Treating Patients with Symptoms—and Symptoms with Patience: Reflections on Shame,Dissociation, and Eating Disorders

I offer the view that the symptom picture found in most patients with eating disorders, as well as in the symptomatology of many other so-called difficult patients, is the end result of prolonged necessity in infancy to control traumatic dysregulation of affect. I propose that the central issue for an eating-disordered patient is that she is at the mercy of her own physiologic and affective states because she lacks an experience of human relatedness and its potential for reparation that mediates self-regulation. She is enslaved by her felt inability to contain desire as a regulatable affect and is thus unable to hold desire long enough to make choices without the loss of the thing not chosen leading to a dread of self-annihilation. Trauma compromises trust in the reparability of relationship, and for symptoms to be surrendered, trust in reparability must be simultaneously restored. Because felt desire is the mortal enemy of an eating-disordered patient, this fact becomes a central dynamic in the analytic field, leading analyst and patient into a struggle over who shall hold the desire and whether the issue of control over food is allowed to become a subject for negotiation. I discuss the inevitability of the analyst's own dissociative reactions in response to the patient's internal war over desire and control, and the different types of interpersonal enactments into which an analyst is drawn. In this tension, as illustrated through clinical vignettes, analyst and patient slip in and out of a constantly shifting array of self-states and thereby have an opportunity to coconstruct a transitional reality within which the patient's impaired faith in the reliability of human relatedness can be restored, and eating can become linked to appetite rather than to self-protection.     

Affective Experiences and Honesty in the Interaction: Discussion of Holly Levenkron's Paper

Anchoring her views in the work of Benjamin and other American relational authors, Levenkron asserts that intersubjective relatedness in which there is recognition of separate realities is essentially the only form of relatedness. Framing growth as coming about through the recognition of another's subjectivity provides a basis for “confrontation” and for a more direct injection of the analyst's subjectivity into the analytic encounter. More specifically, it fosters the expression of the analyst's subjectivity from what this author calls the “other-centered” and “self” perspectives.

In contrast, the recognition of selfobject and caretaking relatedness positions the analyst to express directly aspects of the analyst's subjectivity pertaining to mirroring, idealizing, and twinship selfobject needs. Kohut and classical self psychologists have delineated selfobject needs and the selfobject dimension of relatedness and transference and have emphasized the consistent use of the empathic listening/experiencing perspective. American relational theorists have delineated intersubjective relatedness and the usefulness of the other-centered listening/experiencing perspective. This author focuses on an integrative theory including three forms of relatedness and different listening/experiencing perspectives. Different listening/experiencing perspectives and forms of relatedness fundamentally influence analysts' affective experiences within the analytic encounter as exemplified in Levenkron's case.     

The Compatibility of Hegelian Recognition and Morality with the Ethics of Care

I draw connections between Hegel’s concepts of recognition and morality and demonstrate how they are compatible with an ethic of care. I explore Hegel’s Sittlichkeit and demonstrate the role that intersubjective recognition plays in the development and sustainment of ethical communities. I demonstrate how his emphasis on the community and interpersonal relationships play an important role in his moral theory. I then contrast Hegelian and Kantian views of morality and argue that Hegel’s account places greater emphasis on attending to the needs of others and showing genuine concern for their well-being. By highlighting the intersubjective nature of recognition between self-consciousnesses, and the interconnectedness of agents in an ethical community, I maintain Hegel’s morality is compatible with an ethic of care because it emerges out of intersubjective mutual recognition and its foundation is built upon responding to the needs of particular others and protecting the bonds of the community.     

Kant’s imitatio Christi

This article retrieves Kant’s imitatio Christi as a viable alternative to the recent construal of mimesis as a universal human desire, in particular to Ward’s reformulation of the imitatio Christi in such terms (in which the human condition is defined by an intrinsic desire for God as other). Kant’s writings participate in a very different debate on imitation (one sceptical of its ethical value), and this plays out as a continual ambivalence towards the concept in his work. Kant’s imitatio Christi, however, does, I contend, make possible a moral form of imitation by characterising it as a rational and intersubjective debate upon the good. Imitating Christ becomes part of human ethical living in the world.     

Poetics in the Clinical Encounter

Amidst a mounting impasse, a patient’s startling slip of the tongue opens this analyst to a crucial awareness of her affective experience so that she can begin to reenter her patient’s. The analyst’s openness to her own vulnerability serves to free both participants from collapse into a doer–done-to complementarity. The enactive communication expands the depth of their connection and dis-connection in the moment. Just as a poem says metaphorically what cannot be said in ordinary prose, the slip jolts both participants into more imaginative intersubjective ground that transcends a sense of time and potentiates clinical momentum.     

Commentary on “deconstructing difference: Gender,splitting, and transitional space”;

This essay identifies Kohut's major contribution as methodological: that psychoanalytic inquiry entails the sustained empathic immersion in the patient's psychological experience. Kohut's consistent employment of this method enabled him to discover that it was not instinctual drive derivatives but selfobject needs that were central to all psychological relationships. This discovery was the basis for the transformation of analysts’ approach to the “narcissistic”; aspects of a wide variety of disorders—a transformation whose theoretical and therapeutic importance rivals the revolutionary approach taken by Freud to the vicissitudes of psychosexuality and its disturbances. The author describes the major areas of progress in self psychology—much of which centers on the growing recognition that the health and vitality of the self depend on complex relational, or intersubjective, selfobject experiences. He indicates how this recognition is changing our perspectives on transference and countertransference and is improving our ability to respond optimally to our patients. He describes how optimal responsiveness constitutes the guiding principle for therapeutic work, and how it may both constitute, and be different from, “being empathic.”;     

Simultaneous Group and Insulin Therapy

Abstract

The concept of focus can provide a meaningful bridge between theory and practice. The authors’ aim in this paper is to demonstrate that for theory to be clinically useful, it should provide a sense of focus and organization for clinical work. They illustrate how their particular use of a self–psychological/intersubjective model leads to an emphasis on what they refer to as “sustained empathic focus.” The authors’ choice of concepts leads them consistently to stress the patient’s subjective experience and emerging vulnerability.     

Primary Intersubjectivity: Empathy,Affective Reversibility, ‘Self-Affection’ and the Primordial ‘We’

The arguments advanced in this paper are the following. Firstly, that just as Trevarthen’s three subjective/intersubjective levels, primary, secondary, and tertiary, mapped out different modes of access, so too response is similarly structured, from direct primordial responsiveness, to that informed by shared pragmatic concerns and narrative contexts, to that which demands the distantiation afforded by representation. Secondly, I propose that empathy is an essential mode of intentionality, integral to the primary level of subjectivity/intersubjectivity, which is crucial to our survival as individuals and as a species. Further to this last point, I argue that empathy is not derived on the basis of intersubjectivity, nor does it merely disclose intersubjectivity, rather it is constitutive of intersubjectivity at the primary level. Empathy is a direct, irreducible intentionality separable in thought from the other primary intentional modes of perception, rationality, memory and imagination, but co-arising with these. In regard to the inter-personal level, the concrete relations with others, primary empathy is both the ground for the possibility of the secondary manifestations—pity, sympathy, perspective taking, etc., and motivates them. Thirdly, it is the movement in the core of subjectivity initially generated by shifting attention between the ‘I’ and ‘we’ perspectives and later ‘solidified’ through affect to become shifting identification, which opens up the intersubjective domain. So we can affirm that we are not only born into sociality but our sociality goes to the roots of our being as Husserl, Heidegger and Merleau-Ponty have claimed.     

On Traumatically Skewed Intersubjectivity

ABSTRACT

Beginning with his Interpersonal World of the Infant (1985), Daniel Stern suggested that the infant is driven from birth to connect intersubjectively with his caregivers. By the final three months of the first year of life, as the infant begins to use protodeclarative pointing and jointly attends to the outer world, he also begins to jointly attend with his caregiver to their respective intrapsychic worlds, the mental states of his caregiver and himself. Clinically, analysts observe at this crucial point of development of secondary intersubjectivity mothers who, more often than not, respond only selectively and often unpredictably to their infants. In many instances, this may be motivated out of a mother’s own need for regulation of emotion and arousal as we have shown in our empirical research. This article elaborates on clinical observations that, for the infant or young child to feel his traumatized mother’s affective presence, he must try to enter mother’s state of mind, while simultaneously, mother is seeking to self-regulate in the wake or the revival of trauma-associated memory traces, this at the expense of mutual regulation of emotion and arousal. We call this phenomenon traumatically skewed intersubjectivity. We find that children coconstruct with their traumatized mothers a new, shared traumatic experience by virtue of the toddler’s efforts to share an intersubjective experience with a mother who is acting in response to posttraumatic reexperiencing. The problem is that the infant or young child has no point of reference to decipher the traumatized mother’s social communication. And so, what is enacted leads to a new, shared traumatic event. Both the child’s anxiety and aggression can, in this setting, easily become dysregulated, further triggering mother’s anxiety and avoidance, leading thus to a vicious cycle that contributes to intergenerational transmission of trauma. Clinical examples and implications for psychoanalytically-oriented parent-infant psychotherapy will be discussed.     

Communicative depth: soundings from developmental psychopathology

My aim in this paper is to consider what it means to engage and communicate with another person. I do so by adopting the approach of developmental psychopathology, and compare and contrast the structure of communication that is manifest by typically developing infants on the one hand, and by children and adolescents with autism on the other. I highlight the pivotal significance of human beings' propensity to share or otherwise co-ordinate experiences with others, and analyze the conditions that make sharing and other forms of intersubjective relatedness possible. Often, discussions that oppose cognitive, affective, and motivational accounts of autism are pursued in an inappropriate frame of reference: at root, we need to understand the nature and developmental implications of affected children's difficulties in achieving communicative depth. In the pursuit of such understanding, we may gain insights into typically developing infants' capacities for intersubjective engagement.     

Nishida,Agency, and the ‘Self-Contradictory’ Body

In this essay, I investigate Kitarō Nishida's characterization of what he refers to as the ‘self-contradictory’ body. First, I clarify the conceptual relation between the self-contradictory body and Nishida's notion of ‘acting-intuition’. I next look at Nishida's analysis of acting-intuition and the self-contradictory body as it pertains to our personal, sensorimotor engagement with the world and things in it, as well as to our bodily immersion within the intersubjective and social world. Along the way, I argue that Nishida develops a rich and exceedingly current way of thinking through different facets of embodiment and interpersonal relatedness. I further argue that Nishida's work provides compelling reasons to foreground the mutually implicative, co-emergent nature of embodied self and world in our theorizing about the nature of self and experience.     

Traumatic effects of political repression in Chile: A clinical experience1

The author examines psychic trauma resulting from human rights violations in Chile. Starting from trauma theories developed by authors such as Ferenczi, Winnicott and Stolorow, she posits the relevance of the subject's emotionally signifi cant environment in the production of the traumatic experience. She describes the characteristics of the therapeutic process on the basis of a clinical case. She emphasizes the need to recognize the damage that may be produced within the reliable link between patient and analyst, pointing out the risk of retraumatization if analysts distance themselves and apply ‘technique’ rigorously, leaving out their own subjective assessments. Therapists must maintain their focus on the conjunction of the patient's intersubjective context and inner psychic world both when exploring the origin of the trauma and when insight is produced. The author posits repetition in the transference as an attempt at reparation, at fi nding the expected response from the analyst that will help patients assemble the fragments of their history and achieve, as Winnicott would put it, a feeling of continuity in the experience of being.     

Chilled to the bone: embodied countertransference and unspoken traumatic memories

Starting from a deeply challenging experience of early embodied countertransference in a first encounter with a new patient, the author explores the issues it raised. Such moments highlight projective identification as well as what Stone (2006) has described as ‘embodied resonance in the countertransference’. In these powerful experiences linear time and subject boundaries are altered, and this leads to central questions about analytic work. As well as discussing the uncanny experience at the very beginning of an analytic encounter and its challenges for the analytic field, the author considers ‘the time horizon of analytic process’ (Hogenson 2007 ), the relationship between ‘moments of complexity and analytic boundaries’ (Cambray 2011 ) and the role of mirror neurons in intersubjective experience.     

Creating an Intersubjective Reality: Commentary on Paper by Arnold Rothstein

The author discusses Arnold Rothstein's paper “Compromise Formation Theory: An Intersubjective Dimension” and challenges his definition of intersubjectivity. She offers a perspective in which the import of intersubjectivity theory is less to dissolve the notion of objectivity than to grasp processes of mutual engagement, regulation, and recognition. While it is true that the recognition that the analyst is also a subject and therefore does not have exclusive knowledge is an important shift in the psychoanalytic paradigm, the author suggests that the intersubjective is far more encompassing than this. Intersubjective theory emphasizes the active creation of consensus or conflict about reality rather than merely the recognition that the analyst's perspective on reality is subjective. This cocreation produces a different emotional experience of connection, not merely a change in the quality of insight. Finally, Rothstein's case illustrates how he responds to the need for recognition and regulation. He shows us how focusing on the procedural allowed him to make an intersubjective shift, not simply an intrapsychic interpretation of compromise formation.     

Relatedness support enhances motivation,positive affect,and motor learning in adolescents

Social relatedness is a basic psychological need to experience satisfaction of interpersonal acceptance and closeness with others. In this experiment, the effects of social relatedness on the learning of a task (hitting a ball with a racket toward a target) were tested in adolescents. Participants were assigned to three experimental groups. After a pre-test and before practice, participants in the relatedness support (RS) condition received instructions emphasizing recognition, importance, and interest in the participant's experience. Participants in the relatedness frustration (RF) condition received instructions emphasizing disinterest in the participant as a person. Control participants did not receive specific relatedness instructions. One day later, they performed retention and transfer tests. Questionnaires measured participants' motivational and affective levels. The results showed that supporting the relatedness need enhances task learning in adolescents. Motivation and affective levels were also affected. The findings are the first to show that social relatedness affects adolescent's motor performance and learning and reveal underlying mechanisms implicated in such effects.     

The Empathetic Soldier

ABSTRACT

Empathy’s relation to the conduct of war is ambiguous. It is mentioned sporadically in international relations theory and, perhaps surprisingly, in official military doctrine. Yet empathy’s role in the military profession remains obscure, partly because it sits uneasily in military culture. Many military professionals struggle with how it is to be integrated with other, more clearly martial, virtues. Add to this struggle the confusion over what empathy actually is, and it quickly becomes easier to dismiss it or keep it at the fringes of consideration. It is my intent to clarify the concept of empathy in light of recent scholarship, and then to show the relevance of empathy to the tactical and strategic demands of war. Empathy bolsters soldiers’ understanding of human actors in the operational environment and it improves soldiers’ overall intentions. These benefits derive from the nature of empathy as an understanding of another’s experience, including emotions, beliefs, perspectives, or intentions, and the incorporation of this knowledge into further deliberation, especially important moral judgments.     

On the Patient's Becoming an Individual: The Importance of the Analyst's Personal Response to a Deprived Patient and Her Dreams

What patients mainly want—which Ferenczi noted as early as 1932 in his clinical diary and which Bion later expressed in his Cogitations (1992)—and what some patients need, is to experience how the analyst lives and processes the interpersonal events that lie at the origin of their affective and mental suffering. This is especially true with schizoid patients who were profoundly emotionally deprived in childhood. In this paper, the author investigates this crucial aspect of the intersubjective analytic relationship in his treatment of just such a patient, an extremely silent and inert young woman. Through a detailed examination of clinical material from various stages of her analysis, he explores how the analyst's unconscious emotional response serves as both a tool for comprehension and a key element of environmental facilitation—a “new beginning,” to use Balint's phrase—that may help the patient attain a level of development and emancipation that he or she has never experienced before.     

Making Music Together: Discussion of Gianni Nebbiosi’s “The Smell of Paper”

Finding life in our patients is a common goal for analysts. Historically this project had been defined as one of freeing unacceptable impulses from their imprisoning defenses with the analyst, via interpretation, then contrasting the patient’s internal fantasied reality with “actual” reality. Untangling fantasy from reality could free the impulses to provide energy for more realistic projects. This imagery stands in stark contrast to the fluidity of a contemporary relational conceptualization of human experience where our inner experience is now understood to be the lens through which we construct our vision of external reality, always a subjective perception. Clinical change—finding life—now depends more on the activation of a generative intersubjective process between patient and analyst, which contributes to the expansion of the patient’s subjective experience. Gianni Nebbiosi’s use of music and of mime to help him feel his way into his patient’s and ultimately into his own similarly defended experience demonstrates the creativity and idiosyncratic clinical approaches that emerge from a contemporary relational orientation. This orientation recognizes the analyst’s subjectivity as a fundamental tool of clinical change—a vehicle through which any theoretical approach will necessarily be shaped. Differing approaches to a clinical situation do not always simply reflect theoretical disagreements; they may also reflect the expression of the particular subjectivity of the analyst.     

Unlawful Entry: Male Fears of Psychic Penetration

In this paper, it is argued that males as well as females have an early experience in relation to the nursing mother of being receptive to bodily and psychic penetration. Males tend to lose access to this experience and may come to fear penetration as a threat such that a masculine sense of self is felt to be dependent on an impermeable psychic boundary that is not to be penetrated. Instead, phallicism as a fortress of emotional self-sufficiency—which the author labels the citadel complex—becomes the matrix of a subjective sense of masculinity. The multiple and combined forces of bodily development, the establishment of gender identity, and the process of separation-individuation are examined for their role in this process.

A critique of the Lacanian concept of paternal law suggests that the “law of the father” can be interpreted as a law regulating penetration. Paternal law can be viewed as a code for the establishment of an impenetrable masculinity whereby entry into an adult male psyche becomes unthinkable, “unlawful.” An impermeable bodily and psychic boundary—the ability to penetrate without the ability to be penetrated—collapses a necessary dialectical tension that may affect men's experience of sex and of love and that may shape and limit their desire.     

The holding environment and intersubjectivity

The holding environment is explored in the context of the analytic dyad, where it is seen as rooted in the patient's need to be experientially known through the intersubjective interaction. In examining previous emphasis on holding as an optimally attuned empathic environment provided by the analyst, a broadened view of what constitutes a holding environment is presented, underscoring its interactional nature. A distinction is made between empathic holding based on the patient's expressed material, and holding that is generated through the analyst's intersubjective knowledge, gained via ongoing intersubjective engagements and enactments. It is argued that the unmediated connection to the patient's internal representations resulting from these intersubjective interactions, and the ensuing verbal exploration of them, can create a profound sense of being understood and thus held. A clinical process depicting the experience of holding in an intersubjective context is presented.