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현대정신분석의개입기법
작성자  simonshin 작성일  2017.08.11 15:57 조회수 1344 추천 0
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 현대정신분석과 관계 중심 정신분석 - Article 2부  
 

주제현대정신분석과 관계 중심 정신분석 – 생각보다 가까운 사이

강사과목현대정신분석의 개입 기법

신현근 / 김양자 교수

내용: Levitz, Judy 의 논문

수업일: 2017년 8월 11

교재Levitz, J. (2017). Modern Psychoanalysis and Relational Psychoanalysis: Closer Than You Think. New York, PPSC Annex Presentation. pp. 1-38.

Modern Psychoanalysis and Relational Psychoanalysis:

Closer Than You Think

Judy Levitz, Ph.D. PPSC Annex Presentation June 2, 2017*

V. This section discusses the Modern use of “Subjective and Objective Countertransference” and the Relational use of “Subjectivity”.  

5. Toward the end of the second year of treatment, Karen made a second suicide attempt.  I felt that Karen was still a high suicide risk and to wait to see whether or not she would arrive for her appointments became very anxiety arousing for me. I needed to feel less worried. Thus, at the beginning of her third year of treatment, I decided to telephone Karen about two hours before every appointment. I reminded her of the time of our meeting and told her that I looked forward to seeing her. Within about three to four months, Karen no longer missed sessions. In regulating my distress and in Karens response, we attempted to mobilize a new interactive pattern.  

Dr. Lachmann’s telephone intervention helped Karen become able to keep her appointments consistently.  He framed it as coming from his own need, (“I needed to feel less worried”). I wondered: what if Dr. Lachmann’s worry was not only the reality based worry appropriate to a situation where you assess the patient is in danger of harming herself, or a situation where you naturally care for someone in your charge -- but it was also Karen’s unconscious, or even somewhat conscious intention to worry him?  In other words - not just his need? This would be an example of a type of “anaclitic” narcissistic transference/countertransference phenomenon -- where the patient emotionally communicates feelings that the patient needed but didn’t receive in her early life. It is the patient’s implicit attempt to help the analyst, through emotional communication, understand what she requires to heal and mature.

The Modern use of countertransference is broad: it includes both the therapist’s subjective and objective feelings, and importantly, because we conceptualize countertransference feelings as ones that are elicited in response to the patient’s transference to the analyst, this too is by definition a two-person phenomenon. Through the “induced” countertransference - the “implicit or unconscious contacting” described earlier -  the patient conveys infinite preverbal data especially about the nature of the transference. Induction does not mean that the patient merely “puts” feelings into the analyst, nor does it preclude the fact that the analyst experiences feelings that are rooted in his own idiosyncratic experience, or preclude the fact that the analyst’s feelings have just as much impact on the patient as vice versa. The importance of parsing out the strands of emotions operating in any given moment is to as accurately as possible, capture information being conveyed about the transference.  From Racker to Geltner, authors distinguish objective from subjective countertransference: Geltner writes, by comparing the analysts feelings to the content of the sessions: objective feelings tend to be [primarily] consistent with themes that emerge in the patients life story, while the subjective feelings tend to be [primarily] consistent with the analysts life story...(Geltner, 2012). In other words, The patient has a note, the analyst has a note, and there is a resultant chord when played together. It is useful wherever possible for the three components to be understood. 

Let’s link this back specifically to Dr. Lachmann’s worry for Karen. In a personal communication, Dr. Lachmann asked me: “how could we ever know whether Karen "induced" worry in me or if that came from my own history? He said that her parents, who he called in to a session with Karen after her second suicide attempt, were “remarkably and frighteningly unconcerned”. This is a crucial question for many reasons. I would ask myself: how do I feel in other situations when a patient is suicidal; how is it similar or different from my reaction with Karen? The fact that Karen’s parents were so unconcerned could mean many things in relation to Karen: Maybe she didn’t want them to worry? Maybe she expected them not to worry and therefore protected herself from disappointment? Maybe she was actually attempting to worry them but they were defended against her communication for their own reasons? Of course we’ll never be certain, but there’s much information gleaned from examining the aspects of one’s personal history vs. one’s professional history and the patient’s history to hone in on the part of the countertransference that is an induced emotional communication from the patient. If the core objection to the concept of induction is the implied uni-directionality of one person acting upon another to the exclusion of its co-constructed nature, I argue that this is not how it is meant to be understood when used from a Modern perspective. If Karen needed Dr. Lachmann to be worried and conveyed that to him, it would be an example of a successfully induced feeling. Modern’s would call this an induction that resulted in an objective countertransference feeling. If however, Dr. Lachmann only experienced it as his own worry, coming from his own subjectivity, and not an objective countertransference, his need to be less worried takes on a different meaning -- because it’s the opposite of what she wants him to feel. But this is a theoretical riff -- the actual case material suggests that the way Lachmann dealt with reducing his worry resulted in a successful outcome - Karen experienced a new and reparative response to her behavior. So there are many ways of getting to the same place but different ways of conceptualizing if this one’s own subjectivity or a communication from the patient herself.  

6. Aggression, Joining, Containing, Holding - I’d like to now introduce examples of work with more blatantly expressed aggression. Andrew Blatter (2017), writes about his patient Diana, four years into the treatment. She was hostile, demeaning and he quickly discovered how empathic comments were often rejected:

D: Im really freaking out today.

A: Oh? Whats going on?

D: Aside from my exams next week, I need to give a group presentation on

Friday. And it turns out that this top professor from Yale is visiting and will be

there. Im totally screwed!

A: Oh my god. That sounds like a lot of pressure!

D: (sarcastically) Gee, Andrew, youre really on top of your game today. It only

took you five minutes to figure that one out!

     Blatter describes that Diana didn’t actually disagree with what he said, but she seemed threatened and triggered by any sense that he could understand anything about her. In fact, it sometimes seemed the more accurate he was, the more caustic her response:

D walks in, barely looking at me, throws her bag down and sits down heavily.

She sighs and makes a groaning sound.

A: Wow! I can see youre not having such a great day!

D: (angrily) What the fuck, Andrew? I barely sit my ass down on the couch and

youre already analyzing me? How do you know how Im feeling? Actually, I was

in a perfectly good mood until you said that!

     Blatter sensitively formulated Diana’s underlying dynamics: “She -- like her father -- could be ruthless in demanding that her needs be met. If she didn’t make a demand,  she risked becoming a submissive non-entity (like her mother) but if she did, she risked becoming a destructive force (like her father). He quotes Benjamin (1990) here who described the giver/ taker,  doer/done to positions: “The complementary structure … allows you to reverse roles, but not to alter them” (p. 42).”  ….An empathic interpretation is a kind of attempt to alter the roles and get closer to exposing the wound of Diana’s neediness.  This is a sound Relational explanation of why empathic interventions didn’t work and why, as he says, he needed to find another strategy.  A similar Modern formulation leading to an almost identical strategy, would be this: Diana’s attachment style and defense structure are organized around having to be hostile to ward off intimacy (insecure ambivalent attachment perhaps). The analyst must therefore interact with her in a way that joins, not challenges, her overt defense. A “titrated aggressiveness” in this case is a “truer” join” or matching of her stance. When the analyst is empathic in the sensitive sense of the word, it can make the patient feel worse for being so angry and devaluing and therefore its antithetical to fostering a narcissistic transference. As Spotnitz explains - the kind of person the patient will eventually feel free to love and to hate is someone like himself, not someone different. (Spotnitz, 1976).

      Diana needed her analyst to do two things: a) allow her to be aggressive to an extent, and b) withstand her aggression without being destroyed. Sometimes we work to tolerate or contain the aggression, sometimes to hold it, and sometimes to join it by engaging with some amount of controlled aggression. We can loosely call these “positions” that depict different stances analysts can take to meet the developmental need of the angry patient and here we see again how the theories converge:  Epstein, in his article “The Problem of the Bad-Analyst-Feeling” says: “[In all cases] the patient [must be] protected from the consequences of his destructiveness. When he initially attacks the analyst, it may be out of a need to feel his interpersonal impact; or out of a need to maintain or restore a failing sense of ego-identity....or to achieve a more tolerable distribution of badness. If the attacks do not persist, the patient may need nothing more from the analyst than a feeling of acceptance and respect for the self-other boundaries that the patient needs to maintain.  [The] patient [gradually] comes to internalize the analysts capability for impulse control and for containing and processing conflictual...mental contents. Let’s call this the “first position” where some combination of listening, tolerating bad feelings, not retaliating, etc. are required.

     A “second position” is admitting to the mistakes and owning failures ascribed to the analyst by the patient.  For example, when the therapist asks, “What am I doing wrong”, or “is there something I did that made you feel rejected”, or “Perhaps I missed something”,  he is both taking ownership as well as showing he can take the anger by inviting its expression. A version of this, imbedded in the banter between Blatter and Diana is depicted here:

D: [K and I] were out for happy hour and I got a text from P (this is the man she has

been having sex with). And K grabbed my phone and read the text! I cant

believe he did that!

A: That sounds really inappropriate!

D: Like, duh Andrew, I really need to pay you money to tell me that! I mean,

what a dick! He just doesnt get it.

A: What doesnt he get?

D: You mean I need to tell you?

A: Yet again, Im a failure at reading your mind!

D: I mean, come on, he doesnt get that my phone is private.

    It may seem small, but I believe Blatter’s comment: “I’m a failure at reading your mind!” enabled Diana to move slightly off the full-on angry stance and move a hair closer to stating her need. 

       Slochower, who writes extensively on holding, says that mere holding is not enough with this type of patient — it is critical that the analyst demonstrate that he or she can survive the patient’s aggression through a particular type of affective engagement. “...[Safety] is created not just by refraining from retaliatory interventions, but through a modulated aggressive posture that shows the analyst can handle and survive the patient’s hostility.” (If we took the author’s names away, would we be sure which orientation the person was coming from?) The use of modulated aggression or “third position” - is a more active and interpersonal way of engaging the patient and her anger.  Blatter joined and embodied the aggression which Diana herself felt, and showed he could have his own aggression without shame and without being destructive.  Blatter went (not necessarily linearly) from responses that were of the listening, empathic, tolerating and containing types to this more active way of engaging with Diana - sometimes because the first ones didn’t work, but other times because he was attuned to her different needs and adopted a different stance. This is pretty identical to the way a Modern would work with Diana.

     Spotnitz (1981) argued in 1981 when working first with schizophrenics, that sharing understanding is not the main problem, working with aggression is. The therapist has to learn how to deal with the aggression -- not purely as a matter of technique - [rather with] emotional understanding and emotional communication. In other words, technique charged with emotion. When one “communicates his aggression in language without action”, the patient improves.  Blatter discusses his own relationship to anger, saying that he is comfortable with “bantering”and enjoys humor and sarcasm.  That gave him a huge advantage relating to Diana. Some therapists avoid their own and their patient’s aggressive feelings. They may be very good at tolerating, but engaging proactively with it is a different story.  Note the following interaction which depicts a further shift in Diana’s way of relating to him as a result of the successful ongoing diffusion of aggression through playful humor:

D: I really didnt want to come here today -- youve got your work cut out for you!

A: Uh oh. Not another one of those days. We had so much fun two weeks ago!

(referring to a particularly contentious session).

D: (laughing) Yeah -- I really put you through the ringer, didnt I!

Of particular interest is that we now start to see the fruits of this laborious process --- a growing awareness of Blatter as a separate person. 

      I now turn to Marilynn Massa’s paper (2017) describing her work with Evan, a 34 year old narcissistic, fragile man whose aggression had an even more destructive vein than Diana’s. She writes: “Evan’s initial interactions with me were “shockingly denigrating and harsh and left me feeling humiliated and disoriented”:

 

“You look like one of those cunts who has rejected me. Not now though, you are clearly past your prime. Maybe if you pushed up your tits and did something with your hair you’d look a little younger.”  (refer to each other)

            He constantly cut her off, asked relentlessly intrusive questions about her background and demeaned her. Exploration provoked more rage.  Like Blatter, Massa came to understand the link between Evan’s shame and his attacking behavior. She tried to explore and acknowledge her possible impact on him: “Maybe the look on my face made you feel judged?” and this helped him feel understood. The motivation for this type of intervention has, I think, slightly different roots depending upon your orientation. For Relationalists, I think it’s about validating the feeling and taking responsibility for the co-constructed experience.  For Moderns, it’s about validating the feeling and eliciting the patient’s expression of anger (or whatever feeling is dominant), and only secondarily is it about validating the co-constructed experience. Despite different emphases, both explanations are in the service of understanding how to create a safer therapeutic environment.

     Massa also used limit-setting interventions, which are another type that characterizes the “third position” --- where we adopt a modulated aggressive stance:  “Can we be angry without being insulting?” Or, “We’re going to that place again—what’s going on?” This limit setting is another way of engaging the aggression more directly.  Moderns, by the way, will sometimes do this a bit more “fervently”:  “I would like you to try and tell me about your anger without yelling right now”.  Or, “you can get as angry as you want but I’m not a toilet bowl.”  This may not at all be appropriate for Evan, and of course one must be very careful that the therapist does not evoke feelings of humiliation, but some very tough patients need to feel the force of the analyst’s boundaries quite extremely. Over time, doing a difficult balancing act with these three positions helps diminish a patient’s verbal attacks, as they did with both Diana and Evan. 

Blatter and Massa’s treatments had several things in common: they both were moved - again not always linearly - from empathy to limit setting, “banter-y” or other controlled aggressive stances.  Benjamin (1990), states that the survival of aggression without retreat or retaliation is the thing that enables the child/patient to begin to integrate the parent/analyst as separate subject. Epstein’s (1977) similar description is [that] “the analyst, in standing-up to the patient is, in effect, jarring him awake from a solipsistic nightmare. In presenting a surface hard-enough for the patient to feel, [the analyst]  reestablishes the self-other boundaries”. 307

Finally I want to underscore the place where perhaps the two approaches differ more significantly.  Massa writes: “It was perplexing to frequently implicate myself in the reasons for his attacks when I consciously felt that I had done nothing wrong. But clearly his responses were due in part to something that I was bringing into the room.”

The key words here are “in part”. I believe in their very first meeting, Evan’s transference played a very, very loud note while Massa’s unique contribution played a very, very soft note. Dare I make a distinction between a reaction to who you are (e.g. a woman, a man, a person of color, etc.) vs. to something you are contributing to the actual dyadic interaction?  In any case, I don’t think the contributions are always equally weighted and I think she was a little hard on herself here, possibly giving more credence to her subjectivity than the transference - (as I wondered if this was similar to what Lachmann had done when he was understanding his “worry”about Karen.  Bidirectionality need not ever be denied, and the presence of two subjectivities can be a given, but I suspect the Relationalist would worry that a Modern analyst doesn’t take his or her subjectivity into sufficient account, while the Modern analyst would worry that the Relationalist doesn’t take transference into sufficient account. Hopefully we’re both wrong or we’ll both learn from each other to find the sweet spot and balance the two.

 

The narcissistic transference space morphs into a more differentiate object transference space in its own time, and that is when  believe, the actual, interpersonal processing of subjectivity is more successfully embraced.  The following example from a presentation by Ruth Wyatt (2017), showcases the kind of work that can be done when the patient is ready for processing the analyst’s and her own subjectivity. In the interests of time I will skip the background and details of the specific incident that is referred to that caused a rift but suffice it to say that both patient and therapist had enjoyed a long and deep mutual idealization which was challenged in a session that took place several months after the patient moved away and work continued by phone. In the session below, the patient expressed feelings that Wyatt was more distant, and Wyatt then became aware that she herself felt abandoned by the patient. She writes:

 When I was finally able to pay attention to Mary’s feelings, I got the distinct sense that, although some of my feelings were coming from my own needs and history and some were surely co-created between us, much of what I was feeling was what Mary herself was feeling, feelings she needed me to experience and that, she was inducing in me.   She needed me to provide a hard, calm surface against which she could rail, so that she could shore up her separateness and not feel that she was destroying me with her anger and hate.  She needed me to express my anger in a metabolized, controlled way so that she could feel understood by me and accept the angry part of herself. 

This is almost identical to what we’ve discussed earlier, but here I am specifically highlighting the difference in capacity for experiencing each other’s subjectivities:

M:  I dont feel as close to you as I once did.  I think I am very hurt about the Fran stuff.  Not sure things can be the same between us.

R: I really hurt you.

M:  Yes.  You did.

R:  I know how hard this issue has been for you, but I am curious, the past few months you’ve seemed much angrier about it than before?  Is that right?

M:  That’s true.  Before I was so sick and vulnerable and I took whatever I could get from people because I needed so much from people.  Now I am stronger and have this great life and don’t need to take people’s shit anymore.  I’m not going to put up with any BS!

R: Including mine!!

M:  Right!!

R:  So, partly you’re angry and pulling back from me because you’re feeling stronger and happier with the wonderful life you are building?  Maybe you dont need me in quite the same way.

M: True!! (Beaming)

Skip to further into the session

M:  In the last few months, have you seen a side of me that you didnt like, something that maybe changed your view of me or made you like me less?  Like when I called you stupid and immature? 

R:  Well, I cant say your mean sarcastic side is my favorite part of you. (We laugh).

M:  Well, I think you have that inside you as well.

R:  That may be true, but that doesnt mean I like it. 

M:  Yes, but sarcasm is fun.

R:  Sure, when its directed somewhere else!

M:  (She laughs), Thats true

Skipping again:

R:  Maybe Its hard for us to accept the parts of each other we dont like.

M:  yes, it is hard.   Im sad not feeling close to you.  Are you sad?  

R:  Yes, I’m sad too.

M:  I want to feel close again.  Do you?

R:  Yes, I would like that.

Diana or Evan could not have done this at the time their sessions were described - It took almost 8 years for Mary and Wyatt to get here.  So I imagine that some Moderns and Relationalists have differing expectations when working with each person’s subjectivity --depending upon the point in time in the treatment. 

 

In summary, I’ve touched on the many parallels between: a) matching and joining; b) induction and receiving implicit emotional communications; c) inference and contact;  d) the analyst’s subjectivity and subjective and objective countertransference;  d) similar ways in which Relational and Modern analysts respond to the developmental needs of aggressive patients and finally e) A potential divergent point of view when it comes to the timing of working actively with the two subjectivities.  I would like to close with the following quotes:

Hyman Spotnitz: There are many theories about the human personality...all of which may or may not be correct. Any theory that enables the analyst to understand the patient but becomes a detriment to curing him [should be] discarded (Spotnitz & Meadow, 1976).

Edgar Levenson:  Every advance is initially productive, turns into a doctrine, and ends as a cliche and a countertransference. Then the next cycle of reversal begins. Intrapsychic and interpersonal exist on just such a dialectic wheel (Levenson, 2001).

       Emmanuel Ghent: …[Let] me remind the reader that this paper is about two subjects: one mans psychoanalytic belief system, and secondly, a study of the question of the role of one-person and two-person psychologies in psychoanalytic theory. I hope it is clear that both are actively in flux. 

 

 

 

 

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