Self Creation

Psychoanalytic Therapy and the Art of the Possible

Frank Summers

• Publisher: Routledge
• Year: 2013
• ISBN:
  9781135060886
• Edition: 1
• Topic: Psychology
• Subtopic: Applied Psychology
• Index: Psychology

"Insight" and "Change." The problematic relationship between these two concepts, to which the reality of psychoanalytic patients who fully understand maladaptive patterns without being able to change them attests, has dogged psychoanalysis for a century. Building on the integrative object relations model set forth in Transcending the Self (1999), Frank Summers turns to Winnicott's notion of "potential space" in order to elaborate a fresh clinical approach for transforming insight into new ways of being and relating. For Summers, understanding occurs within transference space, but the latter must be translated into potential space if insight is to give rise to change in the world outside the consulting room. Within potential space, Summers holds, the analyst's task shifts from understanding the present to aiding and abetting the patient in creating a new future. This means that the analyst must draw on her hard-won understanding of the patient to construct a vision of who the patient can become. Lasting therapeutic change grows out of the analyst's and patient's collaboration in developing new possibilities of being that draw on the patient's affective predispositions and buried aspects of self.In the second half of the book, Summers applies this model of therapeutic action to common clinical syndromes revolving around depression, narcissistic injuries, somatic symptoms, and internalized bad objects. Here we find vivid documentation of specific clinical strategies in which the therapeutic use of potential space gives rise to new ways of being and relating which, in turn, anchor the creation of a new sense of self.

Part One
A Psychoanalytic Theory of Self Creation

1
Potential Space in Psychoanalytic Therapy

"I know that, Doctor, but it doesn't change anything!"These words, or similar ones, are the dreaded but all-too-frequently-heard expressions of patient frustration with the inability to translate understanding into sought-after shifts in behavior. Freud's (1914) response to this problem was his concept of "working through," the repetition of the insight until gradually the desired changes come about over time. However, because Freud never developed this concept beyond repeated insight with time (Mitchell, 1997), it did not become an additional clinical strategy. Consequently, Freud's concept of working through was little more than an acknowledgment that therapeutic effect requires time and repetition of interpretations. What Freud could never successfully explain was why time and repetition were necessary Having no clinical strategy with which to address the problem, Freud (1937) ultimately became pessimistic regarding the movement from insight to fundamental therapeutic change. He ascribed the intransigence of symptoms to such unyielding factors as the death instinct, the conservative nature of the ego, and the adhesiveness of the libido. Since Freud's time, the gap between understanding and change has been widely recognized as a therapeutic problem and has been addressed from a broad array of theoretical viewpoints.

At the point in the therapeutic process when a patient is unable to extricate himself from the old patterns despite many hours of hard, insightful therapeutic work, both members of the therapeutic dyad become very frustrated and sometimes concerned that the treatment is failing. Complicating and frustrating the change process is the fact that attempts to overcome stubborn configurations tend to reenact the very pattern the analytic couple is trying to change (e.g., Levenson, 1991; Stolorow, et al., 1987; Mitchell, 1988, 1997). For example, if the patient is competitive, he is likely to experience the analyst's interpretations as an effort to attain an advantage that must be combated. This reaction is then interpreted, the patient again feels on the short end of the competitive stick, and the analytic dyad becomes consumed in a repetitive cycle from which there is no apparent escape. Expecting interpretations to be mutative, both patient and analyst can become discouraged and disillusioned when awareness does not alter long-standing patterns. The frustration of the analytic couple at this point issues from the circle of continually revisiting the pitfalls of the patient's patterns and their developmental origins while failing to alter them by means of this awareness.

Despite Freud's almost cynical end-of-life posture, the classical viewpoint has tended to support Freud in attributing the difficulty to the patient's resistance or intellectualization, leading to a clinical strategy of continued interpretation to undo the resistance. From this perspective, the solution tends to emphasize heavily repeated interpretation (e.g., Fenichel, 1938; Greenson, 1965; Ekstein, 1966). Some classical theorists underscore the importance of infantile fixations and the reconstruction of early trauma (e.g., Novey, 1962; Stewart, 1963). Others see mourning early objects as central (Glenn, 1984). Agreeing with Freud that time and repeated interpretation are the key change factors, none of these authors sees any reason to depart significantly from the interpretive stance.

Ego psychologists have maintained a steadfast adherence to interpretation while offering clinical suggestions for shifting the content of what is understood. Strachey (1934), in his famous paper on therapeutic action, concluded that reduction of superego anxiety was the touchstone of analytic change. Others have proclaimed that attention to ego mechanisms and defenses achieves greater patient responsiveness than does a complete focus on drives and their vicissitudes; other neoclassicists have advocated more emphasis on the here-and-now transference than they find in Freud's clinical approach (e.g., A. Freud, 1936; Hartmann, 1939). Contemporary structural theory holds that therapeutic action is best facilitated by analysis of presenting ego mechanisms (e.g., Busch, 1995). In brief, classical ego psychology, as represented, for example, by Strachey (1934), the newer ego psychology championed by Gray (1990), Busch (1995), and others, and even Gill's (1981) emphasis on the here-and-now transference, are all based on the principle that patients will be able to make the necessary therapeutic movement if they receive properly timed and theoretically appropriate interpretation. This trend has been epitomized by Brenner (1987), who seeing no special phase of "working through," regards the patient's failure to change as just one more resistance to be overcome with repeated interpretation. Nonetheless, Brenner does acknowledge that analysis takes a long time and that the lengthy duration of the process cannot be explained.

Despite the insistence by Brenner and others in the classical tradition that the gap between insight and change is a resistance that requires only continued interpretation, there is good reason to question the usefulness of attributing a therapeutic stalemate to the patient's "resistance." As Freud and subsequent generations of psychoanalytic clinicians have discovered, time and repetition do not necessarily render an interpretation more effective. Patients who do experience insight at a deeply affective level frequently have difficulty translating the understanding into behavioral change. One can find an abundance of evidence for this phenomenon in the analytic literature. Many of the early cases of hysteria, such as Anna O (Breuer and Freud, 1895) and Dora (Freud, 1905), had affective insight into the source of their symptoms without being able to free themselves from them. Indeed, even Freud's later cases, such as the Rat Man (Freud, 1909) and Wolf Man (Freud, 1917), do not demonstrate that repeated interpretation results in symptom reduction. Given the stubbornness of symptoms despite repeated interpretation within the transference, many classically oriented analysts have found the need to go beyond interpretation to make effective use of insight (e.g., Gedo, 1979; Valenstein, 1983; Burland, 1997).

Beyond the classical tradition, one finds in contemporary case material a common theme of the analyst using techniques in addition to interpretation because insight did not achieve sufficient therapeutic benefit. The quandary of the contemporary analyst is well illustrated in a case described by Carlo Strenger (1998). In vivid and exquisite detail, Strenger tells the story of Daphne, who came for help due to somatic complaints, compulsive rituals, and excessive anxiety that was straining her family to the breaking point. Initially Daphne seemed to respond well to Strenger's interpretations. After about four months of treatment, he commented that she had lived a life under the threat of doom. This insight had remarkable effect; soon thereafter Daphne ceased her frequent visits to the emergency room and relinquished an excessive preoccupation that her children were in danger.

However, as happens all too frequently in such cases, the analysis was far from over. It turned out that Daphne was leading an empty life in which she was stalemated by feelings of inadequacy and self-hatred. The analytic pair understood deeply the origins of these feelings, but Daphne could not shake herself from them. After years of apparent impasse, Strenger decided to take a risk by abandoning his interpretive posture and telling Daphne his experience with her insistence on maintaining a sense of failure and self-hatred. Strenger's clinical strategy not being at issue here, the importance of this case for the present purpose is that it illustrates so well the quandary of contemporary analysts. I regard Strenger's stalemated experience with Daphne as representative of what frequently happens when analyst and patient work well together. Some change is made, but the lifelong patterns are stubborn, and, because understanding has only a limited impact on them, the analyst often resorts to extra-interpretive clinical strategies. Furthermore, as previously mentioned, efforts to change the patient's configurations become absorbed into those same patterns in the transference-countertransference interactions. The preponderance of evidence suggests, that such therapeutic stalemates reflect not the patient's "resistance," but the limitations of interpretation to move the patient beyond historical patterns.

Theories of Psychoanalytic Technique

The failure of interpretation by itself to change recalcitrant pathological patterns has led many analysts to amend, rework, or even jettison the classical theory of technique, a trend that has spawned a variety of clinical innovations. Theorists who have departed more radically than ego psychologists from the traditional model fall into two broad categories. One camp sees the problem of classical technique in the content of what is being interpreted. Kleinians, in opposition to ego psychologists, tend to see the limitations of the ego-psychological approach in both the interpretive focus on libidinal wishes and overattention to defenses (e.g., Segal, 1981). Theorists of this persuasion contend that analytic change is best facilitated by addressing early, primitive, especially aggressively dominated fantasies and see little mutative impact in interpreting ego defenses against this unconscious material. Lacanians also believe the problem in the ego-psychological model lies in its focus on ego mechanisms as opposed to direct interpretation of the unconscious (Lacan, 1953). Analysts from both these schools agree with ego psychologists that therapeutic action lies in correct and well-timed interpretations of the unconscious; their argument with the classical model rests on the content of what is being interpreted.

Theorists of the second group do not believe that modifications in interpretive content or style will provide the movement needed to change longstanding patterns. Kohut (1971, 1977), finding that affective understanding did not release many patients from pathological patterns, initially attempted to amend classical theory but ultimately concluded that a new paradigm was needed. Eventually, his clinical experience led him to the view that, even when interpretation worked, the mutative effect was due not to making the unconscious conscious but to the new relationship it formed (Kohut, 1984). His abundant and rich case material is replete with descriptions of patients who were little affected by making the unconscious conscious.

Many of Kohut's most devoted collaborators have extended his paradigm to the point of questioning even more deeply the mutative effect of interpretation. Bacal and Newman (1990) have declared that the analyst promotes change by performing selfobject functions, a viewpoint that led them to question the role of interpretation in facilitating therapeutic change. Bacal (1985, 1998a, b) now believes that an analyst's optimal responsiveness is the key variable in therapeutic change. His case material illustrates the pivotal importance of analytic responsiveness to the patient (Bacal, 1998a, b). Stolorow and his colleagues (1987; Stolorow and Atwood, 1992) also view selfobject functions as crucial to therapeutic action but emphasize the contextual dependency of the process. For other self psychologists, the crux of therapeutic action is the depth of intimacy achieved between patient and analyst (Shane, Shane, and Gales, 1997).

Winnicott (1965) and the British Middle School theorists have reported many cases in which affective understanding had minimal impact while the containing and holding functions of the analyst during the patient's regression to dependence achieved powerful and lasting therapeutic change (e.g., Winnicott, 1954; Balint, 1968; Guntrip, 1969; Khan, 1974). Relational analysis sees the emotional impact of the analyst as the most critical mutative factor (e.g., Aron, 1996; Mitchell, 1997). The relational perspective, along with certain branches of self psychology, breaks decisively from classical theory in the key role given to the affective connection between analyst and patient, an emphasis so important that the efficacy of interpretation is cast into doubt by some theorists of these persuasions. Clinicians in this category believe that the problem of the recalcitrance of stubborn patterns to interpretation is resolved not by changing the content of interpretation but by shifting clinical strategy away from interpretation to the analytic relationship. Stern and his colleagues (1997) also contend that in addition to interpretation the therapeutic relationship is crucial for change, but in a different sense from other relational theorists. The Stern group holds that intersubjective moments occur between patient and analyst that lead to "implicit relational knowledge," an experience that can reorganize the psyche.

All the therapeutic strategies mentioned here—technical emphasis on the defenses, changes in interpretive content, and shifts to emphasis on the analytic relationship—are directed to the analyst's offerings, with the result that the patient is viewed as a recipient of analytic intervention. Although contemporary psychoanalytic approaches conceptualize the analytic process in ways decisively different from the classical perspective, they share, often implicitly, the classical assumption that the patient changes by absorbing the analyst's offerings, even if the nature of those provisions is characterized differently from its conceptualization in traditional theory. The distinctions among theoretical viewpoints lie in the nature of what the analyst provides, but none includes a conceptual place for the patient's role in therapeutic action, as though the patient simply imbibed the right experience, whether that be interpretive content, emotional experience, or analytic functions, the sought-for mutative change would occur.

It may seem surprising to depict the relational viewpoint as casting the patient in a passive role given the emphasis on mutuality of both participants in the construction of transference-countertransference patterns from this perspective (e.g., Aron, 1996; Hoffman, 1998). While this accent on co-construction may seem to conceptualize the patient as an active participant in the process, this concept was meant to underline the analyst's participation in the patient's transference patterns. The patient's construction of the transference relationship is a time-honored analytic principle and not at issue here. To the extent that relationalists emphasize negotiation between patient and analyst in the construction of a new relationship, the relational perspective is an important advance toward viewing the patient as a participant in therapeutic action (e.g., Pizer, 1998; Slavin and Kriegman, 1998). The negotiation that is emphasized from the relational perspective, however, means only that the subjectivities and interests of both parties are involved; it does not imply that new meaning is being created. The analytic pair may negotiate a relationship that meets the needs of both participants without the patient's creating a new way of being. Therefore, a clinical strategy emphasizing dyadic interaction and negotiation is in as much danger of not providing the psychological space for the patient to become an agent in his own transformation as any other clinical strategy. Furthermore, from the relational viewpoint, while both parties participate in the relationship, it is the analyst's impact on the patient that tends to be given credit for the new relationship and its therapeutic benefit (e.g., Mitchell, 1997). In this way, the relational viewpoint shares the assumption of most contemporary analytic schools that the crux of therapeutic action lies in what the analyst does. Such approaches tend implicitly to cast the patient in a passive posture.

Some interpersonal theorists have suggested that the problem of working-through insight can be effectively approached by integrating cognitive-behavioral techniques into analytic therapy (e.g., Wachtel, 1982, 1986, 1993; Frank, 1993). These theorists may seem to represent an exception to the focus on the therapist's activity as they advocate the inclusion of'action techniques" into the therapeutic armamentarium. These methods, however, are introduced by the therapist for the patient's experimentation. Although the patient is encouraged to attempt new behavior, he is doing so at the therapist's exhortation. As in any behavioral strategy, the patient's behavior is not self-initiated; he is performing an activity designed by the therapist. Consequently, the patient is not psychologically active in the sense of finding and creating his own new ways of being and relating. No matter how well intentioned and carefully designed, behavioral techniques subject the patient to following a script written by the therapist. In more exclusively psychodynamic approaches, including the most traditional interpretive posture, the patient must absorb analytic offerings, but at least his behavior is left to him. In the psychoanalytic sense of activity as autonomously motivated behavior (Rapaport, 1953), the patient is put in a psychologically more passive position than is true of even the most conservative analytic theories. Thus, the technical recommendation for resolving working through by including "action techniques" in the therapeutic strategy not only provides no role for the patient's self-initiated behavior, but also actively constricts the patient's ability to create ways to utilize insight.

Action, Creation, and Emotional Growth

There are several reasons to doubt that passive absorption is an effective means of therapeutic change. The minimization of the creative role of the patient in much psychoanalytic theory conflicts with the shift in the goal of analysis from the resolution of intrapsychic conflict to self-realization, the growth of the self. This change is the recognition, from many theoretical viewpoints, that awareness of previously unconscious motives alone is often insufficient to achieve analytic aims. The corresponding implication of this new goal is that the analyst's role includes assistance in the development of new patterns. It is difficult to imagine how a patient can create new modes of being and relating by absorbing the analyst's contributions, whether those offerings take the form of interpretation, new functions, or the emotional impact of the relationship. If self-development is the goal of the analytic process, the therapeutic action of psychoanalysis must include room for the patient to create new ways of being and relating.

That activity and creation are central to emotional growth is demonstrated convincingly by developmental research as well as advances in learning theory. Investigations of the mother-child dyad from a variety of developmental research traditions indicate that the child requires not only affective attunement, but also the space to experience his own affective states and participation in relieving distressing emotions. The opportunity for self-regulation is as critical as caretaker regulation. Beebe and Lachmann (1998, 2002) found that the most secure babies were not those whose mothers were most closely in tune with their affective states, but rather those infants that fall in the midrange of affective and vocal matching with their mothers. They concluded that infants need both mutual regulation and the opportunity for self-regulation, an opportunity impeded by overattunement. Similarly, Bowlby (1988) and Ainsworth et al. (1978), in their studies of attachment, found that securely attached infants had mothers who were emotionally available and made a push toward autonomy. Even more poignantly, Demos (1992), observing children from a different theoretical perspective, found that a child's sense of agency is best promoted not by the parent who relieves stress by providing immediate comfort, but by the parent who allows the child to experience distress and helps to resolve it in a way that makes the infant feel like a coparticipant in ...

Table of contents

• Cover
• Title
• Copyright
• Dedication
• Contents
• Acknowledgments
• Preface
• PART ONE A PSYCHOANALYTIC THEORY OF SELF CREATION
• PART TWO CLINICAL APPLICATIONS
• References
• Index