Psychoanalytic Treatment

An Intersubjective Approach

Robert D. Stolorow, Bernard Brandchaft, George E. Atwood

• Publisher: Routledge
• Year: 2014
• ISBN:
  9781317771678
• Edition: 1
• Topic: Psychology
• Subtopic: Applied Psychology
• Index: Psychology

Psychoanalytic Treatment: An Intersubjective Approach fleshes out the implications for psychoanalytic understanding and treatment of adopting a consistently intersubjective perspective. In the course of the study, the intersubjective viewpoint is demonstrated to illuminate a wide array of clinical phenomena, including transference and resistance, conflict formation, therapeutic action, affective and self development, and borderline and psychotic states. As a consequence, the authors demonstrate that an intersubjective approach greatly facilitates empathic access to the patient's subjective world and, in the same measure, greatly enhances the scope and therapeutic effectiveness of psychoanalysis. Psychoanalytic Treatment is another step in the ongoing development of intersubjectivity theory, as born out in Structures of Subjectivity (1984), Contexts of Being (1992), and Working Intersubjectively (1997), all published by the Analytic Press

1

Principles of Psychoanalytic Exploration

The essentials of an intersubjective approach to psychoanalysis were defined in our¹ earlier book (Atwood and Stolorow, 1984), Structures of Subjectivity:

In its most general form, our thesis … is that psychoanalysis seeks to illuminate phenomena that emerge within a specific psychological field constituted by the intersection of two subjectivities–that of the patient and that of the analyst….[Psychoanalysis is pictured here as a science of the intersubjective, focused on the interplay between the differently organized subjective worlds of the observer and the observed. The observational stance is always one within, rather than outside, the intersubjective field…being observed, a fact that guarantees the centrality of introspection and empathy as the methods of observation….Psychoanalysis is unique among the sciences in that the observer is also the observed … [pp. 41–42].

[C]linical phenomena … cannot be understood apart from the intersubjective contexts in which they take form. Patient and analyst together form an indissoluble psychological system, and it is this system that constitutes the empirical domain of psychoanalytic inquiry [p. 64].

The intersubjectivity principle was applied to the developmental system as well:

[B]oth psychological development and pathogenesis are best conceptualized in terms of the specific intersubjective contexts that shape the developmental process and that facilitate or obstruct the child's negotiation of critical developmental tasks and successful passage through developmental phases. The observational focus is the evolving psychological field constituted by the interplay between the differently organized subjectivities of child and caretakers … [p. 65].

It is our central aim in the present book to flesh out the implications for psychoanalytic understanding and treatment of adopting a consistently intersubjective perspective. In the course of this study, the intersubjective viewpoint will be shown to illuminate a wide array of clinical phenomena, including transference and resistance, conflict formation, therapeutic action, affective and self development, and borderline and psychotic states. Most important, we hope to demonstrate that an intersubjective approach greatly facilitates empathic access to the patient's subjective world and, in the same measure, greatly enhances the scope and therapeutic effectiveness of psychoanalysis.

The concept of intersubjectivity has evolved in our thinking through a series of stages. The significance of the intersubjective perspective first became apparent to us in a study of the interplay between transference and countertransference in psychoanalytic therapy (Stolorow, Atwood, and Ross, 1978). There we considered the impact on the treatment process of phenomena arising out of the correspondences and disparities that exist between the analyst's and the patient's respective worlds of experience. An attempt was made in particular to characterize the conditions under which such phenomena may obstruct or facilitate the unfolding of the psychoanalytic dialogue. At this early stage we already were focusing on interactions between patients' and therapists' subjective worlds, but the more general concept of the intersubjective field within which psychoanalytic therapy takes place had not yet been articulated.

We then were led to an investigation of the situation that arises in treatment when there is a wide but unrecognized disparity between the relatively structured world of the analyst and an archaically organized personal universe of the patient (Stolorow, Brandchaft, and Atwood, 1983). Such a disjunction, we showed, often results in chronic misunderstandings wherein the archaic experiences communicated by the patient cannot be comprehended because of the analyst's unconscious assimilation of them to his own, differently organized subjectivity. The analyst's responses may then be experienced as grossly unattuned, precipitating a spiral of reaction and counterreaction that is incomprehensible to both parties. When the analyst fails to decenter from the structures of experience into which he has been assimilating his patient's communications, the final result is a view of the patient as an intrinsically difficult, recalcitrant person whose qualities perhaps render him unsuitable for psychoanalytic treatment. We thus had begun to understand in a very specific context how the analyst's picture of the patient's attributes crystallizes within the interplay between two personal universes.

A subsequent application of this kind of analysis to the so-called borderline personality appeared in a paper (Brandchaft and Stolorow, 1984) that forms the basis of chapter 8 in the present book. The earlier work offered a critique of the view that corresponding to the term “borderline” there is a discrete, stable, pathological character structure rooted in internal instinctual conflicts and primitive defenses. The clinical observations often cited as indicative of such defenses and conflicts were shown to be evidence of needs for specific archaic selfobject ties and of disturbances in such ties. The defining features of borderline conditions were thereby disclosed as products of a specific intersubjective situation. When a shift in this situation occurs whereby the needed understanding is felt to be present, the borderline features tend to recede and even disappear, only to return when the selfobject bond is again significantly disrupted. At that point we had recognized how the context of relatedness established between analyst and patient plays a constitutive role in forming and maintaining the particular psychopathological configuration that is designated by the term “borderline.”

The intersubjectivity concept is in part a response to the unfortunate tendency of classical analysis to view pathology in terms of processes and mechanisms located solely within the patient. Such an isolating focus fails to do justice to each individual's irreducible engagement with other human beings and blinds the clinician to the profound ways in which he is himself implicated in the clinical phenomena he observes and seeks to treat. We have now come to believe that the intersubjective context has a constitutive role in all forms of psychopathology, ranging from the psychoneurotic to the overtly psychotic. This role is most readily demonstrated in the most severe disorders, wherein fluctuations in the therapeutic bond are accompanied by dramatically observable effects. In chapter 9, we offer a conceptualization of psychotic states from this point of view, with emphasis on failures of archaic selfobject ties in the specific function of validation of perception. The intersubjective context is of equal significance, however, in less severe forms of psychopathology, for example, in anxiety neuroses, depressions, and obsessional and phobic disorders. The exploration of the particular patterns of intersubjective transaction involved in developing and maintaining each of the various forms of psychopathology is in our view one of the most important areas for continuing clinical psychoanalytic research.

PSYCHOANALYTIC KNOWING AND REALITY

A basic and largely unchallenged philosophical assumption that has pervaded psychoanalytic thought since its inception is the existence of an “objective reality” that can be known by the analyst and eventually by the patient. This assumption lies at the heart of the traditional view of transference, initially described by Breuer and Freud (1893–95) as a “false connection” made by the patient and later conceived as a “distortion” of the analyst's “real” qualities that analysis seeks to correct (Stein, 1966). Schwaber (1983) has argued persuasively against this notion of transference as distortion because of its embeddedness in “a hierarchically ordered two-reality view” (p. 383)–one reality experienced by the patient and the other “known” by the analyst to be more objectively true.

A fundamental assumption that has guided our work is that the only reality relevant and accessible to psychoanalytic inquiry (that is, to empathy and introspection) is subjective reality–that of the patient, that of the analyst, and the psychological field created by the interplay between the two. From this perspective, the concept of an objective reality is an instance of the ubiquitous psychological process that we have termed “concretization”–the symbolic transformation of configurations of subjective experience into events and entities that are believed to be objectively perceived and known (Atwood and Stolorow, 1984, ch. 4). Attributions of objective reality, in other words, are concretizations of subjective truth. Analysts' invoking the concept of objective reality, along with its corollary concept of distortion, obscures the subjective reality encoded in the patient's productions, which is precisely what psychoanalytic investigation should seek to illuminate.

A good example of this obscuring effect can be found in the persisting controversy over the role of actual childhood seduction versus infantile fantasy in the genesis of hysteria. What proponents of both of the opposing positions on this issue fail to recognize is that the images of seduction, regardless of whether they derive from memories of actual events or from fantasy constructions, contain symbolic encapsulations of critical, pathogenic features of the patient's early subjective reality.

Our view of the nature of psychoanalytic investigation and knowledge differs sharply from those of a number of other authors who, like ourselves, have been significantly influenced by Kohut's empathic-introspective psychology of the self. Wolf (1983), for example, proposes that “we oscillate between extrospective and introspective modes of gathering data” (p. 685), observing sometimes from outside and sometimes from within the patient's own subjective world. Shane and Shane (1986) argue that psychoanalytic understanding derives not only from the subjective world of the patient and the intersubjective experiences in the analytic situation, but also from “the objective knowledge possessed by the analyst of the patient's life and of human development and human psychological functioning” (p. 148). And Basch (1986) contends that psychoanalytic explanations must be grounded in experimentally validated, objectively obtained knowledge of brain functioning.

In contrast with these views, our own perspective incorporates and seeks to push to its limits Kohut's (1959) proposition that the empirical and theoretical domains of psychoanalysis are defined and demarcated by its investigatory stance of empathy and introspection. Accordingly, anything that is not in principle accessible to empathy and introspection does not properly fall within the bounds of psychoanalytic inquiry.

Thus, unlike Wolf (1983) we hold that psychoanalytic investigation is always from a perspective within a subjective world (the patient's or analyst's); it is always empathic or introspective. When an analyst reverts to experience-distant formulations (a frequent, inevitable, and often countertransference-motivated occurrence), or insists that his formulations possess objective truth, he is not operating in a psychoanalytic mode, and it is essential for the analyst to consider the impact of this shift in perspective on the analytic dialogue.

Unlike Shane and Shane (1986), we do not believe that the analyst possesses any “objective” knowledge of the patient's life or of human development and human psychological functioning. What the analyst possesses is a subjective frame of reference of his own, deriving from a multiplicity of sources and formative experiences, through which he attempts to organize the analytic data into a set of coherent themes and interrelationships. The analyst's frame of reference must not be elevated to the status of objective fact. Indeed, it is essential that analysts continually strive to expand their reflective awareness of their own unconscious organizing principles, including especially those enshrined in their “objective knowledge” and theories, so that the impact of these principles on the analytic process can be recognized and itself become a focus of analytic investigation.

In light of the foregoing discussion, it will come as no surprise that we are in fundamental disagreement with Basch's (1986) belief that psychoanalytic explanations must be grounded in a knowledge of brain functioning. We contend that brain functioning does not even fall within the domain of psychoanalysis, because it is inaccessible, in practice and in principle, to the empathic-introspective method of investigation. It is our view that psychoanalytic theory should, at all levels of abstraction and generality, remain within the realm of the experience-near. To that end, we have attempted to develop guiding explanatory constructs–such as the concept of an intersubjective field–uniquely appropriate to the empathic-introspective mode of inquiry. These constructs are concerned with organizations of subjective experience, their meanings, their origins, their mutual interplay, and their therapeutic transformation.

Goldberg (1985) has described a long-standing tension in psychoanalysis between realism, subjectivism, and relativism. That we place ourselves squarely within a subjectivist and relativist tradition is readily apparent from passages in Structures of Subjectivity (Atwood and Stolorow, 1984) that elucidate our conception of psychoanalytic understanding:

The development of psychoanalytic understanding may be conceptualized as an intersubjective process involving a dialogue between two personal universes…. The actual conduct of a psychoanalytic case study comprises a series of empathic inferences into the structure of an individual's subjective life, alternating and interacting with the analyst's acts of reflection upon the involvement of his own personal reality in the ongoing investigation [p. 5].

The varied patterns of meaning that emerge in psychoanalytic research are brought to light within a specific psychological field located at the point of intersection of two subjectivities. Because the dimensions and boundaries of this field are intersubjective in nature, the interpretive conclusions of every case study must, in a very profound sense, be understood as relative to the intersubjective context of their origin. The intersubjective field of a case study is generated by the interplay between transference and countertransference; it is the environment or “analytic space”…in which the various hypotheses of the study crystallize, and it defines the horizons of meaning within which the truth-value of the final interpretations is determined. An appreciation of this dependence of psychoanalytic insight on a particular intersubjective interaction helps us to understand why the results of a case study may vary as a function of the person conducting it. Such variation, an anathema to the natural sciences, occurs because of the diverse perspectives of different investigators on material displaying an inherent plurality of meanings [p. 6].

Thus, the reality that crystallizes in the course of psychoanalytic treatment is an intersubjective reality. This reality is not “discovered” or “recovered,” as is implied in Freud's (1913) archeological metaphor for the analytic process. Nor, however, would it be entirely accurate to say that it is “created” or “constructed,” as some authors have claimed (Hartmann, 1939; Schafer, 1980; Spence, 1982). Rather, subjective reality becomes articulated through a process of empathic resonance. The patient comes to analysis with a system of developmentally preformed meanings and organizing principles, but the patterning and thematizing of his subjective life is prereflectively unconscious (Atwood and Stolorow, 1984, ch. 1). This unconscious organizing activity is lifted into awareness through an intersubjective dialogue to which the analyst contributes his empathic understanding. To say that subjective reality is articulated, rather than discovered or created, not only acknowledges the contribution of the analyst's empathic attunement and interpretations in bringing these prereflective structures of experience into awareness. It also takes into account the shaping of this reality by the analyst's organizing activity, because it is the analyst's psychological structures that delimit and circumscribe his capacity for specific empathic resonance. Thus analytic reality is “old” in the sense that it existed before as an unarticulated potential, but it is also “new” in the sense that, prior to its entrance into an empathic dialogue, it had never been experienced in the particular articulated form that comes into being through the analytic process.

We agree with Schwaber (1983) that what the analyst “knows...