Close Encounters (by Robert Winer, M.D.)

Close Encounters: A Relational View of the Therapeutic Process

Chapter 3 The Relational Dimension

* Melanie Klein: Projective identification - the way in which the infant, while in a state of mind in which splitting is the predominant way of organizing experience, disowns disturbing aspects of the self or "bad" internal objects and experiences those aspects as though they are in the mother. This serves both to rid temporarily the infant of an intolerable experience, and to locate that which is disowned in another where it can be controlled. For Klein, this was an intrapsychic event, the elaboration of a phantasy. Phantasy, for Klein, was the mental structure through which experience was organized.

* Bion (1959) - The analyst is affected by the projective operations of his patient: "The analyst feels he is being manipulated so as to be playing a part, no matter how difficult to recognize, in somebody else's phantasy," unless the analyst is so taken over by the situation that he loses insight into the fact that the patient is evoking what the analyst is feeling and experiences the projected bad object as actually a part of himself.

* Bion (1959) - Projective identification was a central aspect of communication between infant and mother, and that the mother's failure to be open to the infant's projections could be a basis for later illness.

* Kleinians firmly place the patient at the center of the field: she is the source of intentionality and the cause of her own distress distress, and the work of analysis will be to make manifest her phantasies as revealed in the transference.

* Putting the mechanism of projective at the center of the analytic interchange means recognizing that the analyst is continually being worked on by his patient, maneuvered and manipulated to feel, to think, and to act in particular ways that at least in the short run serve the patient's needs. The analyst's task is to permit invasion and resist capture.

* Segal (1973) - If the patient is to sort out what is external and what is internal, how far his view of the world is coloured by omnipotent phantasy, he can only do so if the analyst remains unaltered in his basic function by the patient's projections. ... The patient was setting a test, testing the analyst's capacity to hold the situation, trying both to subvert her and to evoke a containing response, and the analyst took in both sides of the projective identification and then responded in a therapeutically useful way by ending the hour on time. She felt the tension of conflicting pressures, worked it through within herself, and responded in a constructive way.

Donald Winnicott

* Within the "holding environment" provided by the mother, the pair exist in a state approaching seamless oneness. Over time, as the mother resonates with her baby's wants and needs, he becomes attuned to his functions and desires, begins to experience them as his own, and thus evolves a nascent sense of selfhood. At the same time, the mother's inevitable small failures and lapses in respnsiveness also promote her infant's development of a sense of separateness.

* In some measures, however, the mother's inevitable inability to responsively "go on being" with her baby will lead him to experience her as "impinging." Play now stops as he becomes preoccupied with the need to meet her needs. He manufactures a "false self" based on compliance with what he takes to be her needs and his "true self" goes into hiding (Winnicott, 1960). The false self will become the face presented to the outside world, the instrument through which relationships will be managed.

* Ogden (1986) - To the extent that the mother is able to allow the child freedom to play "in the presence of the absent mother [without her impingement]" (p. 182), he will come to internalize the mother-as-holding-environment and develop the capacity to be self-soothing. To the extent that she cannot grant her child this space because of her own needs, she interferes with this movement and promotes an addiction to herself as an omnipotent object, thereby disrupting the child's progress toward autonomy.

* The analyst does not impinge on the patient with his own needs; he does not stand in the way of his patient's need to regress; he works to counter the patient's making him into an omnipotent object ("I retain some outside quality by not being quite on the mark - or even by being wrong" [1965, p. 167]); he tries hard not to be bright or clever; he withstands the patient's attacks without retaliating; and he does not disrupt his patient's gradual transition toward separateness. During the later stage of treatment, "the now independent ego of the patient begins to show and to assert its own individual characteristics, and the patient begins to take for granted a feeling of existing in his or her own right" (Winnicott, 1965, p. 168). To this reader it sounds like treatment is about being born.

* "Good enough" analyst - to have a capacity for objectivity and freedom from need and ambition that indeed few of us could live up to much of the time (while at the same time disingenously asserting that in doing analysis he aims at simply keeping alive, keeping well, and keeping awake).

* We might, in a spirit of Winnicott excess, say that it is the treatment designed for what he considers to be the universal illness: false selfhood brought about by maternal impingement. The lost heroine is rescued by the mother capable of tolerance.

Harry Stack Sullivan

* Where Winnicott stressed the disruption of the holding environment by the impingement of the mother's needs, which the infant had to mold himself around, Sullivan emphasized the mother's communication of anxiety to her infant, which mobilized him to develop various security operations designed to preclude the repetition of anxious experience.

* How to get heard in a way that could have an effect without scaring the patient off or intensifying his defensiveness. Being heard can hardly be taken for granted, that in fact it is a relatively rare event, that patients are so busy managing us to keep us from (what they fear will be) our traumatizing them that they can hardly pay attention to what we are saying, and that they are in fact so vulnerable to being made more anxious that the vast majority of comments we might feel inclined to make are actually likely to fulfill their prophecy.

* Deflecting the moment from his embarrassment to my asserted incompetence.

* Participant observation - both the intimacy and distance in the position from which the therapist worked.

Heinz Kohut

* The caretakers are the most notably absent in the particular regard that he has brought to our attention - that is, in terms of providing the required responsiveness to the child's narcissistic needs, and thus facilitating the development of a cohesive self.

* For Kohut, what the analyst encounters in working with a patient with a disorder of self-organization is a particular form of transference in which the patient attempts to use the analyst as a "selfobject" to perform functions that she is unable to perform for herself. In particular, her need to have her capabilities recognized and admired, and her need to idealize a parental figure will not have been adequately met during early development, leaving the child, and later the adult, unable to organize self-regard around either healthy ambitiousness or the valuing of honorable ideals. The patient will try to use - or struggle against using - her analyst to fulfill these needs. She will do this in an effort to heal herself, to fashion a self that will be sufficient.

* Task for the analyst: (1) Empathic Stances, comprehend and value the patient, value her profound and desperate efforts to cope with her lack of self-cohesion; Sensetitive to her narcissistic vulnerabilities, and not to be put off by her need to use him for mirroring and idealizing purposes. (2) interprets to the patient by paying attention to the ways in which the patient responds to his inevitable moments of empathic failure or absence.

* Simply being treated empathically may in itself be what is crucial for self0bject internalization.

* If the analyst were perfectly empathic the treatment would never proceed, because there would be no stimulus for internalization. (Winnicott - the mother's incremental failures are needed if the child is to individuate.) It is through his attention to the impact of his inevitable insensitivities that the work goes forward.

* It seems fair to say that they see the analyst's function as parenting rather than as providing understanding.

* The great impact of the self psychology movement on all analysts has been to make them more sensitive to their patients, to challenge them to notice the subtle ways in which standard procedures - silence, interpretation of resistance, insistence on meaningfulness - can become traumatic and persecutory. While it is not true that the self psychologists invented tact, they have been of great service in reminding us that we are treating people.

* Kohut (1971) - Empathy, especially when it is surrounded by an attitude of wanting to cure directly through the giving of loving understanding, may indeed become basically overbearing and annoying; i.e., it may rest on the therapist's unresolved omnipotence fantasies. Provided, however, that the analyst has largely come to terms with his wish to cure directly through the magic of his loving understanding and is indeed not patronizing toward the patient (i.e., he recognizes empathy as a tool of observation and of appropriate communication), the mere fact that the patient dropped his defenses against the possibility of being empathically understood and responded to expose him to the archaic fear of earliest disappointments [which in turn are worked with]. (p. 307)

* Empathy is clearly in the service of a larger undertaking and not a technical approach in itself.


Chapter 4 The Thinker and the Kiss

* Paradox - To become an individual, I must be capable of relatedness, for otherwise my individuality is a shell and I live in schizoid refuge. To be related, I must be capable of standing alone, for otherwise relatedness melts into merger.

* If the schizoid is the paradigmatic unrelated individual, the borderlin could be taken as the opposite pole, the unindividuated relational.

* Reading and rereading Ohio Impromptu, I find in it a moving description of the struggle to mourn, to separate, to join, to become a person.

* It is the paradox of our work that we come together with our patients, that we enable them to love us and to accept our love for them, so that they can bear to be alone. The kiss created by the thinker; the thinker created by the kiss.