The Interpersonal Perspective in Psychoanalysis, 1960s-1990s

Rethinking transference and countertransference

Donnel B. Stern, Irwin Hirsch

• Publisher: Routledge
• Year: 2017
• ISBN:
  9781315471952
• Edition: 1
• Topic: Psychologie
• Subtopic: Psychoanalyse

North American psychoanalysis has long been deeply influenced and substantially changed by clinical and theoretical perspectives first introduced by interpersonal psychoanalysis.Yet even today, despite its origin in the 1930s, many otherwise well-read psychoanalysts and psychotherapists are not well informed about the field. The Interpersonal Perspective in Psychoanalysis, 1960s–1990s provides a superb starting point for those who are not as familiar with interpersonal psychoanalysis as they might be. For those who already know the literature, the book will be useful in placing a selection of classic interpersonal articles and their writers in key historical context.

During the time span covered in this book, interpersonal psychoanalysis was most concerned with revising the understanding of the analytic relationship—transference and countertransference-and how to work with it. Most of the works collected here center on this theme. The interpersonal perspective introduced the view that the analyst is always and unavoidably a particular, "real" person, and that transference and countertransference need to be reconceptualized to take the analyst's individual humanity into account.The relationship needs to be grasped as one taking place between two very particular people. Many of the papers are by writers well known in the broader psychoanalytic world, such as Bromberg, Greenberg, Levenson, and Mitchell.But also included are those by writers who, while not as widely recognized beyond the interpersonal literature, have been highly influential among interpersonalists, including Barnett, Schecter, Singer, and Wolstein.

Donnel B. Stern and Irwin Hirsch, prominent interpersonalists themselves, present each piece with a prologue that contextualizes the author and their work in the interpersonal literature. An introductory essay also reviews the history of interpersonal psychoanalysis, explaining why interpersonal thinking remains a coherent clinical and theoretical perspective in contemporary psychoanalysis. The Interpersonal Perspective in Psychoanalysis, 1960s – 1990s will appeal greatly to psychoanalysts and psychoanalytic psychotherapists wanting to know more about interpersonal theory and practice than can be learned from current sources.

Chapter 1

The “dedicated physician” in the field of psychotherapy and psychoanalysis (1967/1979)

Harold F. Searles

Harold Searles was not part of the first generation of interpersonal psychoanalysts who studied and taught at the Washington School of Psychiatry and the William Alanson White Institute, but his thinking, his conduct, and his spirit were interpersonal. Certainly we, the editors of this book, have felt a theoretical and clinical kinship with Searles during our entire careers. He has always been an interpersonalist to us. But let Searles speak for himself:

I never met Sullivan personally, and do not consider myself to be a Sullivanian. But the early years of my analytic training took place in a Washington strongly influenced, if not dominated, by him and his ideas; I was a student in 2-1/2 of the courses he taught (he died midway through the last of these); and I have acknowledged in earlier writings my debt to him. His term, “participant observation”, seems to me well and succinctly to capture the spirit of the analyst’s functioning vis à vis the patient. (1977, p. 67)

Despite the fact that, as Searles says, he was “not a Sullivanian,” a case can be made that, more than any other psychoanalytic writer, Searles carries forward Harry Stack Sullivan’s credo that analyst and patient are each much more human than otherwise, i.e., that by virtue of the humanity that they have in common, their subjectivities have equal value and their ways of being in the world are equally flawed. The quality and depth of Searles’ writing about analytic work with schizophrenic people expresses a passion of Sullivan’s that no one besides Searles has ever matched. Few people today view psychosis, as did Sullivan, as a human process – a function of internalized, real experience with significant others. The current prevailing wisdom places schizophrenia and other varieties of psychosis in the realm of biology and/or neurology, thereby instantiating in our present day Searles’ picture of the clinical hierarchy of his own era. Searles felt that many therapists of his time believed themselves to be healthy and the troubled people they treated to be afflicted with illnesses that made them “less-than” their doctors. Today’s clinical hierarchy may be even more extreme than the clinical hierarchy Searles blisteringly denounced in his own day. Searles skewers the attitude of condescending therapists who create in themselves a feeling of well-being by convincing themselves of their devotion to their patients, who are, in turn, routinely characterized as “egoless” and therefore less human than their therapists. To the extent that analysts deny their own troubled and darker affective and motivational states in order to be protective, hovering rescuers, all that is bad and weak is attributed to the patient. From the moment that Sullivan introduced the term “participant-observation,” it should have become clear to all who embraced the developing tradition of interpersonal psychoanalysis that the flawed analyst and flawed patient inevitably co-participate with one another, each possessing a wide range of conscious and unconscious affective states. To the extent that countertransference subjectivities are denied or otherwise not experienced, these are invariably acted-out to the detriment of the patient, who will inevitably be perceived as having all of the bad or troubled personal qualities.

Any therapist who views himself as simply a kind and well-meaning healer to an afflicted patient will miss the strengths of the patient; the adaptive nature of the patient’s way of being; and the patient’s wish to heal his troubled family – and in the transference, his troubled analyst. Such a therapist or analyst is also quite likely to deny his self-interest in maintaining a hierarchy in which one person is strong and benevolent at the expense of the other, who, unfortunately, may embrace the role of being the receiver of supplies from the “healthier” psychotherapist or analyst. With equal misfortune, such supplies will never help, since some of the analyst’s genuine motives – to aggrandize himself – are never embraced; and as a result the patient is likely to feel more and more like a fragment of a human being.

In the tradition of interpersonal psychoanalysis, Searles views all psychological development as a function of internalized experience with key others. Perhaps more than any psychoanalytic writer he illustrates the clinical significance of understanding that, for therapists and analysts, not just for patients, the most important part of the experience of the therapeutic situation is deeply affective. To recognize and acknowledge this point is to dismantle the destructive parts of clinical hierarchy. It is no longer clear that one participant in the treatment is weak and the other strong, that one is ill and the other well. No one has ever written more clearly about the degree to which the analyst’s subjectivity fully interacts with and influences that of the patient – and is influenced by the patient. Searles’ unique openness to his own experience, not only about his subjectivity but his personal flaws, set the bar for future interpersonal and relational analysts. Very few of us meet that standard even now.

Reference

Searles, H. (1977). The analyst’s participant observation as influenced by the patient’s transference. Contemporary Psychoanalysis, 13: 367–370.

The “dedicated physician” in the field of psychotherapy and psychoanalysis (1967/1979)

Harold F. Searles

Psychiatric patients, and above all schizophrenic patients, cause one to doubt one’s capacity to love, and to feel that one’s devotion is meaningless or, worse, malevolent. When I used to see a hebephrenic woman, with whom I had been working for ten years, walking about on the hospital grounds appearing vague, disheveled, bleakly unloved, I felt her to be a kind of living, ambulatory monument to my cruelty and neglect. Even though I had not forgotten that I had been subjected to something like 2000 hours of her reviling me, ignoring me, sexually tantalizing me, making heart-rendingly unanswerable appeals to me either mutely or in largely undecipherable words, and so on, I still winced at the sight of her. It was as though the Methodist hell of my boyhood yawned widely for my thus-proved un-Christ-like soul.

A year or two previously, on one of the rare days when she had her wits sufficiently about her to be considered able to come with me to my office, about 100 feet away, she stood in confused helplessness while an ostensibly kind, loving, gentle female aide, who (as I later came to realize) busily infantilized all the patients, was putting shoes on this woman’s feet. I felt remorse because I did not feel at all like doing so – because I was feeling, at that moment, nothing toward the patient except impatience, contempt, and hatred.

My papers have chronicled my finding, to my mingled relief and self-deflation, how able schizophrenic patients are not merely to endure but to turn to therapeutic benefit one’s expressions of deepeningly intense feelings of all kinds. But the events of my final year at Chestnut Lodge showed that I had underestimated to the last, nonetheless, these patients’ strengths. I gave notice, one year in advance, of my intention to leave the Lodge; such notice was required by my contract, which in turn, of course, was based on clinical and staffing necessities. Regarding it feasible to go on working with no more than two of my six patients after I would leave there, I was now faced with the immensely difficult matter of which two, among six persons with whom I had been working intensively for years, I would go on seeing. With one of these persons, I had worked for nearly six years; with each of four, between ten and 11 years; and with one, for 13 ½ years.

My ambivalence toward each of these individuals, like his or her own toward me, of course, knew no bounds. I wanted utterly rid of the whole lot of them, yet felt almost unbearably anguished at the prospect of losing any one of them. A passage from my last staff presentation at the Lodge, just before I left, expresses something of what I had come to learn of the strength that each of these persons possessed:

The one biggest lesson … I have learned in working with schizophrenic patients in my last year here has been to see how very tough they are … I can say that I have, in this last year, burdened or battered, or what-not, each of these six patients with all the sarcasm, harshness, contempt, and just general resentment and reviling that I’m capable of and they’ve all survived it fine, see, just fine, and I have felt that I have just barely been operating in their league – just barely been qualifying to be in the major leagues. When I start this with Edna she is soon on the offensive again; she can take all I’ve got and she can go on for more.

Another way that I conceptualize it is, the work is so god-damned difficult that we cannot do it if we deny ourselves certain parts of our armamentarium. We can’t do it with one hand tied behind our back. So this has been something memorable to me; this I’m going to keep using with patients. I am.

My experiences with colleagues over all these same years, as a supervisor or a consultant in their work with their schizophrenic patients, have shown me, similarly, with what toughness, tenacity, and sadistic virtuosity their patients tend to coerce these therapists into the ever-alluring role of the dedicated physician treating the supposedly weaker patient. Typically, to the extent that one feels bound by the traditional physician role, one feels wholly responsible for the course of the patient’s illness, and believes it impermissible to experience any feelings toward the patient except kindly, attentive, long-suffering, and helpful dedication. The psychiatric resident, in particular, relatively fresh from the dedicated-physician atmosphere of the medical school and general internship, is often genuinely unaware of feeling any hatred or even anger toward the patient who is daily ignoring or intimidating or castigating him, and unaware of how his very dedication, above all, makes him the prey of the patient’s sadism. It has been many years since a young schizophrenic man revealed to me how much sadistic pleasure he was deriving from seeing a succession of dedicated therapists battering their heads bloody against the wall of his indifference, and I have never forgotten that.

In general, if the patient’s illness is causing more suffering to the therapist than to the patient, then something is wrong. But it is not at all easy, technically, to become more comfortable than the patient. With many schizophrenic patients, one tends to feel like a butterfly, pinned squirmingly in their live-butterfly collection, without any reliable way of drawing blood from the pinner, the invulnerable patient. It is our omnipotent self-expectations that, more than anything else, pinion us and tend, as well, to stalemate or sever the therapeutic relationship. The obnoxiously behaving paranoid patient cannot help wondering what ulterior motives make us so concerned to keep him in therapy; instead of our becoming aware of our angrily wanting rid of him, we act out our repressed desires to reject him by manifesting an omnipotence-based, devouring, vampire-like devotion that understandably frightens him away from treatment. And the suicidal patient, who finds us so unable to be aware of the murderous feelings he fosters in us through his guilt-and-anxiety-producing threats of suicide feels increasingly constricted, perhaps indeed to the point of suicide, by the therapist who, in reaction formation against his intensifying, unconscious wishes to kill the patient, hovers increasingly “protectively” about him, for whom he feels an omnipotence-based physicianly concern. Hence it is, paradoxically, the very physician most anxiously concerned to keep the patient alive who is tending most vigorously, at an unconscious level, to drive him to what has come to seem the only autonomous act left to him – suicide.

The therapist’s functioning in the spirit of dedication that is the norm among physicians in other branches of medicine, represents in the practice of psychotherapy and psychoanalysis an unconscious defense against his seeing clearly many crucial aspects of both the patient and himself – for example, his sadism. He does not see how much sadistic gratification the patient is deriving from his anguished, tormented, futile dedication. He does not realize that, as I overheard one chronically schizophrenic man confide to his therapist, “The pleasure I get in torturing you is the main reason I go on staying in this hospital.” I had heard this therapist say that for many months he had never known, when he went into this man’s room on the disturbed ward, whether to expect a blow or a kiss from the patient.

Further, the dedicated therapist does not see how much ambivalence the patient has concerning change, even change for the “better.” He does not see that the patient has reached his present equilibrium only after years of thought and effort and the exercise of the best judgment of which he is capable. To the patient, change tends to mean a return to an intolerable preequilibrium state, and the imposition on him of the therapist’s values, the therapist’s personality, with no autonomy, no individuality, for him. He resents the therapist’s presumption in assuming that the patient is pitiably eager to be rescued, and equally humiliatingly that the intended help is all unidirectional, from therapist to patient.

A dozen years ago, I reached the conviction that it is folly to seek to rescue the patient from the dragon of schizophrenia: the patient is both the maiden in the dragon’s grip and the dragon itself. The dragon is the patient’s resistance to becoming “sane” – resistance that shows itself as a tenacious and savage hostility to the therapist’s efforts.

The heart of this resistance springs from the fact that, since early childhood, the patient’s own raison d’être has been as a therapist, originally to the parent whose unwhole integration he, the child, was called upon to complement, in a pathologic and unnaturally prolonged symbiosis. He was given over to this therapeutic dedication, as a small child, for the most altruistic of reasons – he lived in order to make mother (or father) whole – as well as for reasons of his own self-interest, so that he would have a whole parent with whom to identify, for the sake of his own maturation. But he failed in his therapeutic dedication; and, more hurtfully, his dedication was not even recognized by the parent, who incessantly hurt, disparaged, and rejected him. Now, as an adult schizophrenic patient in treatment, he takes vengeance on this rival, “official” therapist of his, and causes his therapist to feel as anguished, futile, and worthless or malevolent an intended healer as he had been made to feel by his mother or father. Only insofar as the therapist becomes able to see and respond to the patient’s genuinely therapeutic striving toward him and, earlier, toward the parents, will the patient himself be receptive to therapy. Among my feelings during the final year at Chestnut Lodge was, prominently, grief at various of my patients’ having refused to identify sufficiently with my healthier aspects and, by the same token, at my own having failed to help them do so. I surmise that such grief is of a piece with the patient’s own repressed grief, stemming from early childhood, at proving unable to save the sick parent through encouraging him to identify with the healthier aspects of the patient as a growing child.

We therapists tend to feel frightened away from seeing how concerned our patients are to help us, partly for the reason that the transference-distortions, in which this therapeutic striving of theirs is couched, are very great. That is, our patient tends to see us as being not merely somewhat depressed today, but as being his deeply, suicidally despondent father; or he perceives us as being not merely somewhat scatterbrained today, but as being his insane, hopelessly fragmented mother.

Patients’ specific therapeutic aims, and their individual techniques in pursuing those aims, are manifold. As examples, various of my patients have rescued me from periods of withdrawal and depression by presenting themselves as being in such urgent need of rescue that I have felt it necessary to bestir myself, come out of myself, and thus cast off the chains of my depression in order to save them. Others, by presenting themselves as being infuriatingly, outrageously undisciplined, have eventually “made a man of” me – by impelling me into becoming a stern disciplinarian, have made me into the kind of man that they had been unable to make their wishy-washy father into.

Their therapeutic techniques are outwardly so brutal that the therapeutic intent is seen only in the result. One apathetic, dilapidated hebephrenic patient of mine received considerable therapeutic benefit from a fellow patient, newly come to the ward but, like him, a veteran of several years in mental hospitals, who repeatedly, throughout the day, gave my patient a vigorous and unexpected kick in the behind. From what I could see, this was the first time in years a fellow patient had shown any real interest in him, and my patient as a result emerged appreciably from his state of apathy and hopelessness.

As for the many crucial aspects of himself in relation to the patient, against which the therapist is unconsciously defending himself with his physicianly dedication, I have already touched on some. He is unaware of how much he is enjoying his tormenting the patient with his dedication, of which the patient, who feels himself to be hateful and incapable of giving anything worthwhile to anyone, feels so unworthy. He is unaware, similarly, of how much scorn his own “dedication” is expressing. I asked a female colleague, who was describing her work, a very actively dedicated and ostensibly maternally loving work with a deeply regressed woman, how much ego she felt the patient to have. The therapist replied, as though this were obvious, “None.” Such unconscious scorn for the patient – for the patient’s own strength and for his ability to reach out, himself, for help from the therapist without the therapist’s having constantly to keep pushing the help at him – seems to me to betray much self-contempt on the part of the therapist. If the therapist is convinced that he himself is a worthwhile person, with something useful to give – with something, that is, that this fellow human being, the patient, can be relied on to discern and to admire and want – he will not need to try, anxiously and incessantly, to persuade the patient to accept his help.

Further, the “dedicated” therapist, who feels ...

Table of contents

• Cover
• Endorsement
• Half Title
• Series Information
• Title Page
• Copyright Page
• Dedication
• Table of contents
• Acknowledgments
• Introduction: Interpersonal psychoanalysis: History and current status
• Chapter 1 The “dedicated physician” in the field of psychotherapy and psychoanalysis (1967/1979)
• The “dedicated physician” in the field of psychotherapy and psychoanalysis (1967/1979)
• Chapter 2 Countertransference: The psychoanalyst’s shared experience and inquiry with his patient (1975)
• Countertransference: The psychoanalyst’s shared experience and inquiry with his patient (1975)
• Chapter 3 The fiction of analytic anonymity (1977)
• The fiction of analytic anonymity (1977)
• Chapter 4 Psychoanalysis: Cure or persuasion? (1978)
• Psychoanalysis: Cure or persuasion? (1978)
• Chapter 5 Early developmental roots of anxiety (1980)
• Early developmental roots of anxiety (1980)
• Chapter 6 Interpersonal processes, cognition, and the analysis of character (1980)
• Interpersonal processes, cognition, and the analysis of character (1980)
• Chapter 7 Prescription or description: The therapeutic action of psychoanalysis (1981)
• Prescription or description: The therapeutic action of psychoanalysis (1981)
• Chapter 8 Psychoanalytic engagement: The transaction as primary data (1982)
• Psychoanalytic engagement: The transaction as primary data (1982)
• Chapter 9 The interpersonal paradigm and the degree of the therapist’s involvement (1983)
• The interpersonal paradigm and the degree of the therapist’s involvement (1983)
• Chapter 10 The intrapsychic and the interpersonal: Different theories, different domains, or historical artifacts? (1988)
• The intrapsychic and the interpersonal: Different theories, different domains, or historical artifacts? (1988)
• Chapter 11 Countertransference and participant-observation (1990)
• Countertransference and participant-observation (1990)
• Chapter 12 Courting surprise: Unbidden perceptions in clinical practice (1990)
• Courting surprise: Unbidden perceptions in clinical practice (1990)
• Chapter 13 “Speak! that I may see you”: Some reflections on dissociation, reality, and psychoanalytic listening (1994)
• “Speak! that I may see you”: Some reflections on dissociation, reality, and psychoanalytic listening (1994)