Needed Relationships and Psychoanalytic Healing

A Holistic Relational Perspective on the Therapeutic Process

Steven Stern

• Publisher: Routledge
• Year: 2017
• eBook ISBN: 9781351975698
• Topic: Psychology
• Subtopic: Mental Health in Psychology
• Index: Psychology

Needed Relationships and Psychoanalytic Healing is both a personal analytic credo and a multidimensional approach to thinking about clinical interaction. The book's central theme is that of analytic needed relationships—the science and art of co-creating unique, evolving relational experiences fitted to each patient's implicit therapeutic aims and needs.

Steven Stern argues that, while we need psychoanalytic theories to "grow the receptors and processors" necessary to sense, understand, and connect with our patients, these often tend to frame the therapist's participation in terms of theoretical and technical categories rather than offering a more holistic view of the relationship in all of its human complexity. Stern believes that a new set of higher order constructs is needed to counteract this tendency. In addition to his own concept of needed relationships, he invokes principles from the work of renowned developmental researcher and theorist, Louis Sander: especially his concept of relational fittedness. Stern draws on the work of Freud, Bion, Winnicott, Kohut, and a broad spectrum of contemporary psychoanalytic authors, in fleshing out the therapeutic implications of Sander's (and Stern's own) vision. The result is a rich, humane, and accessible narrative.

Needed Relationships and Psychoanalytic Healing offers diverse clinical examples in which you will find Stern engaging with each of his patients in idiomatic, spontaneous ways as he attempts to contour interventions to the evolving analytic situation. This case material will inspire therapist-readers to feel freer to find their own creative voices and idioms of participation, as they seek to meet each patient within the psychoanalytic space. The book is intended for psychoanalysts and psychodynamic therapists at all levels of experience, including those in training.

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Chapter 1

Needed relationships and psychoanalytic healing

The phrase needed relationship, in its broadest meaning, refers to the fact that the psychoanalytic relationship is first and foremost a special human relationship that forms over time between patient and analyst: It is this special relationship that carries the healing power of psychoanalytic treatment and makes psychoanalysis unique among the healing vocations. Whereas in professions such as medicine and spiritual teaching, and in non-relational psychotherapies, the relationship between the persons giving and receiving treatment or guidance is usually seen as an important vehicle for delivering needed help, in psychoanalysis the analytic relationship itself is the primary treatment agent (see also Mitchell, 1997). This is, and always has been, true despite the fact that Freud, and decades of classically minded analysts who followed his lead, wanted to view the relationship between patient and analyst as essentially similar to that between a medical doctor and patient. The treatment relied on the patient experiencing the analyst as if the two parties had a real and important relationship “in the transference,” and it was recognized that the analyst was vulnerable to reactively falling in with that illusion or fantasy “in the countertransference.” But the analyst needed to remain clear that the patient’s experience was indeed an illusion grounded in “pathogenic instincts” (Freud, 1914, p. 154)—an illusion which, in order to be used therapeutically, could not be shared or indulged.¹ Nonetheless, despite his cautions and disavowals, time and subsequent theoretical advances have made clear that one of Freud’s two most significant acts of genius (the other being his discovery of the unconscious), was his creation of a human relationship with new and unique therapeutic properties.

It was not until the mid-twentieth century and the advent of an increasingly explicit relational psychoanalytic paradigm in the writings of Fairbairn, Winnicott, Balint, Sullivan, Bion, Kohut, Loewald, and others (Greenberg & Mitchell, 1983) that the true nature and healing potential of Freud’s invention began to be more fully understood and actualized. Since then, especially with the intersubjective or relational turn in American psychoanalytic theory that began in the early 1980s, there has been an increasing focus on the therapeutic potential of analysis as a multi-dimensional human relationship, and with this focus an elaboration of the many ways that this unique relationship can respond to the therapeutic needs of a wider and wider scope (A. Freud, 1954; Stone, 1954) of patients with increasingly diverse forms of psychopathology, or, as I prefer to think of them, forms of personal struggle. In this book my aim is to further illuminate the complex and mysterious properties of the analytic relationship as a healing agent by opening up the concept of needed relationship and exploring its implications in various contexts.

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In my original, more limited use of the phrase (S. Stern, 1994), the needed relationship referred to the positive, “new object” dimension of the transference-countertransference relationship as opposed to the repeated relationship, which referred to the negative, “old object” dimension. The phrase, in that context, had echoes of Kohut’s (1971, 1977, 1984) (developmentally needed) selfobject relationship, Winnicott’s (1965) therapeutic principle of the analyst’s adaptation (of technique) to the patient’s developmental needs, and Gedo’s (1979) recognition that some patients have developmental gaps in their acquisition of essential “psychological skills” and thus have a need for a uniquely analytic form of “instruction” in those skills. One of my major points in that paper was that the unconscious communications and pulls of patients in psychoanalytic treatment are not only in the direction of enacting old problematic patterns of relational engagement (e.g., Mitchell, 1988, 1997); patients also unconsciously pull for or signal (directly or indirectly) the kinds of responses they long for or need from the analyst. Accordingly, analysts, unconsciously (and/or consciously) responding to this kind of pressure, may find themselves engaging in more positive forms of enactment.²

I still believe this to be the case, and find that this understanding remains insufficiently incorporated into contemporary Relational theory, which continues to focus disproportionately on problematic enactments. Consequently, in this book I am still advocating for more of a balance in how we think about the analytic process and therapeutic action. However, in the present book the phrase needed relationship, while retaining some of its earlier meaning, has expanded to refer to the healing aspects of the analytic relationship in all of its therapeutic complexity.

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The contemporary Relational focus on repetition (Mitchell, 1988, 1997), enactments (Levenson, 1972, 1983; Bromberg, 1998, 2011; D.B. Stern, 2010), impasses (Stolorow & Atwood, 1992), doer/done-to complementarities (Benjamin, 2004), subjugating thirds (Ogden, 1994), crunches (Russell, 2006), and other forms of difficulty caused by conflicts and disjunctions between and within the patient’s and the analyst’s subjectivities, has been critical to the development of powerful new understandings and clinical approaches within the Relational paradigm. At the same time, it has given Relational psychoanalysis a pathology-oriented cast—a disproportionate emphasis on what Tolpin (2002) termed “the trailing edge” as opposed to “the forward edge” of the patient’s moment-to-moment states and self-presentation, and the analytic process as a whole. One might glean from the mainstream Relational literature (with many notable exceptions) that the needed analytic relationship is primarily defined as a set of strategies for recognizing, withstanding, and recovering from or transforming enactments and other forms of relational turbulence, rather than a more balanced view in which recognizing and coping with enactments is only part of a broader conception of what our patients need from us in the service of their treatment aims and psychological growth. In my experience, while working with enactments may be one of the hardest parts of analysis (thus warranting the attention they have received), it is not the biggest or, necessarily, the most important part. The concept of needed relationship is intended as a more balanced overall conceptual and therapeutic frame for relational psychoanalysis.

One of the gains from this reorientation is that it sensitizes analytic clinicians to the fact that new, needed therapeutic experiences in analysis have their own complexity and, in many analytic treatments, become more potent and resilient as they become increasingly nuanced and fitted to the unique needs of the patient. If positive or needed experiences are framed principally in terms of emergence from negative or constricting experience (conflicts, enactments and the like), this limits one’s ability to recognize their co-created complexity, especially as they take on a life of their own and evolve over time.

I should say that the distinction I am making here between negative and positive relational experience is an over-simplification in the sense that all analytic interaction is complex and, by its nature, ambiguous (Baranger & Baranger, 1961–1962/2009). Not only is it true that problematic enactments are often accompanied by positive background elements, especially in established, productive analytic relationships, the same interaction can often be both positive and negative (see also Hoffman, 1998). For example, the power struggle described in the case illustration that concludes this chapter could be said to have simultaneous negative and positive elements.

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I agree with Levenson (1972, 1983) that enactment is constant in analysis. I would even say that an analysis, from beginning to end, is essentially a long, complex “developmental enactment” (Orange, 2012) in the sense that it is primarily a lived experience, and that what is transformative is a function of the unique forms of lived experience that analysis potentially offers (co-creates). Where I disagree with Levenson is with the assumption that what is enacted is always a transform of the problems under consideration at the level of verbal inquiry, or even problems of any kind. That is simply not my experience, and I believe that examining analytic interaction through a lens that is biased in the direction of seeing the difficulty, rather than a totality that includes the remedy as well as the difficulty, runs the risk of interfering with an unfolding connectedness (Geist, 2009), thereby potentially retraumatizing the patient in ways that are enactive in the problematic sense.

I would argue that both the nature and the experienced quality of analytic interaction are so entangled with the ways that the analyst is holding, perceiving, interpreting, and participating in the interaction, that Levenson’s (1983) extremely useful question, “What’s going on around here?” (i.e., what is being enacted even as we speak), becomes a Zen-like koan that cannot be answered from any single frame of reference or vertex (Bion, 1962). For example, if I approach the unfolding analytic engagement with the implicit question, “What does the patient need from me?” and am experiencing, and participating in, the analytic exchange through that vertex, the nature of “what’s going on here” must now include whatever effects my participating in this way have on what’s going on. Similarly, if my dominant approach to the ongoing interaction is through the vertex of the question, “What’s going on around here?” this also will have a particular effect on the nature of what is going on.

To state this issue more generally, the question I am raising is how the analyst’s intentional orientation to the process interacts with and affects the unintentional dimensions of the process implied in the question, “What’s going on around here?”—recognizing that the question, “What’s going on around here?” is itself an intentional orientation to the process. My own current solution to the koan is that, while there are extreme, unresolvable paradoxes involved, overall the question, “What does the patient need from me?” is superordinate to the question, “What’s going on around here?” but that part (though by no means all) of what the patient needs from me is to be asking the question, “What’s going on here?” and employing that question to better approach the question of what the patient needs. This hierarchy tilts the analyst’s primary hermeneutic from one of suspicion (Ricoeur, 1970) to one of relatively greater faith or trust (Orange, 2011) in so far as it assumes that, no matter what’s going on, there is always an underlying forward-edge need (Tolpin, 2002) that is being implicitly expressed in whatever is going on.

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Meta-principle and clinical reality

An admittedly elusive concept, the needed analytic relationship has meaning as both a conceptual frame or meta-principle (really, a set of principles—see Introduction) for imagining and doing analytic work, and as a descriptor of actual clinical interaction, either in the present moment of analytic exchange or cumulatively over time. At first blush, it might seem to imply a reified quality, as if one could specify a certain type of needed relationship for a given patient. While it is possible retrospectively to characterize certain patterns of interaction or processes that seem to have been most helpful to a patient over time, the analytic relationship, in fact, unfolds complexly and unpredictably, and simultaneously on different time scales: the present moment, a period of work organized around certain tensions and themes, and cumulatively over the course of treatment from beginning to end (Marks-Tarlow, 2008). Thus, as all analytic clinicians since Freud (1913) have understood, what is needed in a given moment, session, or treatment phase is complex and not specifiable in advance. The analyst is guided by her history with the patient and thus has many implicit understandings or proto-understandings (senses) of what the patient might need from her at a particular time. Moreover, the analyst is always guided implicitly by her idiomatic, evolving integration of the history of psychoanalytic ideas about needed relationships, and in this sense could probably locate her actions in a given moment within, or at least in relation to, this complex, moving, historical-conceptual frame. These senses and conceptual integrations inform what the analyst says and does but are never the whole story because the moment-to-moment, session-to-session interaction presents complex information, evokes constantly shifting meanings, and exerts constantly changing pressures, all of which call for a moment-to-moment improvisational inventiveness (Ogden, 2009).

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One reason I like the concept of needed relationship is its generality and relative theoretical neutrality or emptiness. There is a tendency in psychoanalytic theories of therapeutic action, from at least as far back as Strachey (1934) through the present day, to take a particular therapeutic idea or set of ideas—in Strachey’s case, the idea of mutative transference interpretation—and generalize it to all analytic patients and situations. As discussed in the Introduction, I think of this tendency as mistaking the part for the whole. The meta-theory of needed relationships invites the analyst to draw upon all existing theories of therapeutic action as well as unique, never-previously formulated ideas that might emerge creatively, as these might seem to apply in a given case in a given moment or period of work.

Sander’s theory of progressive fittedness and specificity of recognition

To state this same idea in different language, the concept of needed relationship encourages openness, creativity, and a certain freedom (from established categories of analyst participation) in generating and attempting to fit interventions uniquely to each patient and treatment situation. (See also Bacal, 1998, 2011.) The developmental researcher and theorist, Louis Sander (e.g., 1995, 2002, 2008), proposed the concept of fittedness to describe the result when a good enough parent or therapist meets the child or patient in such a way that some developmental or therapeutic need or aim of the moment is met or accomplished at a new level. The achievement of fittedness involves collaboration and coordination between the two individuals (the parent or therapist doing most of the accommodating) in the service of the child’s or patient’s overall development: especially, in Sander’s view, development of the senses of “wholeness” or “coherence,” and personal agency. There is almost the implication, in Sander’s account, that progressive fittedness is an inherent property of caregiver-and-infant as a complex system (under good enough conditions) such that the two component sub-systems (i.e., parent and infant) spontaneously move in the direction of coordination and fittedness. Listen to his frame-by-frame narrative of, and commentary on, a now often-cited video segment taken of a member of Daniel Stern’s research team—a father holding his baby daughter in his arms—as he is talking informally with other members of the team, standing together on a lawn during a home visit with one of their neonatal subjects:

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. . . one sees the father glance down momentarily at the baby’s face. Strangely enough, in the same frames, the infant looks up at the father’s face. Then the infant’s left arm, which had been hanging down over the father’s left arm, begins to move upward. Miraculously in the same frame, the father’s right arm, which had been hanging down at his right side, begins to move upward. Frame by frame by frame, the baby’s hand and the father’s hand move upward simultaneously. Finally, just as they meet over the baby’s tummy, the baby’s left hand grasps the little finger of the father’s right hand. At that moment, the infant’s eyes close and she falls asleep, while the father continues talking, apparently totally unaware of the little miracle of specificity in time, place, and movement that had taken place in his arms.

Then, commenting on this interaction, Sander wonders:

Are we looking at some principle of wholeness—that is, building on an underlying principle of specificity in time, place, and movement that joins directionalities between component systems—a joining that is necessary to construct coherent wholeness in a “system” that can be said to “live”?

(2008, pp. 221–222)

It is fascinating to consider the possibility that such a dynamic—a tendency toward progressive fittedness—is also operating in the analyst/patient system. But what would such specificity look like in a moment, or more extended period, of analytic treatment with an adult? What would be required between an analyst and an adult patient with a history of developmental trauma to “join their directionalities” in such a way as to “construct coherent wholeness in a ‘system’ that can be said to ‘live’”? Althou...

Table of contents

• Cover Page
• Praise
• Needed Relationships and Psychoanalytic Healing
• Psychoanalysis in a New Key Book Series
• Title
• Copyright
• Dedication
• Contents
• Preface by Donna M. Orange
• Acknowledgments
• Introduction: An Orienting Principle for Relational Psychoanalysis
• 1 Needed Relationships and Psychoanalytic Healing
• 2 Complexity Made Simple; Simplicity Made Complex
• 3 Fittedness and Its Vicissitudes
• 4 the Tendency Toward Fittedness and the Forward Edge of the Relational Unconscious
• 5 Understanding and Engagement in the Analytic Process
• 6 the Dialectic of Empathy and Freedom
• 7 the Conundrum of Self-Care
• 8 Analytic Peace
• Appendix: The forward edge of the Relational Unconscious: A Theoretical Comparison
• Bibliography
• Index