One Way Out of Enactment: The Patient's Differentiation from the Therapist

ONE WAY OUT OF ENACTMENT: THE PATIENT’S DIFFERENTIATION

FROM THE THERAPIST

James Tobin, Ph.D.Licensed Psychologist PSY 22074220 Newport Center Drive, Suite 1

Newport Beach, CA 92660949-338-4388

Assistant Professor of Clinical PsychologyArgosy University

601 South Lewis StreetOrange, CA 92868

714-620-3804

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Case VignetteSection I.

The Countertransference Experience of Identification

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Section I. The Countertransference Experience

of Identification

• Although there are many forms of countertransference (CT) experience, the therapist’s reaction of tension or difficulty has received the most attention, i.e., when the therapist has the feeling of being “triggered” or “provoked.”

• The therapist is characterized as having his “buttons pushed” – with the emergence of CT signaled by the therapist feeling or acting in ways that are atypical, not his usual style, etc.

• In this perspective, the emphasis is on how the therapist struggles to “manage,” “control” or “tolerate” such feelings in the context of the therapeutic relationship and how, potentially, to use these feelings to understand the patient.

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of Identification

• CT reactions of this form are theorized to be rooted in unresolved issues in the therapist and/or in what the patient is “inducing” in the therapist (i.e., in response to the patient’s transference).

• Another form of CT experience that is often under-emphasized is the therapist’s feeling “identified” with the patient, when some core aspect of the therapist’s personhood is highly connected to the patient (often described as a kind of nostalgic resonance).

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of Identification

• This experience is often construed as “empathy” or “sympathy,” a way of locating the patient, or projective identification.

• Directives in supervision are frequently offered with the intent of (1) helping the supervisee conjure up elements of his or her own subjective life to open up identification pathways in an attempt to understand the patient better or, conversely, (2) warning the supervisee against overly-identifying with the patient (the distinction between 1 and 2 is often unclear).

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of Identification

• Using case material from my work with a 17 y/o adolescent male patient, I want to present how my own CT identifications evolved into a particular type of a transference-CT enactment and how I, with the help of my patient, got out of it.

• What I learned from this treatment informed my understanding of various aspects of clinical technique including the ways in which the therapist simultaneously knows and distorts the patient, and how CT identifications shed light on particular aspects of the patient’s transference and repetitive interpersonal experience.

• The limitations of the projective identification viewpoint: my emphasis is not on what the patient is disavowing/”putting into” the therapist, but the therapist’s “valence” for the patient’s experience that already exists in the therapist.

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Case VignetteSection II.

Seeing Myself in the Patient

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Case VignetteCase Vignette #1

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Section II. Seeing Myself in the Patient

• While there are many interesting elements in this initial interchange with my patient John, I want to focus on the theme of he and I being “like” each other/familiar:

-interview experiences of having our flies undone (exposure)

-the assumed relationship between similarity and understanding (John’s comments about being hip and young)

-my already being identified in John’s mind with someone else in his life (i.e., what seemed to initiate his association to the memory of his interview was

my remark, “I like you already”) 9


• This interchange marked the beginning of a treatment in which the familiarity between us expanded. My personal life and history seemed to reference/match John’s experience more so than my other patients: John often felt “like me” or at least similar to what I remembered of my feelings and struggles when I was his age.

• Early on, I felt this similarity was fortuitous and something I could exploit to promote the alliance between us and enhance the process of inquiry I was able to engender; it was also something I attempted to talk about from time to time: I once told him, “Sometimes I see myself in you” and he replied, “Save me the suspense, and the grief: I don’t want to grow up to become a psychologist.” 10


• As treatment progressed, there were instances in which my identifications with John seemed overly-inflated, intrusive, and misleading.

• Rubin (1999) describes periods when the analyst relates to the patient “habitually, repetitively, and self-centeredly” (p. 20); this was the emerging quality of my interactions with John.

• John’s college application essay about the poem “Letter to My Mother” (Phillips, 2000) became a central topic of our discussions during the Fall of his Senior year, and was revisited over and over again in the treatment.

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Case VignettePoem “Letter to My Mother”

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• My comment (“Right, but ….”) had within it a particular focus and intentionality that diverted me away from the patient’s emphasis: I was trying to get at my suspicion of John’s aggressive longing to tell his mother the truth of his sexual life and, by so doing, shatter her construction of him – this did not converge with his central point (i.e., his need to have and keep the secret and use it as a psychological means of separating from his mother and becoming a man).


• My intervention was motivated by my own interpretation of the poem and my subjective experience with my own mother – in this instance, my CT identification led to a mismatch or disjunction, not understanding.

• I believe these moments are common in clinical practice and are occurring, to a greater or lesser degree, all the time: the way the therapist comes to “know” the patient (often through identification) deviates from the patient’s experience and the metacommunication can be devaluing/causing minor and major ruptures.

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• The central dilemma in the poem, and for John and me, and for the ultimate fate of the therapist who cannot help but to experience CT identifications with the patient is this:

How does the patient emerge out of the CT-identifications and breach the therapist’s coercive self-referential constructions (e.g., “And of course you’ll dress for dinner!”)

• This leads to a related question:

What characteristics of the therapeutic situation support this occurrence, and allow the therapist to tolerate and use it clinically?

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Case VignetteSection III.

Enactment and “Depersonalized

Knowing”

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Section III:Enactment and “Depersonalized Knowing”

• As these CT-identifications continue in treatment and go undetected, enactment occurs.

• A transference-CT bind gradually but definitively formed in which the very way I came to know and understand John manifested a repetitive problematic theme in his relational life.

• I became a version of John’s mother: viewing him from a highly personalized, overly-determined and self-centered vantage point.

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Section III. Enactment and “Depersonalized Knowing”

• The term “enactment” has been described as a transference-CT bind in which one or both participants in the clinical situation become restricted in how the other is viewed, related to and known (the other becomes a limited approximation/faulty construction in the mind of the other).

• As the approximation mounts and the construction becomes more firmly organized, the degree of inquiry, spontaneity of relatedness, and access to disavowed aspects of self and self-other/relational experience become limited.

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• In his important work “Partners in Thought: Working with Unformulated Experience, Dissociation, and Enactment” (2010), Donnel Stern posits, “All experience is subjective, the analyst’s as well as the patient’s … We must now understand that we all continuously, necessarily, and without awareness apply ourselves to the task of selecting one, or several, particular views of another person from among a much larger set of possibilities” (p. 8).”

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• This view of enactment emphasizes the paradoxical (and I would argue, inevitable) development in the therapeutic relationship of illusion and self-deception: as treatment moves through time, the therapist (and the patient) progressively see each other with greater conviction and, simultaneously, with greater error; also, their capacity to detect errors of construction seems to diminish.

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• This raises the issue of the therapist’s epistemological (Everitt & Fisher, 1995) position with regard to the patient, the cognitive/emotional “set” (Wachtel, 1993) with which the therapist uses to organize, comprehend, and understand the patient.

• Christopher Bollas’ (1987) notion of the therapist’s “personal idiom” suggests that all aspects of the therapist’s personal identity (family background, education, ethnic and cultural identity, psychological/clinical preferences) influence and bias what about the patient the therapist is sensitized to, identifies with, and uses to form meaning.

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• Similarly, the psychoanalyst LaMothe (2007) presents the work of the Scottish philosopher Macmurray (1991) who put forth the construct “impersonal knowledge,” i.e., a form of recognition always present in social interactions which involves perceiving the other based on categories, roles, etc. that obscure “the personal.”

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• Compelled to understand, the therapist is destined to use CT identifications with the patient and to inevitably be fooled by them.

• Think of a statistical test such as the mean as an epistemological construct employed to identify meaning within a chaotic array of numbers – the application of the statistical test cannot be made without assuming error.

• “The path of least resistance” to understanding the patient is through the therapist’s personal experience (identifications); sooner or later, impersonal knowledge is generated at the expense of the personal and is confused with the personal.

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• Various accounts of this problem exist in the literature:

Hedges (1992) highlighted the therapist’s premature certainty and avoidance of pursing the meaning of CT experience, along with the patient’s collusion in being known impersonally: “Armed with the truth, the therapist may then assail the person in analysis with an interpretive line in an effort to establish the validity or correctness of the analyst’s view—an endeavor with which the person in analysis is altogether too likely to cooperate” (p. 25).

Benjamin (1988, 1990, 1995, as cited by LaMothe, 2007) dramatically characterized the clinical encounter as an ensuing conflict in which the therapist aims to “struggle to control the other” by understanding (and gaining “autonomy from the patient”) so as to avoid the absence of understanding (“dependence on the other”).

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• This perspective leads to an interesting re-conceptualization of transference offered by LaMothe (2007): transference consists of the patient’s “history of depersonalizing … relationships” (p. 285) and the patient’s corresponding desire for and fear of being personalized.

• LaMothe (2007) views psychological trauma as the parent’s failure to recognize the child’s uniqueness so that the child exists in a depersonalized capacity, objectifying others and viewing his/her exposure of uniqueness as anxiety-provoking.

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Case VignetteSection IV.

One Way Out of Enactment:

Moving Toward “Personalization”

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Section IV. One Way Out of Enactment:

Moving Toward “Personalization”

• This material demonstrates enactment formed by progressive CT-identifications: it is a depersonalized interaction with an implicit directive, a metacommunication about my preferred vision of the patient that is coercive (e.g., “I would have assumed ….”).

• It illustrates LaMothe’s view of transference and Stern’s description of the highly constricted relatedness that defines enactment.

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Moving Toward Personalization

• It also illustrates what I call “differentiation” (LaMothe’s term is “relational disruption”) in which the patient establishes himself outside of the therapist’s CT-identification.

• Surprisingly, and fortunately, in the depersonalizing context, the patient personalizes: John says emphatically, “I am me, not you,” disagrees with my implicit directive, and justifies his own choices.

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• Differentiation is an important clinical event that parallels Stern’s thinking: “Enactments resolve only when one or the other member of the analytic couple reestablishes dialogue by gaining explicit awareness of how, at that particular moment, the context he is supplying is inappropriate to the other (or the ‘other’ within himself)” (Stern, 2010, p. 51).

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• LaMothe (2007) argues: “These ‘old forms’ of association have the illusion of reality. In other words, they are real to the extent that they are part of the person’s memory and identity; however, this reality is not accompanied by a sense of being real, which comes from being recognized and treated as a unique and inviolable subject” (p. 284).

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• Benjamin (1990) theorizes that the capacity for recognition is made possible only through negation. Negation involves the emergence of difference or distinction (the other is “not-me”).

• Negation echoes Davies’ (2004) notion of enactment as the collapsing of the boundary between self and other due to mutual projections and counter-projections (recall Vignette #2 in which John said he no longer wanted to be transparent, that he wanted to have a private life inaccessible to others).

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• A developmental perspective is also relevant here: LaMothe (2007) references Winnicott’s (1971) view of advances in psychological growth and development prompted by the parent’s recognition of the child as like me, but not-me.

• LaMothe (2007) explains: “. . . an individual recognizes the other as a unique person, like me and different (not-me), which involves the individual’s handing over omnipotence and the desire for domination for the sake of intersubjectivity and shared personal knowledge” (p. 274).

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Case VignetteSection V.

Summary and Implications for Clinical

Technique

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Section V. Summary and Implications for

Clinical Technique

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Figure 1. The Continuum of CT-Identification Experience: States of “Knowing”

Enactment/Depersonalization (Restricted Knowing)

Identification

Intellectualization

Negative Capability(Not-Knowing)

Uncertainty

Chaos

Guilt

Shame


Clinical Technique

• The therapist seeks to understand/construct (“know”) the patient according to a personal idiom and epistemological framework.

• A continuum of CT-identification experience exists that corresponds to the therapist’s states of “knowing” the patient.

• This continuum marks distinct relational zones/ways of being with the patient.

• The listening function is inherently subjective and tends to migrate toward CT-identifications, leading to an accumulation of impersonal knowledge and restricted knowing.

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Clinical Technique

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Enactment/Depersonalization(Restricted Knowing)

Identification

Intellectualization


Uncertainty

Chaos

Guilt

Shame

Figure 2. How the Depersonalizing Enactment Evolves: A Model

Relational Disruption/Differentiation

A

B

A: RestrictionB: PersonalizationC: Relapse

C


Clinical Technique

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• In the initial stages of a treatment, the therapist moves in and out of various states of knowing/relational zones; there may be little restriction and active fluctuation as new material is presented by the patient and assimilated by the therapist.

• Gradually, historical/transferential material (patient) and CT-identification experience (therapist) coalesce and restrict the fluctuation between relational zones; the therapist is pulled toward one particular form of knowing (CT-identification) and this migrates the therapeutic enterprise toward depersonalizing interactions.


Clinical Technique

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• An enactment ultimately ensues based on a pattern of depersonalized relatedness.

• Ideally, relational disruption (“differentiation”) interrupts the enactment -- freeing the patient and therapist to experience the patient outside of the therapist’s limited epistemology (“not-me”).

• When this occurs, the therapist’s construction of the patient is challenged/subverted and the patient is recognized uniquely (and embodies the experience of “being real”).


Clinical Technique

• With regard to technique, it is recommended that the therapist approach inevitable CT-identifications with acceptance and curiosity, presuming errors of construction and anticipating depersonalizing enactments.

• The therapist adopts an attitude characterized by “a radical sense of openness” and the expectation of “a radical deconstruction of all narratives” (Safran, 2003, p. 22).

• The therapist observes the state of knowing and the corresponding zone of relatedness he occupies with regard to the patient; opportunities for shifts between zones (often cued by the patient) are sought and optimized when they present themselves.

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Clinical Technique

• The therapist develops the capacity for subjective and objective modes of self-relatedness, i.e., being inside of the identification while also globally challenging the veracity and consequences of the identification.

• The therapist models for the patient humility and enthusiasm for deconstructed knowledge/new knowledge, socializing the patient into an interactive/relational “play space” of ideas, meanings, and subversions.

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Clinical Technique

• As Rubin (1990) describes: “The analyst can literally sit with and through a greater range of affect without the need to shield himself or herself by premature certainty or intellectualized formulations. There is then a greater tolerance for complexity, ambiguity, and uncertainty. There is less pressure to know and to do. Not-knowing is then a more comfortable stance of being for the analyst. The analyst experiences more ‘beginner’s mind.’ ‘In the beginner’s mind there are many possibilities,’ notes Shunryu Suzuki (1970); ‘in the expert’s mind there are few’ (p. 21). The analyst who has a beginner’s mind takes less for granted, is more receptive to the unknown, and is more capable of being surprised” (p. 20). 43


Clinical Technique

• These suggestions for attitude and technique may not prevent depersonalizing enactments, but may foster briefer cycles of convergence/divergence, more rapid transitions between zones of relatedness, and the gradual dissolution of guilt- and shame-based reactions/humiliations when the therapist realizes his self-deception.

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Clinical Technique

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Figure 3. Subjective and Objective Modes of Self-Relatedness: The Optimal Course

Enactment/Depersonalization (Restricted Knowing)

Identification

Intellectualization


Uncertainty

Chaos

Guilt

Shame

Con

verg

ence

Divergence

Relational Disruption/ Differentiation


Clinical Technique

• Implications for supervision involve approaching CT with an interest in:

(1) Exploring the trainee’s possible hesitation to occupy certain segments of the continuum of CT-identification experience/states of knowing;(2) Increasing the trainee’s capacity to detect cues from the patient that depersonalization may be occurring; and(3) Developing the trainee’s capacity for subjective and objective modes of self-relatedness.

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References

• Benjamin, J. (1988). The bonds of love. New York: Pantheon Books. • Benjamin, J. (1990). Recognition and destruction: An outline of

intersubjectivity. In S. Mitchell & L. Aron (Eds.), Relational psychoanalysis (pp. 181-210). London: Analytic Press.

• Benjamin, J. (1995). Like subjects, love objects. New Haven, CT: Yale University Press.

• Davies, J.M. (2004). Whose bad objects are we anyway? Repetition and our elusive love affair with evil. Psychoanalytic Dialogues, 14, 711-732.

• Everitt, N. & Fisher, A. (1995). Modern epistemology. A new introduction. New York: McGraw-Hill.

• Hedges, L. (1992). Interpreting the countertransference. Northvale, N.J.: Jason Aronson Inc.

• LaMothe, Ryan (2007). Beyond intersubjectivity. Personalization and community. Psychoanalytic Psychology, 24, 271-288.

• Macmurray, J. (1991). Person in relation. London: Humanities Press International.

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References

• Phillips, R. (2000). Spinach days. JHU Press.

• Rubin, J.B. (1999). Close encounters of a new kind: Toward an integration of psychoanalysis and buddhism. American Journal of Psychoanalysis, 59, 5-24.

• Safran, J.D. (2003). Introduction. In J.D. Safran (Ed.), Psychoanalysis and buddhism. An unfolding dialogue (pp. 1-34). Boston: Wisdom Publications.

• Suzuki, S. (1970). Zen mind, beginner’s mind. New York: Weatherhill.

• Stern, D.B. (2010). Partners in thought. Working with unformulated experience, dissociation, and enactment. New York: Routledge.

• Stern, D.B. (2004). The eye sees itself: Dissociation, enactment, and the achievement of conflict. Contemporary Psychoanalysis, 40, 197-237.

• Wachtel, P.L. (1993). Therapeutic communication. Knowing what to say when. New York: Guildford Press.

• Winnicott, D.W. (1971). Playing and reality. London: Routledge Press.

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One Way Out of Enactment: The Patient's Differentiation from the Therapist

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Transcript of One Way Out of Enactment: The Patient's Differentiation from the Therapist