Defensive projection, superimposed on simplistic object relations, erodes patient-provider relationships in high-risk pregnancy: an empirical investigation

In an attempt to illustrate the relevance of psychoanalytic theory and research to behavior medicine, an empirical investigation was conducted of females treated at a high-risk pregnancy specialty clinic (N = 58). Drawing from psychoanalytic object relations theory, it was hypothesized and confirmed that use of projection as a defense mechanism during pregnancy, superimposed on simplistic object relations, predicted an erosion of patient-provider relationships during the pregnancy/postdelivery period. Findings are interpreted through the perspective of mentalization, pertaining to individuals' ability to understand the mental states of self and others, specifically under significant stress. Implications for psychoanalytically oriented assessment and treatment, and for the rift between psychoanalysis and research, are discussed.     

On knowing one's patient inside out: The aesthetics of unconscious communication∗1

“Knowing one's patient inside out” is a metaphor that is intended to capture the paradoxical quality of the intersubjective field that we call the analytic relationship. The interface among trauma, dissociation, and regression is discussed in the context of unconscious communication as a transferential enactment of unsymbolized experience.The view is offered that for certain patients in particular, past experience is not so much unconscious as “frozen in time” and that a key element of the psychoanalytic relationship is bridging dissociated aspects of self through the creation of a dyadic experiential field that is both “inside” and “outside.” The writings of Michael Balint, D. W. Winnicott, and several other British object relational theorists are explored in the context of a contemporary interpersonal psychoanalytic perspective.     

Self psychology and its contributions to psychoanalysis

Abstract

A schematic overview of the theory and practice of self psychology is presented with a particular focus on what the author believes to be the most important contributions to psychoanalysis. It is recognized that self psychology, as with all psychoanalytic approaches, is an evolving and non-unitary theory. Fundamental features of self psychology are: 1. the consistent use of the empathic mode of observation, that is, to listen and understand from within the vantage point of the patient; 2. the primary motivation which involves strivings to develop and maintain a positive cohesive sense of self; 3. that each person has unique pre-wired “givens” included in the concept of the nuclear self; 4. that each person has selfobject needs which refer to the use of the object for the development and regulation of a positive sense of self; 5. that selfobject needs include mirroring (acknowledgement and affirmation), idealizing (protection, safety, and admired qualities), and twinship (a feeling of essential likeness, of sharing) needs; 6. that development and maintenance of a positive cohesive sense of self requires a sufficient responsiveness to selfobject needs; 7. that insufficient responsiveness arrests normal development, creates pathological organizing patterns of self, others, and self with others, and causes unresolvable conflict; and 8. that psychoanalytic treatment involves the analysis of the selfobject and repetitive dimensions of the transference in order to facilitate expansion of awareness, symbolic reorganization and self-righting.     

Inter‐ and intra‐cultural variations in self‐other boundary: A qualitative‐quantitative approach

Past research on the theories of self‐construal and individualism‐collectivism in cross‐cultural contexts presents inconsistent and inconclusive results. Some researchers have seriously questioned the validity of major instruments measuring self‐construal across cultural groups. To address the validity issue, this study developed quantitative measures from ethnographic data. In five scenarios mapping self to close‐other boundaries, 171 Anglo‐Canadians and 224 Mainland Chinese were asked to make a decision and offer a reason for the decision. Two intriguing findings emerged from the data. (1) In comparison with Anglo‐Canadians, Mainland Chinese were more likely to share material belongings with close‐others and less likely to share their thoughts/opinions. The first part of this finding provides unequivocal support for the theories of self‐construal and individualism‐collectivism, whereas the latter part challenges an important assumption of these theories, which contends that collectivists should be more likely than individualists to share everything they own (including opinions) with close‐others. This unconventional finding proposes the division of material belongings and thoughts/opinions sharing of the self‐other boundary in future cross‐cultural self‐construal research. (2) There were significant differences in the reasons Canadians and Chinese offered for what they would or would not do in a specific situation. For example, the reasons for not telling the truth about a roommate's nonmatching outfit were “tastes differ from person to person” for a Canadian and “I don't tell others what I think of them” for a Chinese. The Canadians clearly show respect for the other's personal preference and the Chinese were thinking “what can I benefit from telling her the truth?” It was reasoned that underneath the giving and generous Chinese lies a shrewd mind, and underneath the frank Canadian lies a materialistic mind. In conclusion, this article contributes to the field in that it reports pioneering research, via both qualitative and quantitative means, on sharing material belongings and opinions/thoughts in samples from individualistic and collectivistic cultures. The findings of this study illustrate, specify, and challenge the universal utility of the theories of self‐construal and individualism‐collectivism.     

First‐Person Authority and Self‐Knowledge as an Achievement

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Self‐Awareness Part 1: Definition,Measures, Effects,Functions, and Antecedents

Self‐awareness represents the capacity of becoming the object of one’s own attention. In this state one actively identifies, processes, and stores information about the self. This paper surveys the self‐awareness literature by emphasizing definition issues, measurement techniques, effects and functions of self‐attention, and antecedents of self‐awareness. Key self‐related concepts (e.g., minimal, reflective consciousness) are distinguished from the central notion of self‐awareness. Reviewed measures include questionnaires, implicit tasks, and self‐recognition. Main effects and functions of self‐attention consist in self‐evaluation, escape from the self, amplification of one’s subjective experience, increased self‐knowledge, self‐regulation, and inferences about others’ mental states (Theory‐of‐Mind). A neurocognitive and socioecological model of self‐awareness is described in which the role of face‐to‐face interactions, reflected appraisals, mirrors, media, inner speech, imagery, autobiographical knowledge, and neurological structures is underlined.     

State of the Hope: The New Bad Object in the Therapeutic Action of Psychoanalysis

Until recently, most psychoanalytic conceptualizations of the analyst as a new object have tended to equate newness with good experience and safety. Recent papers in the relational literature have explored not only the therapeutic value, but also the inevitability of the patient's experience of the analyst as bad, as well as the analyst's participation in this experience. This author examines the multifarious nature of hope, goodness, and badness in the clinical situation. The patient gets to know not only elements of his or her own self that are held by the analyst, but also ways in which the patient holds elements related to the particulars of the analyst's person in the analytic situation. Shifts in American psychoanalysis regarding conceptualizations of the analyst as a new object are examined. Limitations of a bifurcated approach to goodness and badness in clinical conceptualizations are also explored.     

Three modes of psychotherapy and their requisite core skills

The field of psychotherapy suffers from the lack of an integrative meta‐perspective on the large variety of existing psychotherapies and on the therapeutic skills involved. In the present paper, it is suggested that the development of a more comprehensive view of this field may be facilitated if we differentiate between three modes of psychotherapy, which require different therapeutic core skills: (a) an educational mode, which requires teaching skills; (b) a reparative mode, which requires analytic‐conceptualising skills to identify some kind of disordered functioning, in combination with specific relational‐technical skills to repair this dysfunction; and (c) a developmental mode, which involves engaging in a therapeutic relationship with patients to facilitate their personal growth, and which requires non‐directivity skills. In addition, some therapeutic skills (e.g., awareness and communication skills) may be more or less important in all modes of treatment. Concrete manifestations of the three different modes of psychotherapy are discussed in terms of five different theoretical perspectives on psychotherapy: the common factors, the humanistic‐experiential mindfulness cognitive‐behavioural (CBT) and psychodynamic perspective. The common factors model is criticised as being insufficient in several respects. Finally, it is argued that if personal therapeutic skills are essential to the effects of psychotherapy, then empirical research on psychotherapy needs to be re‐oriented towards a person‐oriented study of therapist skills in action, in the context of a study of the interaction between therapist and patient.     

Self–other differences in multiattribute decision making: Compensatory versus noncompensatory decision strategies

When making decisions where options involve multiple attributes, a person can choose to use a compensatory, utility maximizing strategy, which involves consideration and integration of all available attributes. Alternatively, a person can choose a noncompensatory strategy that extracts only the most important and reliable attributes. The present research examined whether other‐oriented decisions would involve greater reliance on a noncompensatory, lexicographic decision strategy than self‐oriented decisions. In three studies (Mturk workers and college students), the difference in other‐oriented versus self‐oriented decisions in a medical decision context was explained by a subsample of participants that chose the death minimizing operation on all 10 decisions (Study 1) and a subsample of participants who self‐reported that they used a strategy that minimized the chance of death on every decision (i.e., a lexicographic mortality heuristic; Study 2). In Study 2, tests of mediation found that self‐reported use of the mortality heuristic completely accounted for the self–other effect on decisions. In Study 3, participants were more likely to report prospectively that they would adopt the mortality heuristic when making decisions for others than for themselves, suggesting that participants were not mistakenly inferring a lexicographic decision strategy from their past behavior. The results suggest that self–other effects in multiattribute choice involve differential use of compensatory versus noncompensatory decision strategies and that beyond this group difference, individual differences in the use of these strategies also exist within self‐oriented and other‐oriented decisions.     

Discussion: The Analyst's Involvement in the Creative Aspect of Analysis

Recent formulations on the psychology of creativity in the analytic context, such as Albert Rothenberg's “homospacial thinking,” Arnold Modell's “unconscious metaphoric thought,” and Thomas Ogden's “transformational thinking,” are discussed. These concepts enable previously unconnected experiences to be combined within the mind, while emphasizing interpersonal imaginative processes such as identification and empathic knowledge; the dual cognitive features of these formulations permit awareness of the complexity of feelings in oneself and others, essential for psychoanalytic creativity. Further, the articles in this issue are synthesized, highlighting the importance of the analyst making creative (new and valuable) use of his or her entire life experience, feelings, attitudes, and fantasies in treatment. From this dicussion, it is evident that the analyst's creative use of self should be more systematically incorporated into psychoanalytic theory of technique.     

My body and other objects: The internal limits of self‐ownership

Common practices such as donating blood or selling hair assume rights of disposal over oneself that are similar to, if not indistinguishable from, property rights. However, a simple view of self‐ownership fails to capture relevant moral differences between parts of a person and other objects. In light of this, we require some account of the continuity in the form of ownership rights a person has over herself and other objects, which also acknowledges the normative differences between constitutive parts of a person, on the one hand, and external objects, on the other. This paper provides such an account by arguing that there are reasons internal to a general justification of property rights to limit the extent of powers included in ownership of different kinds of object, depending on how the person is situated in relation to them. Rejecting a typical Hohfeldian view of property as a univocal, gradable concept allows us to make space for a new approach to property and self‐ownership: one which can make sense of various uses of the body as property without entailing that our relation to those parts is exhaustively characterised by an ordinary property right.     

Are waves of relational assumptions eroding traditional analysis?

The author designates as ‘traditional’ those elements of psychoanalytic presumption and practice that have, in the wake of Fordham's legacy, helped to inform analytical psychology and expand our capacity to integrate the shadow. It is argued that this element of the broad spectrum of Jungian practice is in danger of erosion by the underlying assumptions of the relational approach, which is fast becoming the new establishment. If the maps of the traditional landscape of symbolic reference (primal scene, Oedipus et al.) are disregarded, analysts are left with only their own self‐appointed authority with which to orientate themselves. This self‐centric epistemological basis of the relationalists leads to a revision of ‘analytic attitude’ that may be therapeutic but is not essentially analytic. This theme is linked to the perennial challenge of balancing differentiation and merger and traced back, through Chasseguet‐Smirgel, to its roots in Genesis. An endeavour is made to illustrate this within the Journal convention of clinically based discussion through a commentary on Colman's (2013) avowedly relational treatment of the case material presented in his recent Journal paper ‘Reflections on knowledge and experience’ and through an assessment of Jessica Benjamin's (2004) relational critique of Ron Britton's (1989) transference embodied approach.     

Narrative Solutions: Using Preferred View of Self to Motivate Individual and Family Change

This article describes refinements of the Narrative Solutions approach to individual and family therapy we first presented in Family Process 22 years ago. The centerpiece of this integrative (narrative‐strategic) model is “preferred view of self,” or the constellation of qualities people would like to see in themselves and have others see in them. We assume that problems generally involve one or more people mismanaging discrepancies or “gaps” between preferred views of self and either their actual behavior or how they see others seeing them and their behavior. Because clients are motivated to resolve such discrepancies, we use specifiable conversational strategies to help people (a) be clear about their preferred view of self, (b) notice gaps or discrepancies, and (c) summon resources to manage these gaps more effectively. Positive clinical effects of these strategic conversations can be rapid and dramatic. Case examples highlight applications to child and family problems, and we discuss some challenges and future directions for the Narrative Solutions approach.     

What's so different about Lacan's approach to psychoanalysis?

Clinical work based on Lacanian principles is rarely compared in the psychoanalytic literature with that based on other principles. The author attempts to highlight a few important theoretical differences regarding language, desire, affect, and time between a Lacanian approach and certain others that lead to differences in focus and technique, related, for example, to interpretation, scansion, and countertransference. Lacanian techniques are illustrated with brief clinical vignettes. In the interest of confidentiality, identifying information and certain circumstances have been changed or omitted in the material presented.     

Intersubjectivity,otherness, and thirdness: A necessary relationship

The author proposes an interplay among the notions of otherness, intersubjectivity and thirdness with its coincidences and oppositions. Its polysemic nature is analyzed in this paper. The relation internal world–external world is at stake and concerns both the construction of subjectivity as well as the way the analytic relation is deemed to assume. This review focuses on the psychoanalytic developments from Freud to posfreudian and contemporary authors plus, at the same time, interdisciplinary proposals are also included. It is also revisited the notion of “analytic field”, proposed by Willy and Madeleine Baranger who, early as 1961‐62, underlined the transition from “the unipersonal to the intersubjective”, emphasizing that this was an expression of a change in the understanding of the analytic treatment. In this paper, the author argues that the concept of otherness introduces a symbolic aspect of decentring into the seeming interactive symmetry of intersubjectivity. At the same time, it is stressed that thirdness places a wedge into the between‐subjects, which opens the way from and to recognition of the other and others.     

Developing a Psychoanalytic Practice

Abstract

This paper examines two methods of developing a psychoanalytic practice. The first is an “internal” approach that helps a patient make the transition from therapy to analysis with the same analyst. This may be accomplished by attenuating the patient's unconscious fears of analysis as a facilitator of an anticipated regressive loss of control and as a reactivator of feared desires and impulses. Increased motivation for analysis may also result from a therapy that leads the patient to an awareness that an ongoing level of distress is internal, together with the experience of a deepened therapy and of the analyst as safe and potentially providing relief. The second method of developing an analytic practice is an “external” approach that provides others, such as analytic, mental health, medical, and academic colleagues, an experience of the analyst as person and some idea of the type of work he or she does.     

Prejudice in person memory: Self‐threat biases memories of stigmatized group members

The present research investigated whether self‐threat biases memory via retrieval‐induced forgetting. Results show that people under self‐threat whose goal is to restore their self‐worth by making prejudicial judgments that deprecate others are more likely to exhibit an enhanced RIF effect for positive items and a reduced RIF for negative items ascribed to a stereotyped target (i.e., homosexual). Overall, the present findings are consistent with the view that motivation can affect the magnitude of RIF effects in person memory and that, in turn, they can serve as mechanisms for justifying desired conclusions.