Hatred in Group Therapy: A Rewarding Challenge

Hatred is a powerful affective experience that can be disruptive to the work of a therapy group, yet it may also enhance a member's capacity to deal with strong affects. This paper explores a particular aspect of hatred, the hate directed at one member of a cotherapy team. An effort is made to explore the experience from an intersubjective and motivational systems perspective, focusing primarily on the therapist and one patient. The impact of the cotherapy relationship is also considered, as well as the whole group's capacity to contain and work with this powerful affective response. The way that the group managed this explosive situation speaks to the power of group therapy in healing and transforming its members.     

‘Characters’ in psychoanalytic and interpersonal therapy: A comparison

In this paper the author considers how the therapist might listen to the characters talked about by his or her patients. In psychoanalytic therapy the emphasis is on listening to the patient's characters as though they are located in psychic reality and as representatives of the transference relationship, whereas in interpersonal therapy (IPT) the patient's characters are taken as inhabiting the realm of external reality. It is argued that clinical thinking in IPT would be enhanced by taking more account of psychic reality, which will make clearer the quality of external reality in which the patient's characters are located. It is also argued that both therapies share an interest in enabling the patient to find characters which can serve as holograms of previously unexpressed affective experience.     

What Are We Doing There? A Therapeutic Tale

In this paper I try to portray our interpsychic work as reflective of an infinite conversation: an intersubjective dreaming of one’s life, moving between multiple positions/self-states, those of the patient and our own; becoming involved while pondering the movement we are part of, sometimes in our hearts and minds, many times aloud and openly with our patient; recognizing her experience and enabling her to see us, and sometimes not reflecting at all—“the “moving talk.” The dilemma of the therapist’s positioning, internally and interpersonally, is further postulated, especially in regard to the posttraumatic patient who suffered severe childhood abuse.     

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.     

From Knowing to Discovering: Some Suggestions for Work with Anorexic Patients

ABSTRACT

In this article I offer some technical suggestions for psychoanalytic work with anorexic patients. Although focused on an outpatient setting, certain parts of the article will also have utility for inpatient work. As an outpatient therapist working with an anorexic patient, especially in the acute stages of the illness, there are case management demands that need immediate attention. The setting up the particular frame is required to augment the therapeutic work. The most urgent pressure felt by the clinician is the precariousness of the patient’s physical health. This can be experienced as if there is a gun to the head of the therapist. This deathly force must be carefully and constantly grappled with, and particularly so in the most symptomatic stages of the illness. The clinician must work with a patient who might die at any time, yet an anorexic patient cannot be managed the way a suicidal patient would be. The question of technique in this situation is a complex one. Above all, the patient must be met where s/he is. Notwithstanding the uniqueness of each patient there are some specific themes that often arise in the acute stage of the illness. Certain technical suggestions are offered.     

The Mutual Development of Intersubjectivity and Metacognitive Capacity in the Psychotherapy for Persons with Schizophrenia

While cognitive behavioral approaches have been shown to help some individuals with schizophrenia, these approaches may be limited when working with patients with impairments in the metacognitive abilities required to form complex and integrated representations of themselves and others. In response, this paper explores the possibility that a key to working with patients with relatively impaired self-reflectivity lies in explicitly focusing on a patient’s intersubjective experience within psychotherapy. We offer theoretical and empirical support for the assertion that the tolerance and capacity for intersubjectivity is a basis for the development of self-reflectivity in general. We also explore how the fostering of intersubjective processes in psychotherapy might enable some patients to form more complex ideas about themselves and so better ward off delusions in the face of the challenges of daily life. To illustrate these principles we present the case of a patient with tenaciously held delusions and limited capacity for self-reflection. We discuss when and how the therapist’s awareness and verbalization of intersubjective processes within session allowed her and the patient to develop more complex and consensually valid ideas about him as a being in the world, which then assisted the patient to achieve improvements in a number of domains in his life.     

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.     

A Country of Two: Race and Social Class in an Immigrant Therapeutic Dyad

This paper explores some of the ways in which social structures and fantasies organized around race and social class emerge in the intersubjective space created by a patient and a therapist who emigrated from the same country. Incorporating some of his own experiences of identity and otherness, the author discusses, through the lens of his countertransference, how communicating with the patient in their native language allowed for access to early internal object-relations, unconscious threats to his sense of belonging, racialized self-states, and feelings of shame associated to some of these dissociated self-states rooted in historical oppression and trauma. The author suggests that the “country of two” populated by patient and therapist is a dynamic co-created space, that emerges from the dialectic interplay of sameness and difference along the lines of race, social class, and culture.     

Anorexia and the Trojan Horse: a reflexive review of written psychoanalytic encounters with anorexic patients

A selective and limited sample of clinical case studies of psychoanalytic psychotherapy with anorexic patients, focussing on the author/therapist’s experience of working with such patients, is examined. Patients’ depressive and often angry states of withdrawal, and projections, are frequently noted. A summary of more hopeful interactions, as selected from the literature reviewed, is offered. An understanding of anorexic defences is explored in relation to the ‘Trojan Horse’ mythology, in the sense that that which purports to be emotionally nourishing and sublime can be suspiciously viewed as seeking to enter and conquer, through subterfuge. Some existing challenges to traditional tenets of psychoanalytic clinical practice with anorexic patients are presented.     

Private Terrors Sexualized Aggression and a Psychoanalyst's Fear of Her Patient

This clinical paper explores the meanings and evolution of an analyst's reaction of fear in relation to her patient's sexualized aggression. From both an intrapsychic and an intersubjective perspective, the author analyzes the coconstruction of this transference—countertransference phenomenon. Case vignettes illustrate the author's attempts to address her patient's sexualized aggression while struggling to free herself from the feelings of intimidation and fearfulness stirred by his sadomasochistic fantasies and patterns of interaction. The analyst's unconscious identification with the patient's disowned femininity and narcissistic vulnerability is seen as central to this countertransference “stranglehold.” Release from the analyst's masochistic position comes through a shift in her own affective participation. The importance of the analyst's recognizing her own unconscious contributions to this sadomasochistic dynamic is emphasized and elaborated. Discussion also focuses on the relevance of gender to the issue of countertransference fear, as illustrated in this particular male patient—female analyst dyad.     

When the Tree Falls and No One Hears It: On Being Dropped and Learning to Hold

This case study focuses on a student therapist’s reflections upon a premature termination that occurred in her work with an adolescent male patient. The therapeutic process is traced back to the beginning of treatment, and the article delineates the extent in which the patient’s early interpersonal experiences influenced the development of the therapeutic alliance. The author addresses several themes that evolved throughout the treatment, including the patient’s experience of unpredictability and instability and his inconsistent understanding of time, and the ways in which these experiences ultimately influenced the treatment’s ending. The article describes the therapist’s development as a clinician over the course of the treatment, focusing on the various experiences that helped her consolidate a dynamic understanding of the holding environment.     

Anorexic and bulimic states of mind in the psycho-analytic treatment of anorexic/bulimic patients and psychotic patients

SUMMARY

This paper discusses the relationship of bulimic and anorexic states of mind, and their interchangeability as manifested in the transference. The anorexic making bulimic-like greedy demands upon his/her objects. The bulimic showing all the qualities manifestly presented by the anorexic, an appetiteless approach to possibilities and peculiar searches in a non-specific fashion for satisfaction. Clinical material for discussion is presented from the analysis of three patients — one of whom was psychotic.

The paper attempts to show how in the transference in the true anorexic and bulimic, attacks are directed towards the awareness of the meaningful and intended specificity and function of all objects, so that any specific function can be mis-directed or nullified by the patient. The paper shows how some of these characteristics can appear as well in the treatment of borderline cases and affect the countertransference of the therapist.     

To Know Another Inside and Out: Linking Psychic and Somatic Experience in Eating Disorders

ABSTRACT

This article explores the role of the body in the psychoanalytic treatment of eating disorders from a relational and developmental perspective. Many who struggle with eating disorders and related issues have had early experiences that adversely affected the development of flexible, adaptive self-regulation, including the ability to experience affects as psychic states that can be safely shared in the context of a relationship. Because of their difficulty symbolizing and expressing feelings, patients with eating disorders often experience affects as somatic problems, for which they seek somatic solutions. Tuning in to patients’ bodily experience can open up pathways for accessing and, eventually, verbalizing and reflecting on internal states in the therapeutic relationship. As shown through a detailed case illustration, the therapist can discover and engage aspects of the intersubjective matrix that may not meet the eye by attending to his or her own bodily experiences and associations in and out of sessions.     

Implicit relational knowing: Its role in development and psychoanalytic treatment

It is increasingly apparent that “something more” than interpretation is needed to bring about change in psychoanalytic treatment. Drawing on clinical and developmental observations, we propose that interactional processes from birth onward give rise to a form of procedural knowledge regarding how to do things with intimate others, knowledge we call implicit relational knowing. This knowing is distinct from conscious verbalizable knowledge and from the dynamic unconscious. The implicit relational knowing of patient and therapist intersect to create an intersubjective field that includes reasonably accurate sensings of each person's ways of being with others, sensings we call the “real relationship.” This intersubjective field becomes more complex and articulated with repeated patient–therapist encounters, giving rise to emergent new possibilities for more coherent and adaptive forms of interaction. During a transactional event that we term a “moment of meeting,” a new dyadic possibility crystallizes when the two persons achieve the dual goals of complementary fitted actions and joint intersubjective recognition in a new form. We argue that such moments of meeting shift the relational anticipations of each partner and allow for new forms of agency and shared experience to be expressed and elaborated. © 1998 Michigan Association for Infant Mental Health     

Interior experience within analytic process

In this paper, I consider the feeling of interiority as it evolves within the treatment relationship. A capacity to access and sustain one's interiority reflects a sense of personal solidity within which the validity of subjective process and privacy is taken for granted. When this capacity is relatively undeveloped, individuals rely on the “other”; (including the analyst) to help them contact, elaborate, or manage their affective experience. Quite paradoxically, the analyst's active investigation of dynamic or intersubjective process may obfuscate rather than clarify this core difficulty. I suggest two alternative approaches to the treatment situation that stand in some tension and yet also complement each other. One emphasizes the “active”; investigation of dynamic and dyadic process, wherein the analyst works interpretively and/or around relational issues. The other is organized around the “interior”; dimension of the treatment experience, emphasizing the patient's need to develop or manage her affective process in the relative absence of input from the analyst. Two clinical situations are described, the first illustrating the use of silence with a patient whose difficulties involved affect articulation, and the second involving a patient whose need for affect regulation made her highly dependent on the analyst for soothing.     

Ghostbusting Transgenerational Processes

Transgenerational processes contribute to organizing and disorganizing attachment. The past (in all its forms and potentialities) lives on in the present, influencing the affective field of the parent–child intersubjective matrix. In a child's construction of self, he or she may run up against the confounding presence of ghosts: the dissociated, and thereby unreflected upon past of their parents. This implicitly felt, yet explicitly unknown transmission interferes in the processing of emergent experience and impedes the child's development.

Attachment theory, informed by psychoanalysis, and nonlinear dynamic systems theory, is the main theoretical underpinning of this paper's examination of the mechanisms involved in the transfer of dissociated dynamics from parent to child. The child's symptoms grow out of an incoherent affective field that defies representational mapping into a flexible usable theory of mind. Through play a child therapist finds openings to enter the attachment system, reflecting on how a child's experience is being felt, yet unthought about by both child and parents. A parent's recognition process, thereby making what was implicitly felt explicit and consequently more coherent, supports the child in his or her efforts to reorganize aspects of the attachment relationship. Both clinical experience and quotations from literary works are woven into this paper in an attempt to convey the texture, emotional depth, and universality of the subject under discussion.     

Emergence,Adaptation, and Relational Improvisation: Commentary on Terry Marks-Tarlow’s “From Emergency to Emergence: The Deep Structure of Play in Psychotherapy”

Dr. Marks-Tarlow’s paper provides a valuable examination of play processes in psychotherapy, using the novel synthesis of psychoevolutionary and nonlinear dynamical perspectives. The author’s sophisticated blend of psychobiological and intersubjective accounts is of great clinical value, illustrating the need for a rapprochement between affective neuroscience, intersubjectivity, and complexity paradigms. Comparisons are made to the Dynamical Systems Therapy 10 (DST) model (Shapiro, this issue), which similarly aims to integrate psychobiological and intersubjective accounts of psychopathology with internal representations.     

Language and Intersubjectivity: Multiplicity in a Bilingual Treatment

This paper explores the psychodynamics of analytic work conducted between a French patient and an American analyst who are both bilingual in French and English. The depth of the patient's early traumatic relational history is initially bound and cloistered in French, her mother tongue. The author argues that through the symbolization of a series of initially dissociated enactments a transitional space is created in the treatment, facilitating the integration of the patient's (and analyst's) early French-speaking selves. Language is considered as a container for both dissociative and associative forms of multiplicity, as it serves to mediate an external and internal intersubjective expansion both between and within patient and analyst.