Talking with Patients --
A Self Psychological View
By Sanford Shapiro
[ Self Psychology Bulletin Board ]
The Self Psychology Page is pleased to offer the
complete text of chapter 1, A Tale of Two Theories,
from Sandy Shapiro's 1995 book, Talking
with Patients -- A Self Psychological View of Creative Intuition and
Analytic Discipline, courtesy of Jason
Aronson, Inc.
You can send an email to Dr. Shapiro at sshapiro@ucsd.edu.
1
A Tale of Two Theories
Art is exactitude winged by
intuition.
Paul Klee
Psychoanalysis, like art, requires both precise technique and
intuition. My teachers, being conservative, taught me technique; they
didn't trust me enough to encourage my intuition -- they worried about
wild analysis, a term introduced by Freud. Freud (1910) was
concerned about technical errors and bad technique by unsophisticated
and inexperienced analysts, "to . . . dangers to patients . . .
which are inherent in the practice . . . of a 'wild'
psycho-analysis" (p. 226). Concerns about wild analysis in
psychoanalytic education has led to a reliance on rules, a stunting of
spontaneity, and an inhibition of intuition.
The Random House Unabridged Dictionary defines intuition as
"immediate apprehension:" perceptions that are independent
of a reasoning process. Intuition, in other words, refers to a type of
unconscious, creative activity. Intuitive analysts use their emotional
experiences to enhance their understanding and to inform their
interpretations. My teachers used intuition in their practices, but it
took me years to realize it. I thought they had formulas and rules
that kept them on track. They always knew what to expect, what to say
and what not to say. I believed that when I learned the rules, I would
know the "right" way and avoid the "wrong" way. I
didn't realize then that what I didn't do could have as much impact as
what I did.
I now believe that the major challenge in psychoanalytic education
and practice is to strike a balance between analytic discipline and
creative intuition. Hoffman (1994) says that a dynamic relationship --
a dialectic -- always exists between spontaneous self-expression and
analytic ritual. I believe that much of the tension between classical
theory and self psychology is in how one maintains this balance.
CLASSICAL THEORY
The conservative nature of classical psychoanalytic education
encourages "proper" analytic technique and discourages
spontaneity. My first lesson in being "proper" was in 1959
during my first year of psychiatric residency at Detroit Receiving
Hospital. There, immersed in diagnostic assessment, handling
psychiatric emergencies, and managing medications, I began my first
psychotherapy case, a young woman with depression and marital
problems. I was pleased that my supervisor was psychoanalyst Frank
Parcells, a wise, kindly man with an excellent reputation.
I had detailed process notes for our first supervisory meeting, and
I described how the patient came in to a session and said:
"Hello, how are you?" "I'm fine," I answered,
"And how are you?" Parcells interrupted me: "Why did
you say that?" he asked. "Well," I said, "It
seemed the natural thing to do." Parcells gently explained that
it would be natural in a social situation, but this was therapy, not a
social situation. Thus I learned my first rule of proper technique.
Each rule that I subsequently learned acted as a restraint and led to
an increasing rigidity in my style of working. My colleagues felt
similarly restrained. This rigidity continued until the time of Kohut,
when a shift occurred, and analysts began taking patients more
seriously.
A reliance on cautiousness and on rules was started by Freud with
his admonitions to analysts. Freud said: "The doctor should be
opaque to his patients and, like a mirror, should show them nothing
but what is shown to him" (Freud, 1912, p. 118), and analysts
should "model themselves during psychoanalytic treatment on the
surgeon who puts aside all his feelings, even his human sympathy . .
." (p. 115). Other "rules" suggested that the analyst
must not "follow his expectations or inclinations" (1912, p.
112), or let the patient "leak" his material "with some
intimate friend" (1913, p. 136).
Lichtenberg (1994) thinks that Freud used technical rules to deal
with political problems: early adherents like Adler, Stekel and Jung
did not follow Freud's theories. Although Freud trusted himself to be
spontaneous, and could feed the Rat Man when he was hungry and
organize financial support for the Wolf Man when he was destitute, he
did not trust his students nor did he write down guidelines for being
spontaneous or using intuition. So in the beginning, Freud determined
what was proper analysis and what was not.
His death left us without an authority, and defining proper
analysis now causes controversy, confusion and anxiety. Many teachers
play it safe and teach rules rather than what they do in their own
practices. Sandler (1983) states that the fear of appearing
"improper" has caused many analysts to keep much of their
work secret from colleagues and students. Differentiating "public
theory" from "private theory" Sandler says:
The conviction of many analysts [is] that they do not do
"proper" analysis . . . that what is actually done in the
analytic consulting room is not "kosher," that colleagues
would criticize it if they knew about it . . . that any analyst
worth his salt will adapt to specific patients on the basis of his
interaction with those patients. He will modify his approach so that
he can get as good as possible a working analytic situation
developing. I believe that the many adjustments one makes in one's
analytic work, including the so-called parameters that one
introduces, often lead to or reflect a better fit of the analyst's
developing intrinsic private preconscious theory with the material
of the patient than the official public theories to which the
analyst may consciously subscribe (p. 38).
Sandler is saying that analysts are pleased with their work but are
reluctant to share what they do with colleagues and students because
their intuitive creativity will be criticized.
SELF PSYCHOLOGY
Self psychology has brought new understanding to analytic
interactions, has helped free analysts from the stricture of rules,
and has helped analysts make sense out of what they had known
intuitively and had done privately. I had thought that my job was to
be the expert who understood, deciphered and explained to patients
their behaviors -- to help them overcome their resistances and see
things my way. I was taught to suspect a patient's motives, which left
me feeling burdened. Self psychology, by teaching me the value of
trusting patients' motivations and of seeing things first from their
perspectives, has freed me from much of that burden. One of my
favorite quotes of Kohut (1984) follows:
If there is one lesson that I have learned during my life as an
analyst, it is the lesson that what my patients tell me is likely to
be true -- that many times when I believed that I was right and my
patients were wrong, it turned out, though often only after a
prolonged search, that my rightness was superficial whereas their
rightness was profound (p.93).
A common misunderstanding of self psychology is that understanding
someone's experience means you agree with it or condone it, but I have
learned that understanding a patient's experience does not mean I have
to give up my point of view. With self psychology I now have a
theoretical framework in which I can teach analytic spontaneity
alongside of analytic discipline.
Illustrating how self psychology has influenced my technique is a
successful 35-year-old professional woman named Anna who entered
psychoanalysis because of frustration with her inability to find a man
with whom she could stay in love. Anna was in a relationship with Art,
and they were living together. Although they cared deeply for each
other, they could not stop fighting. Anna felt Art was trying to
control her, and Art, when angry, said cruel things to her. Anna
reacted either with violent rage -- she wanted to hurt him -- or with
hopeless resignation -- she wanted to leave him. She could not stand
up for herself without being cruel.
In the analysis, the reasons for much of Anna's difficulty became
clear: an older brother who abused and molested her, a mother who
criticized and blamed her, and a father who kept his distance. She had
learned early to wall off and disavow painful experiences. When
feeling vulnerable with Art, she kept her distance, and when she felt
overwhelmed, she lashed out at him in a violent rage. When she felt
safe with me, she began to recall early experiences of rejection,
hurt, humiliation and shame.
She developed a new sense of confidence, and her professional life
became even more successful, but, although she and Art became closer,
their fighting continued. Each time Art hurt her, she felt betrayed
and victimized, and her rage knew no bounds.
At that time, working in a classical mode, I felt it was my job to
point out, and bring her face to face with, her contributions to the
difficulty. I thought that the fighting would be resolved if she could
confront Art without trying to destroy his self-esteem and if she
could stay present and assert herself with him, instead of running
away and hiding. My theory was that feelings from her past were being
displaced onto Art, and that because of her resistance to the
transference, Art had become the focus of her rage instead of me. Her
resistance arose from internal pressures, and I was a blank screen
that could observe but did not basically contribute to her resistance.
My interpretations about her internal wishes and fears did not help,
and as she became discouraged, I also became discouraged.
I had read some of Kohut's papers but did not understand how to
apply his ideas clinically. Then Bernard Brandchaft, a gifted teacher
from Los Angeles, presented a series of lectures on self psychology in
San Diego. He explained Kohut's ideas, and he demonstrated their
clinical applications. I immediately thought of Anna, and realized I
had been trying to get her to understand what was going on from my
point of view, and was not trying to understand her experience from
her point of view. Feeling pressured and criticized by my
interpretations, she no longer felt safe. She was not resisting me;
she was trying to protect herself in a way that I had not understood.
I also realized that I was not trusting her or the psychoanalytic
process. I was trying too hard to "help" her and to get her
to see my point of view. I needed to decenter from my perspective,
Brandchaft explained, and try to see things from the center of her
experience, including my contributions to that experience.
I had been reluctant to do that, and thought that understanding how
victimized, helpless, and vulnerable she was feeling, would be
condoning those attitudes and not encouraging her to take
responsibility. I would not be doing my job of pointing out her
contributions to the conflict, which stemmed from unconscious wishes.
Brandchaft pointed out that understanding her point of view did not
mean agreeing with it or approving of it, and if I could not
understand her experience from her point of view, it was unlikely she
would be able to understand my point of view.
I also had not appreciated the importance of maintaining a listening
perspective (Schwaber, 1981, 1983b). Ornstein and Ornstein (1985)
state that "understanding . . . has either been taken for granted
or seriously underplayed as a specific and necessary intervention in
psychoanalysis . . ." (p. 44). Some patients require a long
period of being heard and feeling understood before they are able to
assimilate interpretations. Much strength and confidence often comes
just from being listened to in an understanding way. Now I relaxed
with Anna and listened patiently to her complaints, frustrations, and
her discouragement. I did not try to interpret or to "fix"
her pain, and I limited my comments to appreciating how frustrated and
discouraged she felt. As I stayed with her painful experiences, her
discouragement progressed into despair and hopelessness. Although I
did not feel hopeless, I appreciated how painful it was for her to
feel hopeless. I told her, spontaneously, that I appreciated her being
able to share such painful feelings with me.
She reacted to my comments with new memories of being molested and
abused by her brother. For example, if she refused to do something he
wanted, he held his hand over her mouth and nose suffocating her. When
she was about to pass out, he let her breathe. Feeling terrified of
him, she did what he asked. Adding to the trauma was her parents'
unavailability; neither of them would tolerate any complaints. She had
to keep her feelings to herself, and walled off all feelings of fear,
hopelessness and despair. These feelings emerged anew in her
relationships with Art and me. Being able to encounter and talk about
these emotions with me was an integrating experience for Anna. She
became stronger, her confidence returned, and her relationship with
Art improved.
My attempts to explain her problem and "fix" her pain,
cut off her emerging affect, and inadvertently gave her the message
that I, like her parents, did not want to hear her complaints. I had
unwittingly become involved with her in reliving that traumatic
experience. This shift to a new way of hearing clinical material is
illustrated by Schwaber (1983a) when she describes "Kohut's most
creative contribution":
. . . the understanding of the resistance had shifted from being
viewed as a phenomenon arising from internal pressures within the
patient, from which the analyst, as a blank screen, could stand
apart and observe, to that in which the specificity of the analyst's
contribution was seen as intrinsic to its very nature (p. 381).
As I relaxed, I began to trust her, to trust the analytic process,
and to trust myself. I worried less about rigidly following rules and
reacted more spontaneously. I was pleased, not ashamed or apologetic,
that I could spontaneously express my appreciation to her for being
able to share her painful feelings with me. My appreciation was not
contrived but was something I genuinely felt. In self psychology
lingo, I had provided her a validating, developmental selfobject
experience.
As a result of self psychology, a new openness has emerged in
psychoanalytic practice. I first heard this openness acknowledged
publicly in 1981 by Arnold Cooper, then president of the American
Psychoanalytic Association. Cooper was the keynote speaker at the
Fourth Annual Conference on the Psychology of the Self, and discussed
the implications of self psychology for clinical practice. He told of
the time he was called for a referral in another community, and not
knowing any analysts there, he made some inquiries. He was given the
name of a Dr. A with the comment: "He's a good analyst, but he is
a little bit stiff." He wondered about that, made further
inquiries, and was told about Dr. B who also was similarly described.
Cooper remarked, "It seems that nowadays besides being competent,
one also has to pass a certain stiffness test. This is something we
were not concerned about ten years ago."
I believe that analysts are able to loosen up as I have done
without necessarily becoming "wild." I feel less pressure to
know the answers, to be smart, and, not assuming I am a blank screen,
I can then systematically look for my contributions to the patients'
transference experiences. Trusting them more, I ask more questions and
make intuitive remarks more spontaneously. As a result, my patients do
better, I enjoy my work more, and I can offer guidelines to students
to help them develop their intuition and creativity without derailing
the psychoanalytic process.
Psychoanalytic education is a twofold process: it develops from
within and from without. Freud developed the psychoanalytic method, the
talking cure, from his work with patients. He learned from them
and, as his clinical experiences grew, he developed and changed his
theories. Like those of most students, many of his major discoveries
resulted from therapeutic failures. For example, Freud discovered the
importance of transference after his patient Dora, a 16-year-old girl,
prematurely quit her analysis (Freud, 1905).
Freud listened to colleagues and mentors, talked to patients, and,
learning from his experiences, continued to develop and modify his
theories. Richard Sterba, a graduate of the Vienna Psychoanalytic
Institute, told me that his classmates felt a sense of betrayal when
Freud (1926) announced the change in his theory of anxiety. "How
can he do this do us?" they complained. "Just when we are
starting to understand how things work, he turns everything upside
down!"
Psychoanalytic students develop similarly, and following Freud's
model, learn from both mentors and mistakes, and their ideas develop
as they grow. No two psychoanalysts are the same, and each develops
his or her own style. Students struggle to be like their mentors yet
maintain their individual ways of working; and teachers struggle to
show students what to do, yet encourage them to follow their own
paths. "We eventually move beyond our models; we take what we
need and then we shed those skins and become who we are supposed to
become" (Zinsser, 1988, p.15).
In this book I will describe contributions from self psychology,
selfobject theory and intersubjectivity theory, and I will discuss
technical guidelines for talking to patients -- balancing rules with
intuition.
© 1995 Jason Aronson, Inc.
Reprinted with Permission.
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