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현대정신분석의개입기법
작성자  simonshin 작성일  2017.08.15 06:51 조회수 1059 추천 0
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 현대정신분석과 관계 중심 정신분석 - Article 1부  
 

과목: 현대정신분석의 개입 기법

주제: 현대정신분석과 관계 중심 정신분석 생각보다 가까운 사이

강사: 신현근 / 김양자 교수

내용: Levitz, Judy 의 논문

수업일: 2017811

교재: Levitz, 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*

 

Modern Psychoanalysis, founded by Hyman Spotnitz, is a modified version of classical Freudian theory which is perceived as:  a) being rooted in the one-person model, b) having special emphasis on the role of aggression, and c) using prescribed technical interventions to work with initially with severely narcissistic or psychotic patients -- but later applied to all patients. The Relational approach in contrast, is perceived as a soundly two-person model, where co-creation of meaning is tantamount, mutuality is a given, and drive is not a particularly relevant concept. More and more, the relational dimension of Freudian theory and the intrapsychic dimension of Relational theory are increasingly acknowledged, but we are still pretty far apart.   

    In the tradition of the Relational orientation, I will add a bit about my own subjectivity here:  I trained intensively as a Modern analyst. I think it has made a brilliant contribution, primarily to the theory of technique of psychoanalysis. And, I also feel it has been greatly misunderstood and marginalized, not in small part due to our own cult-like legacy and not coming out to play with the rest of the psychoanalytic community. 

*This is a presentation format of an article submitted for publication: please do not share or reproduce without the author’s permission.  Thank you!

 

But for a long time I’ve argued that the object-relatedness of Modern theory made it an utterly two-person approach -  just one that hasn’t been very well articulated. The language in most Modern writings, with too few exceptions, is still one-person imbedded, but as Ghent in his article: The Dialectics of One-Person and Two-Person Psychologies, said, “We are often blinded... by language whose referents have become blurred…. from seeing essential similarities of approach.” One of my agendas tonight is to continue putting the Modern’s two-person-ness forward.  I’ve also studied Relational theory, though not to the same extent, and my second agenda, using clinical excerpts from Relational writings, is to highlight the many specific similarities and the few notable (but not terribly outrageous) differences between the theories.

Influences of Sullivan (Interpersonal School), Winnicott (Object Relations School), Kohut (Self Psychology School), Dan Stern, and other contemporary infant researchers led to a sea change in the face of psychoanalysis - from the notion that drive is just discharge seeking to the idea that it is object seeking. We all agree now that intrapsychic structure is built through interactions in the early infant-mother field.  But we still gravitate towards orientational camps. Thomas Ogden (1994), who was analyzed by Spotnitz and one of the very very few non-Modern authors to ever reference him in his writings wrote: “Our goal is to escape the pitfalls of ideology and learn from the different systems of ideas that together constitute psychoanalysis”. In this spirit here are some key concepts most often associated with Modern and Relational which I will refer to throughout the talk. At first they seem terribly different, but really they are not. (Note: They are not listed below as equivalents.)

 

 

MODERN TERMS

RELATIONAL TERMS

Contact Function 

Dissociation

Object Oriented Questions &

Ego oriented Questions

 

Authenticity/disclosure

 

Narcissistic Transference &  Narcissistic Defense    

Co-created/bidirectional/

The Analytic Third

 

Role of Aggression   

The Therapeutic Conversation and Meaning Making

Free association &                                                          Progressive Communication    Ÿ

Enactment

Joining, Mirroring and                            Emotional Communications

Subjectivities

 

Verbal/Oedipal &                                       Preverbal/Preoedipal

Unformulated/Implicit experience

 

                        Ÿ                    Ÿ                                      

Even within each orientation, analysts might define their concepts somewhat differently and that’s fine, but we are also prone to latch onto terms like badges of a brand which is not so fine unless we can be clear about what we mean.  Drilling down into as much specificity as possible is I think the best way to highlight similarities and differences, so  I’m going to “microanalyze” my sources of clinical material:  One source is Frank Lachmann and I would like to thank him for his permission to use his work, and I’m also going to use excerpts from papers by 4 graduates of PPSC: Andrew Blatter and Marilyn Massa whose two award winning papers were written, respectively, using a primarily Relational and Intersubjective approach; and two wonderful papers by Ruth Wyatt and Robert Schmehr, whose writings are in part an outgrowth of their pluralistic training at PPSC - I thank them also for their generosity in allowing me to share their work.

I begin with several extracted segments of vignettes from Beebe and Lachmann’s article: “Organizing Principles of Interaction from Infant Research”. In it, Dr. Lachmann beautifully described his case of “Karen” from a Relational perspective. 

In the first section I discuss the Modern concepts of “Contact Functioning” and “Object Oriented Questions” and the Relational concepts of dissociation and Unformulated experience.

1.  “Karen found it difficult to speak to me. She began sessions by asking, somewhat mechanically, “What shall we talk about?”  I inferred her distress behind her affectless demeanor. So as not to increase her discomfort, I often responded by summarizing previous sessions, for example, “Last time we spoke about how messy and dingy your apartment is.” I came to understand Karens opening question as an attempt to orient herself and to determine whether or not a connection could be established with me. Overtly, Karen hardly acknowledged my presence, although her question, “What shall we talk about?” did contain “we.”

In the first  part of this description, Lachmann says that Karen’s question, “What shall we talk about”  was an attempt to see if establishing a connection to him was safe, and notes that he did not want to increase her discomfort.   In Modern terms, this attempt to connect is referred to as the “Contact Functioning” of a patient. It denotes an active venture to engage with the analyst and is like Winnicott’s (1945) infant seeking contact with external reality, or Dan Stern’s (1985) description of the infant’s early self-regulation of social stimulation. Contacts may be conscious or unconscious, direct or indirect, verbal or non-verbal, and they reflect the patient’s desire to engage the analyst either as a separate individual or as a provider of an early selfobject need (Margolis, 1983a; Levitz, 2005).

Dr. Lachmann responded to Karen’s question with what Modern analysts call an “object-oriented” comment.  This is a question or statement which takes attention away from charged subject matter in order to regulate the amount of affect and potential flooding (Margolis, 1983b). Because Lachmann felt she was already distressed, he moved the exchange along by a) sticking with a topic that was concrete (messy apartment); b) he referred to something from the previous week thereby providing some emotional/temporal distance, and c) he returned to content that was already safely discussed, so there was greater certainty it would not exacerbate her discomfort.  He did NOT respond to her question by saying:  “What do YOU want to talk about?” or “Is there something going on that is making it hard for you to talk?” Those would have been “ego-oriented” questions, and they are more burdensome to a fragile ego. Most importantly, he did not balk at taking the lead in this way. 

When Dr. Lachman says he inferred her distress. I  want to bring attention to the question of: How does “inferring” happen? Are we: 1) observing a behavior and making a cognitive assumption based on our human experience.  2) Are we experiencing empathy on a purely emotional plane?  Relationalists and Intersubjectivists sometimes describe empathy as a function of the contact between the analyst’s and patient’s self states. Modern analysts describe it as the receiving of pre-verbal or pre-Oedipal experience (which is the same as Relational terms implicit or unformulated experience).  Geltner (2013) describes induction or emotional communication as the earliest form of communication.  Only later in life do language and emotional induction go hand in hand.  (I say more about the term induction later on.)  In this case, Karen’s words, “What shall we talk about” were the vehicles for her pre-verbal need - The emotional need, likely unconscious on her part, infused the question which was aimed to reach her analyst, who “correctly” per-ceived and re-ceived it.

Dr. Lachmann said did not want to increase Karen’s discomfort.  Moderns use the horrible one-person terminology to describe the same thing: “Patients should be ‘allowed’ to ‘resist’”. But resistance here does not mean the patient is being uncooperative or must be made to un-repress something or to connote pathology.  It means the patient should not be pressured to change a pattern of relatedness before they are good and ready.  Karen’s difficulty speaking freely might also be called by the Modern analyst: a “resistance to free association” or a “resistance to progressive communication”.  In this context resistance means obstacle. Obstacles show up as interruptions of spontaneous expression and the absence of progressive communications (which is evidenced by the offering of new thoughts, or new feelings). This alerts the Modern analyst to silently study and hypothesize what the obstacle might be, including something the analyst is contributing. It is a bookmark that something is keeping thoughts and feelings out of awareness or restricting the patient’s spontaneity.   We respect those defenses and adaptations and work in the treatment to avoid narcissistic injury by not challenging them too quickly. An intervention that results in progressive communication is studied in contrast to one that does not as a compass for understanding whether what we are doing is helping.

To ensure interventions don’t unduly pressure the patient, we generally follow the Contact Function principle as mentioned previously. If the patient asks a question, seeking contact with the analyst, the analyst responds. But if Karen had been silent, this contact would be matched and met with silence, until or unless the analyst sensed an “implied contact”, in which case the analyst would respond in some way, again with the goal of helping the patient speak more freely. 

       II. In this second section, the Modern concept of “Joining” is discussed along with more about the Relational notion of Unformulated or Implicit experience.

2. Although we sat facing each other, Karen looked away from me. Her face was immobile. Her voice had no contouring. She kept her coat on. In response to Karens extreme forms of self-regulation of distress, I dampened my facial expressions. Even when I spoke to her she did not look at me. Her self-constriction powerfully affected me. I felt reluctant to jar her precariously maintained presentation. To coordinate our vocal rhythms more closely, I partially constricted myself, allowing myself to be closely influenced by her rhythm, and narrowing my own expansiveness to more closely match Karens narrow affective range. Many of these adjustments were made initially out of my own awareness….I looked at Karen continuously, but I kept my voice even and soft. In my initial comments I remained within the limits of the concrete details that she offered. I thus altered the regulation of my arousal, keeping it low. Gradually, her tolerance for positive, affective arousal increased and I could become more expansive. Our verbal and nonverbal range expanded. 

Dr. Lachmann’s goal was to enhance Karen’s tolerance of affects and expand the range of nonverbal and verbal communications, which would in turn lead to a transformation of her core self capacities and object relationships. This parallels the Modern concept described above of facilitating progressive communication. (Sidebar - Modern’s like to name and categorize interventions. That has partially contributed to our reputation of being technique-y. But if you don’t let the label flatten out what you are doing, you can see that we all do similar things, no matter how we were trained. I disagree with Philip Bromberg (2012) in ‘Stumbling Along and Hanging in” where he offered an Interpersonal/Relational viewpoint that in the psychoanalytic relationship, the skill an analyst must bring is not acquired through learned technique.  I think when we understand the theoretical explanation behind the technique, it is quite learnable and gives all therapists a significant leg up on intuition alone.) 

In the service of enhancing her tolerance for greater affect, Lachmann  describes matching her non-verbal and verbal expressions, keeping his voice low and soft, constricting himself to mirror her affective range.  This response to a patient’s affect, demeanor, etc. is a version of what he and Beebe call “optimal responsiveness” and what Modern analysts call “joining”.  In an attuned relationship, much of this occurs naturally and spontaneously.  However, there are times when we struggle to be attuned, and that’s when the process becomes more conscious and deliberate, which should not be equated with manipulative or inauthentic. When Lachmann became aware of a mismatch between Karen and himself and “adjusted” accordingly, he joined her.  She needed to experience her analyst as more like herself, to be in an interpersonal space that was holding, even mirroring her state. It is how the patient’s “narcissistic cocoon” (Modell, 1976; Slochower, 2013) is protected as long as it is required and the narcissistic transference is encouraged (Margolis, 1981, 1994a).

A crucial, though seemingly paradoxical outcome accompanies joining and this is described by Benjamin Margolis: when a patient is thoroughly comfortable and safe, she can then explore, expand and shed old patterns. She is more likely to move out of the narcissistic space the longer she is supported in remaining in that space. We recognize this idea in developmental literature - it’s what a child needs to be able to play, to be curious, etc.

This matching or joining is a parallel way we would respond to unformulated or pre-verbal communications. One difference is that there were aspects of joining and following the contact that a Modern Analyst may have taken further than Dr. Lachmann. When Karen avoided eye contact, the analyst might have done the same. (Of course, that is hard to say without being in the room and knowing what it felt like.)  If this moment could be examined in ultra-slow motion and the analyst could consciously process what was going on, he might ask himself the question, “By maintaining eye contact with Karen when she is avoiding it with me, am I: a) impinging (even ever-so-slightly) on her space, or b) am I letting her know I am connected, and that I’m here and available whenever she is ready?”or even c) Am I facilitating her awareness of an “other” in the room.  There is the question of which of these is transferentially and developmentally most useful in the moment, but there is no question about the two-person nature of this thinking.

 

III.  This 3rd segment discusses the Modern concept of “Narcissistic Transference” and the one or two-person meanings of non-verbal communications.  Theoretically, this may be the most fundamental overlap between the two orientations.

3. Karen moved from descriptions of her environment, the inanimate world, to descriptions of interpersonal relationships, and to explorations of her subjective states. Sometimes, before verbally responding, her right upper lip would twitch and constrict briefly, or her leg would jiggle rapidly. Inadvertently, my face would take on a more somber quality, mirroring her distress. (similar to above)

We came to understand Karens signals as an indication that she was tense and had been feeling moody, depressed, or without energy since our last meeting. We focused on her specific reactions and searched for their context. I detailed nuances of feelings and moods such as annoyance, rebuff, eagerness, enthusiasm, or disappointment. It seemed to me that she experienced many emotions as annoying intrusions.

My comments were directed toward facilitating her attempts at self-definition. As her dread of new situations diminished, she showed a wider variation of facial expressions.

An interesting component to compare here is the one-and two-person meanings of physically or behaviorally expressed communications. When Karen’s lip twitched or her leg jiggled, Lachmann inadvertently (his words) mirrored her distress.  Moderns view this as a natural consequence of them both being in the narcissistic transference-countertransference matrix where non-verbal, emotional communications are being constantly invisibly exchanged.

In his paper,  Schmehr (2015) writes:  Long before theories of Intersubjectivity were part of psychoanalytic literature, Spotnitz was drawn to perspectives that, today, would likely be included in this literature. In his 1969 book, Spotnitz drew from writers from the 1930’s including Jung’s (1935) reference to the analytic process as the “reciprocal reaction of two psychic systems” and the Balints (1939) inevitability of “interplay”. Spotnitz maps out his entire theory of technique in this book. He said: “In treating an extremely narcissistic individual, it is helpful to operate on the assumption that two-way non-verbal communication goes on from the initial contact without either party necessarily being aware of it”. In a personal communication from Dr. Bob Marshall, senior Modern Analyst who knew Spotnitz intimately, he offered me a reference from a slightly obscure paper of Spotnitz’s (1977) where Spotnitz (who was medically trained and liked to link things to neurology) describes the reciprocal processes of “intra and inter - cerebral synchronization” which are characterized by an awareness of and response to the psychic messages received [both] from others and from one’s own sense organs!” (p.101). This sounds very much like the bi-directional phenomenon that Stolorow and Atwood describe as, “a system of reciprocal, mutual influence” (1984). 

Dr. Lachmann noted Karen’s occasional twitching before she verbally responded.  I would wonder: Did this occur in response to something he had just said or was it independent of his active participation?  In other words, was this physical tension more internally or interpersonally generated? What if, in response to what he said,  she activated this body defense to deal with her discomfort?  If so, I would note this and consider the distressing impact of what was said even if it were mild.  It would be a slightly different story if Lachmann had not said anything and the bodily reaction reflected tension generated by having to move from her own inner world to the interpersonal world. In any case, since Karen’s actual communications in this vignette did proceed from her physically twitching to verbalizing her discomfort, wso e witnessed an overall positive, progressive experience. Were I unsure of whether or not the work was progressing, I would probably revert back to silence or to asking neutral, object-oriented questions so the person had more time to become stronger before venturing into the interpersonal world of discourse. 

    Later, Dr. Lachmann refers to Karen’s lip twitching and leg jiggling as signals, which parallels the Modern concept of the non-verbal contact (Levitz, 2005).  The one-person model illuminates the behavior as a) a reflection of the individual’s internal state, b) the physiological manifestation of increased emotional stimulation and c) the discharge of affect that is not well tolerated.  The two-person model shines light on a) the bi-directional impact of the patient-analyst interaction, b) the contribution of the analyst to the patient’s behavior and c) the implicit communication of the patient to the analyst. All 6 must be equally considered.

When Karen reverted to non-verbal signals of distress, Dr. Lachmann reverted to a more somber demeanor as well. He followed her non-verbal contact, then joined, via mirroring, her communication. Other times, he described the nuanced meanings of her signals, and other times still, he discussed their shared understanding of those meanings. Each of these moments is developmentally distinct and his attunement fostered the flow between the implicit and explicit realms of interaction.

This is a good segue to the more specifically Relational concepts of “the therapeutic conversation” and meaning making. I think there is a different kind of conversation and meaning making in the very early states of therapy as compared to later. Benjamin, when discussing mutual recognition,  says:  "The other must be recognized as another subject in order for the self to fully experience his or her subjectivity in the others presence." (Benjamin, 1990, p. 34). I agree with this, and I believe that the process of trying to free associate, or facilitating progressive communication, is inherently linked with enabling the patient to experience how to be alone and safe with the other, to learn who one is and learn the difference between one’s inner vs. interpersonal experiences.  It is “on the way” towards differentiating both subjectivities. So initially when working in the more narcissistic transference realm, we’re talking about how emotion gradually informs language, enabling dissociated states to become more integrated, and how free association helps the patient gain more emotional and lingual access to experiences that were previously unformulated. Here, the analyst is involved more, I think, for his or her facilitator and selfobject role than as an independently subjective being.

Later meaning making tilts towards the discovery of two more differentiated subjectivities (and I describe a specific example of this later on).  While two subjectivities are always present, I believe that overt reference to the analyst’s subjectivity should remain more in the background initially and come forward gradually as development requires and allows.  Many authors note this more and more, including Geltner (2013), Aron (1991), Fosshage (2003), Slochower (2013), in their discussions of the asymmetrical analytic relationship, and the responsibility of the analyst to take the lead in the co-constructed endeavor. 

IV.  Section IV elaborates on different conceptualizations of Enactment and “the Narcissistic Defense”.

 4.  Nonverbal mechanisms played a role throughout Karens treatment. They interfaced with, amplified, and subsumed the many dynamic issues that were explored, such as her dread of alienating her mother and the extent to which she sacrificed her health and comfort to maintain her attachment to her.  Her suicidal preoccupation, her neglect of her physical well-being, her social withdrawal and minimum functioning in life, all converged in her conviction that her parents life would have been better off had she not been born.

Lachmann’s compassionate description of Karen’s evolution in treatment highlights the shift from seeing her nonverbal communications as just signals for the analyst to come close or stay away or help the patient stay regulated, to -  seeing them as repetitions and enactments of her internal relationships.  Three definitions of enactment span the 1 to 2 person continuum: a) Focus on the repetitive and transferential nature of an enactment - (this comes from Freudian theory); b) the role relationship enactment - (this is from early object relations theory); and c) the contact between dissociated self-states of the analyst and patient  - (which is the most relational and intersubjective model) . I believe each facet is present in all enactments.

We hypothesize that Karen wants Dr. Lachmann to experience what her relationship with her mother felt like in its most horrific sense, and she hopes he will do something maturationally different.  If you are familiar with Steven Stern’s article on needed and repeated relationships  (Stern, 1994) and Tony Bass’s discussion of enactment (Bass, 2003) they are especially useful here. Additionally, attachment researchers Hesse and Main, in introducing a fourth category of disorganized attachment, discussed how physical behaviors, including jerky movements, etc. correlate with infant’s attempts to not cry.  (Hesse and Main, 2000).  It would make sense that Karen’s body was telling Dr. Lachmann all about her pain and anger, all the while trying not to cry.

These physical manifestations of Karen’s angst, along with her withdrawal, self neglect and suicide attempts constitute versions of another important Modern concept, called the “narcissistic defense”. It is used to describe how the infant protects the parent from negative feelings.  According to Spotnitz, aggression that can’t be healthily discharged and expressed gets turned against the self during the early phase of development when there are overlapping self and object boundaries.  We are most familiar with this when we formulate depression as a self-attack. Spotnitz additionally theorized that it was aggression turned on the self that damages cognition (hence thought disorders), affect states (hence mood disorders) and the body (hence somatic disorders). This inspired his emphasis on finding ways to elicit negative feelings and reverse the self-attacks as the primary way to relieve pathological adaptations. One can view this as a one-person drive theory if we focus on the mechanism of managing the aggressive drive, but we must view it as a two-person theory if the motivation is to protect the maternal object, and hence the relationship.  

 
 
 
 
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