connect with us, patients may probe beneath our professional façade. Do not mistake striving to know the therapist as [only] hostile or as [only] resistance. Consider the wish for connection and a longing to have an authentic effect on others. Sometimes patient silence is hostile as when the patient is too furious to speak or is withholding. Sometimes an experience or memory has no words. But sometimes it reflects a wish to be accepted as one is, without having to perform or produce. It is okay to admit that you do not know what the silence is about but would like to know, and likewise, it is okay to sit in silence, intimating your willingness to wait. I remember Hermann Hesse’s Siddhartha: I can think, I can wait, I can fast. Sometimes the therapist must be so willing, too.

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

Psychoanalytic Training Changed My Life, Really

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

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

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

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

An Analytic Attitude

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

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

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

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

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

Lycia Alexander-Guerra, MD

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.

Assurance to those who bring difference (of opinion)

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

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