My Current View of the
Psychoanalytic Process
Paul H. Ornstein, M.D.
Presented in part on 10/22/98 at the
21st Annual Conference of the Psychology of the Self
[ 1998
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I would like to introduce this essay by inviting comments, questions,
agreements, disagreements, contrary ideas, etc. I promise to respond
promptly. Please submit your comments at the bottom
of this page.
I shall offer a thumbnail sketch of my view of the conduct and process of
psychoanalysis with one single emphasis: the centrality of the concept of the
selfobject transferences. I shall do that under three headings: (1) I shall
define the nature of the analytic process (as I see it) and the centrality of
the selfobject transferences, as these guide my responsiveness. (2) I shall
focus on my patients’ subjective experiences as my entry-points into their
inner world and highlight a common and enduring problem that arises in the
necessary responsiveness to patients. I shall illustrate this with the aid of
two brief clinical vignettes. And finally, (3) I shall venture some general
statements about my approach with specific reference to where the openings are
in my system for continued expansion and change.
Many of you might consider my topic fitting for beginners and not for an
advanced audience of this panel. I hasten to assure you that the problems in
clinical responsiveness I have chosen to illustrate are lifelong problems in
our work
I. The Conduct and Process of Psychoanalysis:
The Centrality of the Selfobject Transferences
By "conduct" I mean all of my deliberate contributions to
the development, maintenance and progression of an analytic dialogue,
(including the setting and the ambience) which furthers my own and the patient’s
engagement in our joint task of the specific exploration of the patient’s
subjective experiences. My unintended (i. e., unconscious) contributions also
have a decisive impact on these experiences and the specifics of this impact
have to be discovered in the course of our dialogue, since these affect the
treatment process. Therefore, my conscious and unconscious conduct of the
analysis needs to be open to self-scrutiny, in order to discover my
contribution to the evolving or stagnating analytic process and I need to
listen carefully for how patients portray the nature of
my participation. It is through the patients’ portrayal that I may discover
the nature of my own contribution.
By "process" I mean the ongoing, reciprocal impact of
patients’ experiences and my responses to these, which are usually outside
of immediate awareness. These experiences are expressed as well as hidden in
our manifest behavior and communications. And it is this expressed and yet
hidden reciprocal impact—"the process"—which needs to be brought
into awareness as the core of our analytic work. What is between the lines has
to be brought into the main text as much as possible, to make the dialogue
more intelligible and restore its cohesiveness (i.e., the meaningfulness of
free associations).
A brief example will illustrate what I mean. A very creative patient of
mine, a prolific dreamer, analyzed his dreams with considerable ingenuity. I
was able to participate in his interpretive work with alacrity and
considerable interest. Yet, for a long period after each session’s good work
by both of us—as I experienced it—the patient would leave with the remark:
"It [the interpretive effort] didn’t work for me." While he was
always interested in every detail of his dreams and insisted on the
"accuracy" of their interpretation to his own and to my
satisfaction, the interpretive work still left out something of decisive
importance for him. It took us some time to discover that what was missing for
him, what he desperately wanted and needed from me, in order to feel satisfied
with our work together, was some form of a positive response to his sustained
craving for recognition and admiration for his extraordinary creativity. The
interpretation of his dreams had little intrinsic value for him, his creative
efforts were at that stage only the means to gain what he craved.
The analytic response to this clinical moment, a response that would propel
the process forward, would be an interesting topic in itself. However, here I
only wish to illustrate my use of the concept of the analytic process, which
refers to the more or less hidden inner experiences of the patient and my
responses to these. In this vignette the patient needed and longed for
something but he could not explicitly say what. I could not respond adequately
because I was unaware of what was missing for him from our good work together.
This formulation is a cross-sectional snapshot of the process at this
particular moment in the analysis.
My recognition and appreciation of his creativity in interpreting his
dreams, was only one aspect of the patient’s "mirroring" needs.
Being a bright and creative man, he could not feel pride in his
accomplishments, thus his transference was centered on his craving for
recognition and admiration—it was an archaic mirror transference.
To put this in more general terms: This patient entered the analysis with
his particular, mostly hidden needs, longings, fantasies and expectations.
Whatever the explicit reason for seeking analysis, these hidden needs,
longings, fantasies, and expectations were at the core of his "opening
move," requiring some sort of an "opening response" from me.
The patient’s opening move and my opening response are the beginning of the
verbal and non-verbal dialogue that unfolds. Under felicitous circumstances,
the patient’s "moves" and my "responses" inexorably
progress toward some convergence and resolution. This is what I call the process
of analysis. If the patient’s moves and my responses converge—that is, if
we talk to each other, rather than diverge and talk past each
other, the process has a felicitous beginning and then progresses. If there is
no convergence—if the patient does not feel responded to and understood—a
fruitful analytic process may never develop. Instead, a prolonged, fruitless
struggle ensues and may go on and on as a form of pseudo-analysis, extracting
from the patient some form of adaptation to my unrecognized demands--if the
patient does not have the courage to leave such an untenable situation. This
remains a veritable stalemate, if I cannot develop a more attuned empathic
responsiveness and do not recognize and cease my inappropriate, often very
subtle but emotionally enslaving, demands.
I focus my attention on the process just described, from two related
perspectives: (1) I try to grasp what the patient’s subjective experience is
(including his or her experience of me) from moment-to-moment,
session-to-session, week-to-week—the microprocess (shaped by the
nature of our verbal and non-verbal interaction). (2) I try to grasp what the
patient’s experience is over time; what psychic terrain he is traversing in
his relationship with me—the macroprocess (shaped by his past
experiences). I can only make adequate analytic sense of the microprocess if I
can project this on a wider screen of the macroprocess and register what of
the past is re-enacted in the present and can simultaneously also grasp the
purpose of this re-enactment—namely, mastery and a new beginning. After all,
meaning emerges in the particular context.
As in all forms of psychoanalysis, assumptions about development of health
and illness, i. e., the genesis and the nature of psychopathology as well as
the nature of cure, will decisively determine the conduct and process of
treatment. This means that my interventions have to be in keeping with my
theory of the genesis of psychopathology, my clinical theory, and my theory of
cure. . [I assume familiarity with the core-tenets of self psychology and I
shall not repeat them here.]
It is my consistent, and sustained empathic immersion in the patient’s
inner life—the required observational stance—that creates the
necessary analytic atmosphere for the spontaneous emergence of a pathognomonic
selfobject transference. This observational stance, coupled with a
non-judgmental, non-confrontational, truly accepting attitude toward
whatever the patient brings to his or her sessions, contributes to the
development of trust and the feeling of safety. This trust and
safety are prerequisites for the emergence of hitherto thwarted archaic
wishes, needs, longings and fantasies—the specific contents of the
selfobject transferences.
My focus—as I said--is on the patient’s subjective experiences, his
strengths and vulnerabilities. These are my entry-points into his or her inner
world. These experiences will emerge against "resistance," elicited
by the fear of re-traumatization. My empathy-based approach to the patient’s
subjective experiences is guided by my self-knowledge, my world-view and my
preferred theory—self psychology. What the patient brings to our analytic
encounter, and what I bring to it, shape the nature and content of the ensuing
process. The analytic relationship is thus determined by the specific
contributions each of us makes to this emerging and ongoing process and is a
crucial component of any favorable or unfavorable outcome.
It is here that the detailed steps in the interpretive process reveal the
curative impact of psychoanalysis. Focusing on the patient’s subjective
experiences provides the opportunity to mobilize the curative impact inherent
in the triad of accepting, understanding and explaining. My
understanding (transmitted on many levels), including its explicit
communication to the patient, lead him or her to feel understood , This
feeling understood by the patient (again on many levels), at first temporarily
enhances self-cohesion. This makes the patient’s disabling defensiveness
(the so-called "defensive structures") less necessary . These
changes are then replaced, stepwise, by newly developing capacities (the
"compensatory structures"). These may occur at first only in the
analytic setting. The working through helps to consolidate these temporary
gains, allow for the maturation of selfobject needs and thereby enabling the
patient to find a supportive selfobject milieu in his or her post-analytic
life.
Empathy and the Selfobject Transferences
I wish to underscore my commitment to using the empathic mode of
observation, in the form of empathic immersion in the inner life of my
patients, in order to gain access to their inner experiences, including their
experiences of me. My empathic observational mode leads me directly to the
discovery of the patient’s fantasies, needs, wishes and demands—under the
rubric of the selfobject transferences. It is my adherence to the empathic
mode of observation, therefore, that necessitates putting the selfobject
transferences into the center of my clinical approach, since these are the
core-experiences that my method of observation leads me to and which otherwise
might elude me. With the empathic mode of observation I embark on the most
"direct" road to those inner experiences I label as the selfobject
transferences. Empathy as vicarious introspection leads me to the patient’s
subjective experiences and not to the inferred "dynamics" and
"genetics"—which requires a different kind of cognitive step in
relation to the empathy-based observational data.
Placing empathy at the center of my listening perspective does not mean
that other observational methods might not inevitably be activated. These,
however, I subordinate to the method of empathy. This subordination means
that, all other modes of observation in the analytic situation (be they
related to the emerging historical data, to the theories applied, or to my
personal reactions to the patient) are to be in the service of enhancing my
empathic perception of the patient’s experiences, from his or her vantage
point. My countertransference reactions may sometimes serve to enhance my
empathy-based perceptions; other times they may block them.
I can well understand that other modes of observation lead to different
findings and necessitate a different central focus. I do not suppress in
myself other modes (inevitably present in all of us) that provide me with
different kinds of data. I use these other data, however, as already
mentioned, in the service of enhancing my empathy-based understanding of my
patient. Empathy, as used in every human encounter, provides access to another’s
inner world. The same applies to the psychoanalyst’s use of empathy as a
method of observation. His or her findings may then be organized with the aid
of a variety of theories. I, on the other hand, use the empathic mode of
observation (the empathic immersion) along with formulating my findings from
an empathic vantage point—that is, from the patient’s subjective
perspective. This—and not empathy as a ubiquitous human capacity per se, or
its general psychoanalytic variant—is in my view the distinct
methodologic-epistemologic feature of self psychology. There is, for me—as
was for Kohut—an inextricable relationship between method of observation and
data; and he later added to this the formulation of experience-near theories.
Method, data and theories are in self psychology of one cloth, and therefore,
inextricably intertwined. Our many different formulations and theories in self
psychology today are, to a very large degree, based on different modes of
observation and different kinds of responsiveness.
It follows from what I have said so far that each analytic process has its
idiosyncratic features, and—especially on the level of the microprocess but
even on the level of the macroprocess—no two analyses are ever alike. Every
analysis involves a sorting out and resolving the inevitable entanglements
that arise from the encounter between patient and analyst. The specifics of
this entanglement and their sources in the patient as well as in the analyst—especially
when the analyst’s contributions become obstacles to the task—are the
content of the analytic exploration.
In my effort to sort out our entanglements in the clinical situation, I
respond with an effort to understand (and later to explain), the immediate
context (and later also the earlier antecedents) of the patient’s
experiences. I communicate my tentative understanding repeatedly, from the
very beginning, to indicate how I listen and how I understand what the patient
brings to the sessions. I am open to being corrected, if the patient signals
that I am on a false track. This is a way to engage the patient in his
or her analytic task. Without such an engagement the analytic dialogue might
be devoid of commitment and emotional content—it remains a mere intellectual
exercise. It is my effort at engaging the patient that also elicits his
curiosity in his own inner life. My response underscores the legitimacy of the
patient’s expression of previously thwarted needs as well as current
strivings in the transference for a belated acquisition of those capacities
that remained undeveloped or inadequately consolidated.
Trust and safety do not develop once and for all. The patient tests for the
presence of safety continually, throughout the analysis and when he cannot
feel it, the issue of trust and safety require immediate attention. This is
especially important whenever an inadvertently unempathic response (e.g., a
misunderstanding, a judgmental remark, or an injury to the patient’s
self-esteem) disrupts the transference. It is crucial for the
"repair" of the disruption to identify what has led to it in the
"hear and now," and acknowledge, when appropriate) how I might have
contributed to this disruption. A successful repair always leads to a revival
of memories of earlier, similar, painful injuries. This sequence of disruption
and repair significantly contributes to the necessary "structure
building," which is an essential component of cure. But, of course, prior
experiences of feeling understood, strengthen the vulnerable self and are
crucial to the repair that follows inevitable disruptions. Both are thus sine
qua non for analytic cure. The endpoint of the analysis is reached when
the patient can be comfortably and successfully self-assertive and/ or has
acquired previously missing internalized values and ideals. The most
significant achievement, signaling the attainment of "cure" is
reached when the patient is able to create an accepting selfobject milieu in
his or her post-analytic life.
This is the barest sketch of the fundamentals. Instead of discussing the
many significant details further abstractly, I shall illustrate with two
vignettes one key issue in the process of analysis, a recurring problem that
has often arisen in relation to my responsiveness in the clinical situation.
These vignettes show how crucial it is to focus on the patient’s inner
reality, (on his subjective experiences) and on the analyst’s reaction to
this inner reality.
II. A Recurring Problem in Responsiveness in the Clinical
Situation
First Vignette
Mr. T. complained during one of his Friday sessions that he experienced his
childhood as if he had lived in a dungeon. He illustrated with many examples
how his father mistreated him and how much he still suffered from that. He
expressed these thoughts at a time when he was already beginning to free
himself from the consequences of those experiences. I was therefore surprised
that he compared his childhood to living in a dungeon. In his Monday session,
Mr. T. complained bitterly and accused me of having disrupted his
efforts at experiencing himself once again in his childhood dungeon. He
believed that I could not tolerate his experiences and asked him questions
that dislodged him from these painful experiences. I asked him for his
reflections, instead of remaining with his experiences and accompanying him in
his descent into his dungeon. Although I was astonished at his new image of
his childhood on Friday, I thought I was able to stay with his experiences and
able to accompany him and resonate with his affects. I did not experience the
task painful or repulsive as he experienced that I did. Nevertheless, this is
how he pictured the reasons for my interference with his efforts. I
then responded by saying that, I could well understand his embittered
complaints, if he experienced me as not accompanying him on his descent into
to his dungeon and actually obstructing his descent. After a short pause he
said thoughtfully: "I am not so sure now whether you stayed with me or
not. To me it seemed that you did not stay with me. Perhaps it was my anxiety
that you would not accompany me that created in me the feeling that you did
not remain with me. I know, I am very sensitive on this score."
This sequence shows that Mr. T. could now reflect on his reaction to me
because I accepted his reality, without confronting him with my own
view of his Friday experience. The vignette also demonstrates how necessary
and fruitful it is to remain with the patient’s subjective experience. If I
could have done that successfully on Friday, Mr. T. could have re-experienced
his early childhood affects more fully, and this would have been a crucial
moment in the process of overcoming his feelings that he still lived in a
dungeon. Even if this image is overdrawn it is important to accept it,
understand it, later explain the meaning of its re-emergence at this time,
rather than view it and interpret it as a distorted perception, by insisting
that I had, indeed, accompanied him.
Second Vignette
This shows the same issue more dramatically in a patient with a severe
self-disorder. When, on one occasion, I did not succeed in following him in
his somewhat "bizarre" subjective experience, he looked at the brown
door in the front of him as he lay on the couch and said in a desperate tone
of voice: "I understand it with my mind that that door is brown--you don’t
have to tell me that. When I say it is orange, than I tell you what I feel.
When you do not accept my orange statement then you don’t accept what I
feel. And when you don’t accept what I feel, then you don’t accept me.
Then I am exactly where I was with my parents—they have never accepted me.
How could I then get rid of this feeling with your help?"
This patient taught me rather forcefully that I had to engage his
"orange feelings" with full acceptance. To have his feelings
accepted as a way of accepting him, was at the center of his deepest concerns
and therefore it had to move into the center of my interpretive activity. As a
result, the focus of my interventions was not on the dynamic or genetic
aspects of his experiences but on the experiences themselves and their meaning
and function.
My patient demanded that I engage and take seriously his orange feelings,
no matter how "bizarre" or "distorted" they might have
been to an outside observer—his communications to me had to be accepted and
understood as they were presented. "Where else could I express these
feelings and have them accepted and understood, if not here?"—he asked
once in a challenging tone. I acknowledged my mistake, of introducing the
"brown," where upon he said: When we can together enter my
"orange feelings" then I can feel myself "real," otherwise
I feel nothing."
The examples I offered follow two fundamental principles: (1) all
interventions have to be formulated from the patient’s subjective
perspective; (2) they have to be in keeping with what I hold as the curative
ingredients of the treatment process. For this very reason, certain kinds and
forms of interventions, which may be appropriate in another theoretical
context, are avoided in a self psychologically conducted treatment process.
One last comment to conclude my brief portrayal of the analytic process. It
is always the fundamental vulnerability as well as the strength of the patient
and not any single symptom, behavior pattern or motivation that is in the
center of my analytic efforts. My interventions address the patient’s
strength and vulnerability as these manifest themselves within and outside of
the transference. It is this vulnerability that is at the root of each
symptom, syndrome or behavior that the patient wishes to overcome with his or
her available strength. The examples of the treatment of narcissistic rage,
(Ornstein, P.H.& Ornstein, A., 1993), omnipotent fantasies (Ornstein, P.H.,
1997) and other symptoms demonstrate that analytic focus has to be on the
emotional soil in which these symptoms and behaviors are rooted. My basic
stance focuses on the patient’s strivings for a belated development (the
"leading edge") and this requires the acknowledgment of the
patient’s often barely visible strength.
Openings for Expansion and Change
You may be left with the question: Where are the openings for expansion and
change in the approach I have sketched. There is a long and a short answer to
that question. I shall touch on the short answer in a few words. I consider
the method of empathy as the more enduring aspect of self psychology—although,
at present, I see no alternative to the selfobject transferences as the center
for understanding and treatment. While I am a political integrationist, I am a
theoretical purist. I need clinical problems to lead me to expansion and
change, although I value the elegance of theoretical refinements. I am open to
learning from other paradigms but do not wish to borrow bits and pieces from
them because none of them mix well with mine and might give me and my patients
an unwelcome stomach ache. While the method of empathy is never theory-free,
it is nevertheless the best open road we have to clinical work and
experience-near theorizing. On that note I shall end here.
* * *
References available on request: ornstep@email.uc.edu
Comments, questions, agreements, disagreements,
contrary ideas, etc:
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