Phenomenology, Uncertainty, and Care in the Therapeutic Encounter

Mark Leffert

• Publisher: Routledge
• Year: 2015
• eBook ISBN: 9781317479321
• Topic: Psychology
• Subtopic: Mental Health in Psychology
• Index: Psychology

Phenomenology, Uncertainty and Care in the Therapeutic Encounter is the latest in a series of books where Mark Leffert explores the therapeutic encounter as both process and situation; looking for evidence of therapeutic effectiveness rather than accepting existing psychoanalytic concepts of theory or cure without question.

Mark Leffert focuses on the uncomfortable fact that analysts and therapists can and do make many mistaken assumptions and false moves within their clinical practice, and that there is a tendency to ignore the significant levels of uncertainty in what they do. Beginning with a discussion of the phenomenology of the self and its relations with the world, the book moves on to explore the notion that interdisciplinary discourse both opens up possibilities in the therapeutic encounter but also imposes healthy constraints on what can be thought or theorized about psychoanalytically.

Phenomenology, Uncertainty and Care in the Therapeutic Encounter contributes a new understanding of familiar material and brings a new focus to the care-giving and healing aspects of psychoanalysis and psychotherapy leading to a shift in the analyst's identity from that of one who analyses to one who cares for and heals. This book will be of interest to Psychoanalysts and psychotherapists, neuroscientists and academics in the fields of psychiatry, comparative literature and literature and the mind.

1 The self and its contexts

DOI: 10.4324/9781315707266-2

Introduction

William James (1893/2007), for perhaps the first time in modern psychology, offered an expansive definition of the conscious, empirical self as “the sum total of all that [a man] CAN call his.” He went on to include in this total “not only his body and his psychic powers, but his clothes and his house, his wife and children, his ancestors and friends, his reputation and works, his lands and horses, and yacht and bank account” (p. 291). James had, rather shockingly for the times, and still not seen all that much today, offered up a post-Cartesian definition of the self, whose essence is that of a social and physical creature, inseparable from its social matrix.

Taking the first of several narrative turns, in 1987 (one of two years in which the Minnesota Twins ultimately won the World Series), I went to a playoff game with my family at the Hubert H. Humphrey Stadium. Sitting halfway up behind the third base line, I looked across the stadium and saw a band of people, perhaps ten seats wide, begin to stand up and then sit down, moving clockwise (perhaps that’s why clockwise is clockwise) around the stadium. When this phenomenon, a so-called human wave, reached me, I stood up and sat down as well, feeling at once free, happy, and not at all in control of my actions. If you knew me, you would know just how odd this was.

The question we have to ultimately concern ourselves with is how these two ways of being – ontologies of being, if you will – can approach each other. We are already beyond the post-Cartesian critique of the self-in-isolation that still characterizes some of current (as opposed to Contemporary) and all of past psychoanalysis. James (1893/2007) had leapt past this critique even as Freud succumbed to a theory of the analysis of an intrapsychic self that only responded defensively to impingements upon it and later became only an element of a psychic structure dealing with other internal structures (objects as mental representations). What we are about here is first to flesh out and set in context James’s definition of what constitutes a self, and second to consider the nature of human waves in Network Studies and neuroscience terms along the lines that I have previously suggested (Leffert, 2013).

Psychoanalysis has not as yet approached the gap between the self and human waves;¹ indeed, it has been treated as one of Lyotard’s (1983/1988)différends: conflicts between parties with such radically differing epistemologies that no agreement – even in how to resolve their differences – is possible. These differences include, among others, the nature of therapeutic discourse and its contents, dialogue, accessibility to consciousness, neuroscience, hermeneutics, and network studies. I will posit that instead of différends what we are dealing with is a matter of différance (Derrida, 1978, 1972/1982), in which the two strands – one of selves, the other of human waves – remain but are braided together in a kind of sheaf, distinct autres, always in relation to one another.

¹ This is as true for the Relational and Intersubjective schools as it is for the Freudians and Kleinians.

The world of clinical psychoanalysis should be a world of selves and their overlapping social networks. It is not. It is a world much taken up with theory; it should not be. There is little agreement among diverse authors concerning the nature and location of the self and, despite the appearance of the new science of Network Studies (Barabási, 2003, 2005; Christakis & Fowler, 2009), as yet little understanding of the nature of the bonds between individual selves that form these networks. Instead, psychoanalysts and psychotherapists² usually consider social relationships in terms of relational dyads (attachment pairs, analytic couples) or, at most, triads. New developments in the neurosciences should be taking up more of our time as they relate to clinical psychoanalysis. Since I last wrote on these subjects (Leffert, 2013), neuroscience and Network Studies have begun to approach each other, recognize that each has much to offer the other, and start to exchange information (Sporns, 2011). A new, very fast form of functional brain imaging, diffusion tensor imaging (DTI) (Assaf & Pasternak, 2008; Le Bihan et al., 2001), shows a promise of being able to map changes in the brain in response to its activities in real time. In addition to what all of these approaches will tell us about the self, they will also put therapists who prefer to think hermeneutically about their patients³ under increasing pressure.

² I find the distinction between psychoanalysts and psychodynamically oriented psychotherapists of little practical merit, in that whatever particular clinical procedures we may be talking about, we will find some members of both groups carrying it out. ³ Throughout this book, I use the term patient to refer to the people that come to see me for help. I do so only in part because, as a physician, I grew up with the term. But far more important to me is that it refers to people who come to us for help and healing, concepts that will recur in the chapters ahead. Client seems (to me at least) cooler and distant from healing and care. My only regret is that contemporary clinicians with other degrees are not trained to use it. However, it is worth noting that both Rollo May (1958b) and Ella Freeman Sharpe (1950/1968), the gifted second-generation psychoanalyst who was originally trained as an English professor, both use the term patient to refer to the people they treated.

The self

Heinz Kohut (1977, 1984) introduced contemporary American psychoanalysts and psychotherapists to the idea of a depth psychology of the “tragic man” (1977, p. 132), manifesting a damaged self and impaired selfobjects, existing beside the older, more usual psychoanalytic depth psychology of the “guilty man” (p. 132), beset with anxiety. The former involved a self that was, perforce, located within the psychic apparatus, while the latter involved a psychic apparatus taken up with isolated drives whose expression was inhibited by intrapsychic conflict. Kohut’s healthy self is a continuous self; discontinuity involves fragmentation and should always be guarded against. This danger, he said, led him to terminate the second analysis of “Mr. Z” (Kohut, 1979). Kohut had chosen, in effect, to mount a conservative critique of ego psychology and libido theory, perhaps in the hope that traditionally minded psychoanalysts would find it more palatable. But what if he was wrong about all of that except for the central importance of the self?

I would argue first, as I have in the past (Leffert, 2010, 2013), that what Kohut terms “depth psychologies,” and I call competing schools of metapsychology, represent collections of artificial and unstable constructs operating as closed systems, unsupported by direct observation and unable to survive deconstruction. In keeping with this view, Roy Schafer (1979), in a not recent paper cited only eight times in our literature, observes procedurally that “what makes each school a school is its having a substantial body of literature and eminent members who make persuasive claims as to their special vision of the psychoanalytic truth and the results to be obtained by those who share this vision” (p. 346). Truth does seem to be in the eye of the beholder and in no way guaranteed by its partisan connections. There are many thoughtful and sensitive clinicians in our field who have had important and clinically useful ideas, but to make these into metapsychologies at the pinnacle of truth only offers constructs that beg for subsequent deconstruction.

Second, along with James (1893/2007), I would contend that the self is not simply a psychical structure, cannot be just a psychic structure;⁴ just what it is we will discuss shortly. Third, selfobjects are also constructs, and the real self as opposed to the constructed self is, or attempts to be, very much taken up with objects in the external world, not their internal representations. Finally, tragic man (or woman) and guilty man are, to the extent that they exist, existential states of the self, not representatives of competing metapsychological doctrines.

⁴ I’m getting ahead of myself here, but that would make it a self-representation.

When we try to get a fix on the self in order to talk about it, we find psychoanalytic authors (as well as neuroscientists and philosophers) in a jumbled confusion of self, selves, bodies, and self-representations. As if that weren’t enough, there are more problems. Experientially, most of the self is wrapped up with consciousness and has been with us in that capacity for a very long time. Then there is the problem of the relations of the self with its world. This too is complicated by the fact that we mostly experience ourselves autocentrically (Schachtel, 1959) as quite separate from others and unique, since our experience of other selves is different. Sullivan (1938/1971a, 1950/1971b), in an oft-referenced comment, observes that any such thoughts of uniqueness are entirely illusory. But I think that he misses the point. It is not that most of us not of a narcissistic bent do not know that there are other people around who are quite like us (a kind of normative knowing), but rather that our means of knowing and perceiving them results in a different kind of awareness than we have of ourselves. What, then, have psychoanalysts made of this jumble?

The self in psychoanalysis

To begin contemporaneously and then work backwards, Stephen Mitchell (1991) was aware of the definitional problem and lack of consensus surrounding it.

Stern (1997) illustrates the problem when he describes Sullivan’s ideas about the self as involving “multiple and discontinuous selves or self-states” and “most particularly the idea that a self or self-state can be understood” (p. 147, italics added) in terms of multiple interpersonal fields. The problem is with the “ors.” This particular conjunction means to say that selves and self-states are equivalent, that they have fundamental properties in common; they do not. Where, then, is the self located, what is the nature of its states, of its multiplicity, of its representations, and where do they reside?

What Mitchell (1991) and Stern (1997) are most concerned with is defining the self as a relational self, inseparable from its interpersonal field. Bromberg (1996), Mitchell, Stern, and Sullivan (1938/1971a, 1950/1971b) share the view that the concept or the experience of a unified self is entirely illusory. It is worth noting that none of them offer us a definition of what a self might actually be. Stern (1997) goes so far as to posit a “multiple-self-theory” (p. 149), to wit, that selves are multiple and discontinuous. He further attributes widespread acceptance for such a hypothesis. We will have to see. Although they are able to free the self from consciousness as James (1893/2007) was unable to do, there remain two fundamental problems that cause these authors difficulty: navigating the real distinction between self and self-representation that they blur, and the location of the self.

Despite these assertions, the radical ego psychologists of the mid-twentieth century better understood the problems of a psychical self than many authors today. Rapaport (1957/1967) was very much aware of both the distinction between and the difficulties inherent in the concepts of self and self-representation.

The self in subjective experience is something which can observe itself. [The problem is that] The self will have to be so defined in the psychological apparatus that it is observable by an ego function which is at the same time defined as a subsidiary organization within the self. [Yet] The self cannot simply be re-defined. It is a concept that has been with man for a long time… . [Instead] the self will have to be so formulated within the psychological apparatus that it is amenable to observation, though not necessarily to full inspection, because many parts of it may be, like Erikson’s identity, unconscious.

(p. 689, italics added)

Rapaport, unlike many authors who consider the self and some of its properties without actually defining it, gets most of it right. He acknowledges its murkiness, its relations with narcissism and identity, and is not as ready as some (Bromberg, 1996; Mitchell, 1991; Stern, D. B., 1997; Sullivan, 1950/1971b) to abandon its common usage. The one thing he does not consider, as other authors with the exception of James (1893/2007) do not, is the possibility that the self might not reside within the psychic apparatus, and what might follow from an acknowledgement of a different location. I would posit such a change in location to be unavoidable.

George Klein (1976), in a rather business-like way, dispenses altogether with a self-representation. The self is the single psychic apparatus of control, “the focus of which is either an integration experienced in terms of a sense of continuity, coherence, and integrity, or its impairment, as cleavage or dissonance” (p. 8, italics added). As far as the question of how conscious or unconscious of itself the self might be, Klein observes (as he does about other psychic processes) that it is as conscious of itself (or not) as it chooses or as it is compelled by internal or external circumstances to be.

Schafer (1976) viewed the widespread interest in the self appearing in the work of mid-century psychoanalytic authors as arising out of a growing sense of failure in what was then standard psychoanalytic theory and technique. He observed, “in recent decades particularly, many psychoanalysts have become increasingly dissatisfied with the apparent remoteness, impersonality, and austerity, as well as inordinate complexit...

Table of contents

• Cover Page
• Halftitle Page
• Title Page
• Copyright Page
• Dedication
• Table Of Contents
• Acknowledgments
• Introduction
• 1 The self and its contexts
• 2 Phenomenology and existentialism
• 3 Psychoanalysis and Daseinanalysis
• 4 The phenomenological unconscious
• 5 The role of decisions made under uncertainty in clinical psychoanalysis
• 6 Care and suffering in therapeutic situations
• 7 So what is psychoanalysis, really, and what are its therapeutic goals and actions?
• References
• Index