Object Relations and Intersubjective Theories in the Practice of Psychotherapy

Bruce Brodie

• Publisher: Routledge
• Year: 2019
• Print ISBN: 9780367428792
• eBook ISBN: 9781000051070
• Edition: 1
• Topic: Psychology
• Subtopic: Mental Health in Psychology
• Index: Psychology

The evolution of psychoanalytic/psychodynamic psychotherapy has been marked by an increasing disconnect between theory and technique. This book re-establishes a bridge between the two. In presenting a clear explanation of modern psychodynamic theory and concepts, and an abundance of clinical illustrations, Brodie shows how every aspect of psychodynamic therapy is determined by current psychodynamic theory.

In Object Relations and Intersubjective Theories in the Practice of Psychotherapy, Brodie uses the theoretical foundation of the work of object relations theorist D.W. Winnicott, showing how each of his developmental concepts have clear implications for psychodynamic treatment, and builds on the contributions of current intersubjective theorists Thomas Ogden and Jessica Benjamin. Added to this is Brodie's vast array of clinical material, ranging from delinquent adolescents to high-functioning adults, and drawing on nearly 40 years of experience in psychotherapy. These contributions are fresh and original, and crucially demonstrate how clinical technique is informed by theory and how theory can be illuminated by clinical material.

Written with clarity and detail, this book will appeal to graduate students in psychology and psychotherapy, medical residents in psychiatry, and young, practicing psychotherapists who wish to fully explore why psychotherapists do what they do, and the dialectical relationship between theory and technique that informs their work.

Part I
The psychological birth of the infant

1 The holding environment

Commencing a semi-developmental structuring of this book, Chapter 1 reexamines Winnicott’s concept of the holding environment in terms of both the mother/infant and the therapist/client relationships. The holding environment is commonly thought of as a unidirectional communication: the mother/therapist communicating safety and caring to the infant/ client. I argue that Winnicott actually presented a two-way communication model wherein both the mother/therapist and the infant/client communicate to the other and, in doing so, learn about themselves. As such, the holding environment becomes not a precursor to therapy but a prototype of therapy.

Winnicott’s term “holding environment” has become a buzzword in psychotherapy theory. Like all buzzwords, it has lost, through overuse, much of the power of its original meaning and it is well worth reexamining the concept. The term “holding” is both highly symbolic and fundamentally concrete. The original holding environment is the mother’s (or mother-substitute’s) arms. It is through the mother’s arms that the infant first learns about itself and the world. The infant does not focus visually for the first week of life, nor does it appear to make much sense of sounds (with the exception of the startle response to sudden, loud noises). But infants appear to be exceptionally sensitive to the way they are held. By the way she holds her neonate an anxious mother will communicate to her baby that the world is a dangerous place. So too will a depressed mother convey to her infant the world’s (her) indifference. And likewise will a secure, loving mother let her baby know that he or she is safe and cared for.

This is not simply a matter of holding a child firmly. It involves the mother’s intuiting the baby’s humanness, its sensitivities, and its needs, and responding appropriately. How does the baby want to be held? What feels good to the baby and what does not? What degree of firmness is too much and what degree is too little? It is the mother trying immediately to discover who this baby is (as opposed to all the other babies in the world) and to respond accordingly. Holding does not refer simply to the way the arms of the mother hold the infant. It refers to the way the arms of the mother probe the infant, seeking to discover who it is, so that they can respond to its idiosyncratic needs. Winnicott (1960a) says that this kind of mothering cannot be taught. It is intuitive and is based on the mother’s cellular memories of her own infancy. Classroom-taught mothering is, at this stage, robotic and inadequate.

What does the infant learn in this early holding environment? It learns (hopefully) that it is safe (that its mother protects it) and that it is loved (that its mother loves it). But far more important, says Winnicott, the infant begins to learn who he or she is, what feels good and what feels bad, what satisfies and what frustrates, what frightens and what soothes. It is the beginning of the discovery of what Winnicott calls the True Self, of a sense of who I really am and what makes me similar to and different from every other person on the planet, of what makes me feel real and alive.

Winnicott (1960a) emphasizes the mother’s intuition, her ability to access the cellular memory of her own infancy, her ability to project herself into her infant and discover what she would want (feel like, be afraid of ) were she in her infant’s skin. But it is also clear that Winnicott does not envision the holding environment as a one-directional system involving an active, observing subject-mother and a passive, observed object-infant. Winnicott emphasizes a nonverbal, dialectical dialog between mother and infant. It is the mother using her arms not just as a kind of “mouth” to inform her infant but as “ears” with which to hear her infant’s preverbal communications.

The holding environment starts out concretely as the mother’s arms but quickly expands into a whole range of factors that symbolically equate to the way the world “holds” the infant, the child. There are myriads of ways the environment can respond to, or fail to respond to, the infant’s True Self. Is the infant fed when it cries (feels hunger) or by the clock? Does the infant learn about satiation by feeling full or is it told that it has eaten enough? Is it picked up when it needs comfort or allowed to cry for fear of being “spoiled?”

So what?

There is much current discussion over the appropriateness of hugging in the therapy session. Even therapists who are comfortable giving hugs to their clients tend to do so judiciously and infrequently. Yet the holding environment in the therapeutic setting, like the maternal holding environment, has its roots in the physical. Midway through my own therapy I began to notice how important it was to me to shake my therapist’s hand at the end of each session. I brought this up to him with some hesitation, expecting, as he was a fairly orthodox Freudian, some interpretation in terms of “latent homosexual tendencies.” Instead, he simply shrugged his shoulders and nonchalantly said, “Of course! Physical contact!”

The holding environment in the therapy session, like the maternal holding environment, tries to establish an aura of safety and caring. Early discussions about confidentiality, the adoption of a non-judgmental manner, nodding, smiling, (the warmth of a handshake), all contribute to a feeling in the client of being safe and cared for. Aspects of what is often referred to as “the frame” also contribute to feelings of safety and concern. Charging a client for a missed appointment is best explained as being done (in part) in the client’s best interest: “That hour is reserved for you, whether you use it or not. It is yours and yours alone.” The fairly strict policy of ending the sessions on time also contributes to the safety of the holding environment: “No,” the message is, “you may have unconscious fantasies of devouring me with your unfathomable neediness, but I can take care of myself. In not allowing you to devour me I will remain present to meet your needs.”

But again, as with Winnicott’s original concept, the idea of the therapeutic holding environment goes far beyond safety and caring. It involves providing an environment in which each client can discover himself or herself. If I have at 9:00 a client, Sally, who was sexually abused for years by a stepfather and who feels for me a mixture of longing and loathing, attraction and disgust, a desire to crawl into my lap and an urge to rip my testicles off, and if I have at 10:00 a client, Tom, who was raised by a single mother and who sees me as being unreal, “like somebody from a television program,” then it is incumbent on me not just to remember that these are two very different people but to remember also that each needs something very different from me: a different kind of holding. How much I smile, how much I introduce my own material into the session, how much eye contact I maintain, even how often I nod, all of this has to be determined by who the client is and what his or her needs are. As with Winnicott’s mothering, this, I believe, cannot be taught. To try and teach a therapist how to act with certain types of clients is to teach a programmed response that is inevitably artificial and inhuman. It is teaching to treat the diagnosis instead of the client. Irvin Yalom (1997, 2002) virtually shouts out his credo, “Create a new therapy for each patient!” I believe this is part of what he is talking about.

Programmed, by-the-book holding is like being held by a robot. It does not facilitate true feelings of safety or trust, nor does it enhance self-awareness. It is never helpful and, at times, it is disastrous.

A client came in for treatment following the breakup of a relationship. It was not, he hastened to explain, the breakup itself that was upsetting to him, but rather that it was the young woman who had left him. “It’s not supposed to be that way. I am the one who is supposed to leave them.” I struggled to find a way of being helpful to him in that first session. I was appalled by the callousness with which he used other people. But I felt compelled to offer him some modicum of “support.” I tried to speak empathically, offering some sympathy and understanding for the injury he had sustained and the resulting “disintegration of self” (Kohut, 1971).

The following week he returned to my office but, he said, for the sole purpose of telling me how enraged he was at me. He had left my office swearing to himself that he would never return, but had then decided to come back just so that he could tell me what a horrible therapist I was. I had made him feel “like a pathetic whiner,” and he had been sputtering with rage towards me for the entire week.

Clearly, my attempt to “hold” this client had failed. In my desperation to provide some kind of empathic response (an empathy I did not feel), I reached for a textbook response and failed miserably.

Winnicott’s holding environment is not just a model for the identification and recognition of infantile (inarticulate) needs. It is also the vehicle through which many of those needs are met. So what does it mean to “meet our clients’ needs”? There is an ancient (and by now somewhat tedious) debate within the psychoanalytic dialog, dating back at the very least to the Freud-Ferenczi disagreements of the early 1920s, on the appropriateness of the therapist (psychoanalyst) meeting the client’s (patient’s) needs. Winnicott’s (1960b) solution is to distinguish between different kinds of needs. Using the Freudian jargon that still dominated the field, Winnicott differentiated between what he called “id needs” from those he termed “ego needs.” Id needs are those relating to drives or instincts. They are essentially physical needs such as the needs for food, liquid, (physical) warmth, and sex (in all its Freudian permutations). Ego needs are the needs of the ego for its full development. They include such needs as the need to be seen, recognized, and appreciated as well as the opposing needs for privacy and secrecy; the need for object relatedness and its opposite need for solitude and aloneness; the need for novelty or new experience as well as the contrary need for familiarity and security. Winnicott’s rule of thumb is simple: id needs should never be gratified in psychotherapy; ego needs should always be.

What does this look like in therapy? Let me start with a very simple example.

A client of mine had been working on the horribly inadequate mothering she had received from her severely alcoholic mother and on the paucity of nurturing figures in her present life. In the middle of a session she suddenly blurted out, “You know what I want? I just want somebody to feed me. I’m sick of cooking all my own meals.” This client had a very strong maternal transference towards me and I, in return, was aware of a powerful complementary countertransference. So I was not surprised when, upon hearing her wish, I suddenly had a vivid fantasy of greeting her in our next session with a huge submarine sandwich.

I, of course, thought better of this and did no such thing. Instead, however, I told her of my fantasy. To have actually brought her a sub would have been to have completely missed the point. Because it was not her body (id) that she wanted nourished, it was her ego. She had not been starved for food in her childhood. She had been starved for attention, love, and validation. And in sharing my fantasy with her I was nurturing her ego by giving her something from my own ego (imagination). I was not giving her milk from my breasts. She hadn’t really been asking for that. Nor was I giving her my penis (the phallic shape of the submarine sandwich in my fantasy did not escape my notice). I was giving her a counter-fantasy to her fantasy. I was letting her know not only that I recognized, understood, and validated her needs, but that I responded to them with an emotional reaction of my own, one that was completely complementary to hers.

A second example was much more difficult, both for me and for my client.

I had spent some time trying to work with a client with severe abandonment issues around my upcoming three-week vacation. “It’s alright,” she had said, “neither of my parents came back. I know that you are coming back.” But when I came back it was not alright. It took weeks for her to work through her rage at me. At one point she reported a fantasy of stabbing me with a knife.

The “id” (physical) aspects of her reaction were clear. There was her murderous aggression (granted, it was reactive rage rather than instinctual aggression. Still, her fantasy was very physical). And the rage was in reaction to a very primitive equating of abandonment with destruction and annihilation. She had felt like a baby antelope on the savanna, abandoned by its mother to a world of lions and jackals.

I was aware of two brief impulses to respond directly to her id issues. To her rage and aggression, I had the impulse to become her whipping boy, to say, “Oh my god! I’m so sorry to have caused you so much pain.” To her abandonment issues I was tempted to sooth and reassure her: “Don’t worry! I rarely take vacations this long. It won’t happen again for a long time.” Both of these impulses would not only have been inappropriate, both would have been inaccurate: they would have missed the mark. I did not, after all, cause her pain. My actions triggered some pain that had been buried deep inside of her since her early childhood. I had not stabbed her. I had inadvertently lanced a long-festering boil. To have responded as though I had caused the pain (that the pain was about me) would have been to miss the essential nature of the pain.

Instead of saying either of these things, I listened. I listened as intensely and as empathically as I could. I tried to put myself inside her and to feel for myself (as much as I could) the terror and the pain that underlay her rage. I made no apologies and no promises. I did not allow myself to become defensive or to counterattack. I simply tried as hard as I could to find, appreciate, and feel the pain and the terror that had been triggered and to communicate that understanding to my client. In processing this, weeks later, my client was able to confirm that this was exactly what she had needed.

Another example:

Jasmine, a client in her early twenties, had been sexually abused when she was seven by a friend of her grandparents (who probably would have been the age I was when I was treating her). When she finally felt comfortable enough with me to give me details about the event, I was struck not by the vileness of the molestation itself (some inappropriate touching) but by the terror evoked by his subsequent threats in his attempt to silence her. I had an image of a small child terrorized by a creature twice her size. In a certain way, to young children all adults are giants. But this had been a rampaging, threatening, out-of-control giant.

By our second year of therapy her fondness for me had grown considerably, and her fear of me had diminished. But they were still pretty evenly counterbalanced. In one session she was talking wistfully about how much safer she felt around women than around men. “That includes me,” I offered neutrally. “Yes,” she replied with a rare direct (and somewhat defiant) glance, “You are a man.”

Now this young woman wanted desperately to be able to trust me, as she wanted to be able to trust all men. And I, on my part, always find it gratifying to be trusted. But rather than attempt to directly satisfy an id need (the need for physical security), I chose to speak to an ego need, the need to be seen. “I’m not just a man,” I said, “I’m a very big man” (I am six-feet-four and my client was nearly a foot shorter than I) and I proceeded to share with her the impression I had had when she first told me about the assault.

My client reacted to my intervention the way clients tend to when they feel seen. She smiled with gratitude and she physically relaxed. She also spontaneously produced the insight that she never dated men taller than herself. Ironically, my effort to make her feel seen allowed her to feel more secure.

Before moving on I would like to reiterate that “holding” is not just informing the client (or infant) that the environment (world) is safe, accepting, and loving. It is equally learning from the client (infant) what feels safe, what needs accepting, what feels loving. Holding involves finding out from the client whether love is a good thing or a bad. Holding is definitely not always desired. One client told me that for him receiving love felt like “being suffocated.”

For Hester proper holding initially meant not being touched. It is difficult to imagine what kind of holding Hester received as an infant from her mother. When Hester was 18 she went to a psychiatrist and was placed on antidepressant medications. After some months of little improvement, she overdosed on her remaining pills and, in a desperate attempt to reach out, told her mother what she had just done. Her mother looked at her and said, “This therapy thing doesn’t seem to be working. Maybe you should stop,” and turned her back and walked away. This was not a warm, loving mother.

When Hester came into therapy with me in her late twenties she was severely depressed and severely withdrawn. A self-described misanthrope, she had no friends and professed not to like people. Whenever I saw her the refrain from one of Kipling’s Just So Stories came to my mind, “I am the cat that walks alone. All places are the same to me.”

But Hester wasn’t a cat. Cats like to be held when they choose to be held. Hester did not want to be touched. So the metaphor that I kept in mind working with Hester was not a cat but a chipmunk – the kind I had seen as a child while vacationing in the mountains. As a child I was taught that if you squatted down near a chipmunk with a peanut in your hand, arm extended, and if you were very patient and...

Table of contents

• Cover
• Half Title
• Title
• Copyright
• Dedication
• Contents
• Acknowledgments
• Preface
• Introduction
• Part I The psychological birth of the infant
• Part II The paranoid-schizoid position and internal objects
• Part III The depressive position, intersubjectivity, and the discovery of external objects
• Bibliography
• Index