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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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