From somatic to psychological Self and consequences for the concept of Transference. (Milano 2008)
2 Basic principles
2.1 Conscious – Unconscious
2.2 Intersubjectivity and the inner working model
2.3 Inner structuring
2.4 Inner world versus outer world
3. Two different forms of pathology
3.2 Conflicting mental representations
3.3 Disturbances of the mental process
4.1. Adequate mentalizing ability
4.2. Inhibited mentalizing ability
5.4 Psychoanalytic listening
6. Finally: Freud and Ferenczi
Within modern psychoanalysis, the meaning of the concept ‘development’ is again the focus of attention and we see a revival of the ideas of Bowlby and his theory about attachment, or rather, about the attachment representations. Within the human infant research, much research is done about the way in which the interaction between the individual with his specific constitutional disposition and his environment determines the nature of his development. Of much value here seems to be the affective quality of the attachment-relationships the child is involved in. A central concept within the world of attachment is the attachment representation or the inner working model and the quality or nature of this. By this, we mean the internalization of characteristic interaction patterns. These patterns come into being because they happen constantly in the relationship between the child and its attachment object. Attachment representations or inner working models acquire the shape of mental representations which regulate the child’s behaviour now and in the future, and which are also connected with the development of the Self, the self image and the self-esteem. This way of thinking greatly influences the way we look at fundamental psychoanalytical concepts such as the unconscious and transference, as we will see later on.
By the way, the renewed attention for the concept of development does not mean that, in psychoanalysis, the main focus must be the reconstruction of the early childhood because this is, supposedly, the time the trouble has started. It does mean that from the beginning, individuals gain experiences on the basis of which they build up the inner working models with which they meet their environment, so they will be able to anticipate on what they expect to be in store for them. Sometimes, these inner working models are productive and constructive and lead to creativity. However, sometimes they are fruitless and destructive and lead to rigidity. Psychoanalysis should be a revision-workshop, a place where non-constructive inner working models are detected and revised. On top of that, there is increasing evidence that says that early environmental factors influence the development of the human neural system and neurobiological research points to the importance of the affective relationship between the child and its carer(s) when looking at the development of neuro-hormonal structures. This implies that effective psychoanalysis should take this into account. The renewed interest in the importance of attachment representations is, therefore, not at all remarkable.
In Bowlby’s opinion, psychopathology is linked to the loss or the serious failing of attachment-figures and the response to this of the individual. Psychopathology, to Bowlby, is linked to pathological responses to traumatic separations. His viewpoint is that people are driven by a universal need to form emotional attachments to others. Attachment, to him, is a result of genetic dispositions and environmental factors. Intersubjectivity and mutual interaction are central in his way of thinking. Psychoanalysis, to him, means correcting inadequate inner working models. We have to see this, not as making old and trusted behavioural patterns disappear or writing them off, but as developing a new alternative, next to the old one. This means that in seriously traumatizing or scary situations, the individual will automatically call on the old behavioural repertoire, if for shorter periods and less compulsory, after all, there is an alternative. This does lead, however, to the revision of concepts like ‘structural change’, a concept that some parts of our professional group are inclined to claim for their way of psychoanalytic treatment.
In a psychoanalytical process both the analyst and the patient are entering a new primary object relation with each other, which is later internalized and is more productive than the old one. Next to attachment, there are other factors that play a part in the coming into being of a healthy development and a healthy individual, and of forms of pathology, such as attention and affect regulation. So far, we have emphasized, when talking about the development of pathology, the deficiency of the inner working models. However, inner working models can also be the cause of the development of conflicts between inner mental representations. Here, we encounter the difference between structural and neurotic forms of pathology. We will come back to this later.
2 Basic principles
2.1 Conscious – Unconscious
Increasingly, there is evidence that our behaviour is mostly controlled by unconscious and implicit processes which have been procedurally registered in the implicit memory system. The concept ‘unconscious’ is central in psychoanalysis. Freud distinguished three aspects when he was talking about the unconscious:
* In the first place, he meant that which is not accessible for the consciousness and yet is not repressed, also called the procedural unconscious, which has to do with habits and skills.
* In the second place, he meant that which had to be repressed because it was unacceptable on a conscious level. It is about conflicts and impulses. By interpreting, this part can be brought back to the conscious.
* And lastly, Freud described the pre-conscious: that which you cannot remember spontaneously, but which can become conscious as soon as the attention is focussed upon it.
The unconscious and the memory are interdependent, which is why we will consider for a moment the functioning of the memory, and especially the long-term memory. The long-term memory is divided into the implicit and the explicit memory. The explicit memory is supported by the hippocampus, which has to develop, which only happens when the child is about three or four years old. This means that experiences from before that age cannot be filed away in the explicit memory and therefore cannot be remembered. The explicit memory is subdivided into a semantic part (memory for facts and knowledge) and an episodic part (memory for the biography of Self). When Freud is talking about removing the early amnesia as the aim of the psychoanalytic treatment, there is a limit to this. In other words: the possibility of repression can only begin from the third or fourth year. Experiences from the years before that cannot be filed in the explicit memory. This does not necessarily mean they are lost; they can be filed in our second memory system, the implicit memory.
The explicit memory uses linguistic symbols and verbal mediation to register experiences. These experiences can then be remembered, though not as an objective copy of what happened at the time. It is the actual context which activates the memory and which determines how and what is remembered. The interior of the treatment room, the timbre of the psychoanalyst’s voice, the words he chooses, these are all determining what and how the patient remembers. Material which is registered in the explicit memory must be stimulated in order to be remembered. The idea that a neutral and silent psychoanalyst stimulates the process of association and remembering in a patient is therefore incorrect. On the other hand, it is also true that an experience that is registered in the explicit memory is determined by the emotional context in which the experience took place at the time. That which is remembered is determined by the actual emotional context, by the stimulating quality of the therapeutic relationship. That which is remembered, can therefore not be considered to be a historic fact or an objective reality. It is not about pictures gotten from a photo archive. The subjective meaning has taken the place of the objective fact.
The second memory system, the implicit memory, has the use of a different brain structure which is formed earlier than the hippocampus. We are talking of the amygdale. This amygdale develops from birth. The working of the implicit memory is not verbally mediated; in it, there are certain characteristic skills and routines, certain characteristic ways of doing things, of dealing with things. In the implicit memory, also called the procedural memory, it is not about verbally mediated images or mental representations such as we see in the explicit memory. It is more about automatisms, self-evident convictions which show in the behaviour.
In short, in the explicit memory, it is about mental representations which become manifest in the relationship in order to be interpreted, or about memories which are accessible to the interpretative activity of the psychoanalyst within the context of adequate holding. In the implicit memory, it is much more about behaviour than about memories. We do not so much speak about transference manifestations, but more about enactments. In the beginning of our lives, we only have the implicit memory system available. Later, we also have our explicit memory. This division between the two is, by the way, not absolute. Certain experiences can be transported from the explicit to the implicit memory. An example is learning how to drive. At first, driving and how to do it is in the explicit memory. The moment when driving becomes automatic, something you do with your hands, your feet and your eyes, and no longer with your head, and you don’t have to think about it anymore, that is the moment when it has been transferred into the implicit memory.
2.2 Intersubjectivity and the inner working model
All this implies that a lot of our behaviour is unconscious, but most of the time not because of repression. Very often, it is also about behavioural patterns that stem from a period in our lives in which we did not yet have our explicit memory system available, but we did have our implicit memory system. To the psychoanalytic practice, this means that the psychoanalytic couple is the focus. Within the interaction between patient and analyst implicit procedures, ways of doing and dealing, become manifest. The aim of the psychoanalytic treatment is to come to a revision of these procedures. So, in psychoanalysis, the aim is not to bring back the past into the memory, or to reconstruct forgotten objective experiences. It is not about the past, but about the way that the patient perceives the other, and interacts with him. The past is only important to help us understand the present. In the treatment, implicit procedures that have become shaped in unconscious inner working models and conflicts between unconscious inner mental representations are re-activated in the here and now. These implicit structures, built in the past, have come into being and registered in a very complex way. Continually, there is interaction between the individual and his environment. Gradually, repeated interaction patterns are internalized and established in what we call inner working models. This is more the case with patterns of interaction than with incidental and individual experiences. It is these inner working models which organize and determine the later behaviour. These inner working models contain inner representations about the Self, about others and about the interaction between them. As Stern (1994) puts it: “Inner working models are the result of a natural process of abstracting of the invariant aspects in various social situations with a special person”. These patterns have a certain stability and continuity during a lifetime.
Several things play a part in the coming into being of the inner working models: the way the patient was treated by his primary objects, how he responded to that, and the way the parental objects dealt with his response, and also the fantasies the child had about this. All this takes place within the context of an attachment relationship. It is the quality of this attachment relationship that determines how and what of all this becomes internalized and established in the implicit procedural memory. In psychoanalysis, it is about making these inner working models manifest and, if they are dysfunctional, to correct them.
2.3 Inner structuring
The small child develops its inner structure within the mutual interaction with the primary caring parental objects. The small child does not yet experience itself as intentionally determined. However, if the primary caregivers are adequately attuned or, in other words, if there is a safe attachment relationship, the child sees, as it were, its own intentions, wishes and feelings mirrored in the other’s eyes. This mirroring must be adequate and this means that it must be obvious that the parents mirror what comes from the child. This mirroring is, however, not an objective mirroring; fathers and mothers look at their child with obvious emotional involvement. Parents love or don’t love their child and therefore either look with or without love to their child. So mirroring is, by definition, always loving, caring or frightening. The primary object will behave towards the child as if the child’s behaviour is intentionally determined. The parent gives mental content to the child’s behaviour, for example: ‘crying’ becomes ‘hunger’ or ‘sadness’ or ‘pain’. Because the parent explicitly gives meaning to the child’s behaviour, he or she encourages a process of mentalization in the child. The primary objects are helpful in creating reflective functioning within the child, or they help the small child by stimulating the process of mentalization, by connecting external experiences with inner perceptions.
The mediation of language is very important in this. In other words, it is within the safe interaction with the primary objects that the child gradually develops an inner space in which it can experiment with behaviour by means of thinking. In other words, thinking as a way of ‘test-behaving’. The child starts to look at itself on the basis of the introjections of the primary objects, or to think about itself in terms of intentions, meanings and feelings. With that, it is not so much the objective image of the other which is being internalized, but the affectively coloured way in which the other looks at the child. Thus, gradually, the child creates an inner mental space, and a ‘mental state’ is developed. Inner representation is an affectively coloured process. A. Freud described something like this when she wrote that when object constancy is reached, the inner image is affectively coloured, and that without this emotional colouring there cannot be object constancy, and neither can there be a realistic relationship between two persons without object constancy.
Observing mental states in oneself is based on observing mental states by the other. But the other must communicate this in order for it to happen. Here, also, the intersubjective element is important. The development goes from the outside to the inside. For that matter, also the ability of the primary object to observe the changes in the child’s mental states and to respond to that is essential (reactive sensitivity) to the child’s mental development. The main thing is always that the child and the primary caring object are well attuned to each other. Of course, sometimes it can and will happen that, in spite of all good intentions, the primary caring object is not adequately attuned to the inner world of the small child. At such a moment, there is miscommunication and at such times it is important that the parental object is able to repair things. This ability to repair is of fundamental importance in the interaction with the child.
If a child develops adequately, it will, at first, not distinguish between the inner and the external reality. Fonagy calls this the ‘equivalent mode’. The inner world corresponds with the outer world, there is no distinction between the two, and thoughts are realities. Apart from that, the child develops the ‘pretend mode’ by means of the ‘as-if’ game. The child ‘knows’ that its own inner experience is different from the external reality and will not want to connect the two. Until the third or fourth year, the child knows these two ways of dealing with the inner and external world as functioning separately. After that, the two ways become integrated and the child starts to function in the ‘integrated mode’, which is no longer either equivalent or dissociated, but from that moment on, inner and outer world are both connected and separated. By mentalizing, both alternative possibilities are connected and mental states can be perceived as representations. Gradually, the child starts to perceive itself as the owner of its actions (Stern, 1985) and the other as the owner of his own actions. There is an adequate differentiation between the Self on the one hand and the objects on the other.
Behaviour has gradually changed from something purely in itself to something expressing a mental state. Behaviour and mental states are no longer the same and there is a difference between inner perception and externally observable behaviour. There is adequate internal space. The child starts to think about itself and others in psychological terms, the reflective functioning comes into being. In other words: there is a process of un-mentalized to mentalized representations. Experiences acquire meaning and continuity and the ability to anticipate comes into being. With patients with structural pathology, we can conclude that their pathology is characterised by a defective mentalizing ability, or a failing reflective functioning. In such cases, there is no such thing as an inner psychological reality, a ‘mind’, and the body maintains an extremely central part concerning the continuity of the self-esteem. The Self is perceived as a somatic instead of a psychological reality. This points to the difference Freud was discussing between ‘Anxiety- Neurosis’ and ‘Psycho-Neurosis’; the first was not open to psychoanalysis and the second was.
2.4 Inner world versus outer world
The aforementioned distinction between ‘equivalent mode’ and ‘pretend mode’ which are gradually becoming integrated in the ‘reflective’ mode, must be examined more closely. In a normal development, the child at first makes no difference between the inner and the outer world. There is no distinction, they are, as Fonagy says, ‘equivalent’; there is equality between something that ‘seems’ and something which ‘is’. Later on in the development, but separate from the ‘equivalent mode’, the child develops the ‘pretend mode’. The child ‘pretends’ that it is playing and knows that the game is not reality, but it does not test the reality of it and in how far it is true, reality and fantasy, inner and outer world must remain strictly separate. Thus, in all safety, by means of playing, the inner world can be built or, in other words, by playing the child learns how to mentalize, in a normal development. Later again in the development, there is integration of both thinking-modalities, and there, too, the safe interaction with a mentalizing other facilitates this, the mentalizing other is internalised. And, as we said before, it is not about the child internalising the other, but the child internalising the “other who looks lovingly to the child”; what is internalized is an object relational dyad.
Adequate mirroring is very important for the integration between equivalent mode and pretend mode. It is also important to mirror in such a way that it is obvious to the child that what is mirrored comes from him and not from the mirroring parent. In other words, next to mirroring, there must also be a good ‘attunement’. If there is good mirroring but it is not clear whether what is mirrored is from father/mother or child, then there is inadequate containment, and the child will make use of the mechanism of the projective identification to defend itself and it will be predisposed to function in the equivalent mode. If the parent does not mirror congruent with the inner world of the child, the development of a ‘false Self’ is encouraged and the child will be predisposed to function in the pretend mode.
Traumata, too, have a big influence on the development of the integrative mode. On the one hand, a weak mentalizing ability will increase the influence of later trauma. On the other hand, trauma also influences the mentalizing ability in the sense that there is a regression to the equivalent mode (not wanting to think) or the pretend mode (dissociation), or to oscillate between these two. In the equivalent mode, the child tries to control and manipulate the other in order to keep its grip on a threatening reality (externalisation). Functioning in the pretend mode, the child cuts itself off and makes little contact (internalising problems). With the borderline personality disorder, or in the case of structural pathology, there has been no adequate integration between ‘equivalent’ and ‘pretend’ mode and so the ‘reflective mode’ could not adequately develop. We then do not speak of a form of pathology on the basis of intrapsychic conflicts, but of pathology on the basis of a failing developmental process, in other words: it is not about conflicts, but about deficiencies. These deficiencies are the result of genetically determined vulnerabilities which become manifest or become activated and acquire their specific appearance in the interaction with the primary attachment objects.
3. Two different forms of pathology
Fonagy and Target (1993; 1995, 1998) distinguish two forms of pathology, one which results from conflicting mental representations and one which results from the dysfunction of the mental processing system.
People with serious personality pathology or, in terms of Kernberg, with structural pathology, inhibit the working and further development of the process on the ground of which mentalizing becomes possible. They are unable to take a third position and to reflect about themselves and others, they cannot adequately use the symbolic functions of language and they cannot give meaning to their behaviour or that of others. Their ability to think in terms of intentions, opinions and feelings is inhibited. Such people ‘know’ and do not have opinions (Britton 1995). Because to have an opinion means that it can also be different, there is room for alternative possibilities, pros and cons can be considered. Where there is adequate ‘reflective functioning’, people function, as Fonagy says, in the ‘reflective mode’; equivalent and pretend modes are integrated. With people who ‘know’, this reflective functioning has fallen behind, they lack the inner space to play with words as a form of test-behaviour. They function at the level of the equivalent mode, what is within is also without, everything that is thought also exists in the outer world. In other words, it is about the difference between personality pathology in terms of the DSM-IV, and neurotic pathology.
Patients with that type of personality pathology are characterised by the dysfunction of the mental processing system, or by an inadequate mentalizing ability. Their reflective functioning is inadequate and they are unable to build up inner mental representations of the outer world, of the other and of themselves. Patients with neurotic problems, on the other hand, are able to develop inner representations, but these are conflicting because the patient is as yet unable to integrate contrary object representations. Psychoanalytically spoken, there is a different type of personality pathology here. The ability to develop mental representations is present, but some aspects are not mentalized, which results in conflicting mental representations. With all this, we must keep in mind that the mental process system itself cannot be observed directly, it is through the inadequate quality of the mental representations that the failing of the mental process is shown. This is why Fonagy sees ‘change’ at several levels. On the one hand at the level of conflicting mental representations and on the other hand at the level of the ‘mental process system’.
3.2 Conflicting mental representations
In patients with neurotic pathology, the inner structure is more or less adequately developed. In such cases, the patient is capable of forming inner mental representations; he can observe behaviour of himself or others in terms of intentions, feelings and opinions. In other words, he can organise experiences of himself and of others, observe in terms of ‘mental states’. He does not have to take things at face value; he can look behind the observable appearances. He can take a third position and think about his own thinking and that of others. This reflective ability gives continuity to the perception of Self; it makes behaviour understandable and predictable. To do this, a necessary condition is that inside and outside, fantasy and reality, as-if and real can be distinguished. It is the basis of seeing oneself and the other and to perceive them as two separate people with each their own wishes, meanings, intentions, feelings and opinions. The ability to build up inner mental images is present, in other words: there is mentalizing ability. This form of pathology requires that conflicting mental images are corrected by means of interpretations. These conflicting mental representations become visible within the transference relationship which develops within the psychoanalytic dyad between the patient and his psychoanalyst. In such cases, the focus is the working through of the transference, in order to reach insight on an emotionally lived-through level. This emotionally lived-through insight on the basis of interpretations will then lead to change.
3.3 Disturbances of the mental process
The second form of pathology does not involve conflicting mental representations; it is about the inner structure itself which is deficient. The process to come to mental representations, or the mentalizing ability, fails. Such patients do not so much suffer from inner conflicts, but from inner chaos. They do not perceive themselves and others as intentionally directed, their behaviour is momentaneous and instrumental. Also the ability to take a third position fails, the distinction between inside and outside, fantasy and reality cannot be made adequately. They cannot see themselves and the other as two separate people with each their own intentional lives. The Self is not (yet) a psychological but a somatic Self, and that is not a kind of regression but an inhibition of the development itself. We now find ourselves in the area of what Balint called the area of the ‘basic fault’, what Klein used to call the ‘paranoid schizoid’ position and what Kernberg describes as serious personality pathology or structural pathology. In such cases, the treatment must be focussed on stimulating the mentalizing ability. In the treatment, this needs not so much obtaining insight through the instrument of interpretation and the development of a transference relationship which is subsequently worked through. It is much more about the psychoanalyst offering himself as ‘developmental object’, a ‘Self object’ which stimulates the stagnated development again, in other words it is about stimulating and activating a process of internalisation and linking behaviour to intentions, feelings and wishes. It must be kept in mind here that the failing mentalization process itself is not directly visible. It is through the failing quality of the mental representations that the deficiency of the mental process itself becomes visible. The consequence of all of this is that the same kind of behaviour sometimes is a form of regression, but in others it is not regression but an inhibition of the development itself.
4 Therapeutic Attitude
4.1 Adequate mentalizing ability
If there is adequate mentalizing ability, or in other words there is neurotic pathology, then the attitude of the psychoanalyst must be as neutral and abstinent as possible, but without losing contact with the patient. Like parents are focussed on the needs and wishes of their child without losing themselves but also without forcing the child to be too focussed on the needs of its parents. The psychoanalyst must offer himself, as much as possible, as a blank screen onto which the patient can project his fears, wishes, inner problems and fantasies, so the transference or the inner working model of the patient can unfold in the therapeutic relationship. With this, the specific attachment representation that the patient has developed during his life will be provoked, within a context in which things can be different from the way they have gone previously, and subsequently be revised.
We must keep in mind, here, that neutrality and abstinence are relative concepts, because both patient and psychoanalyst bring themselves into the treatment. Both are in one way or another involved in the process, there is always an intersubjective relationship. Neutrality and abstinence imply an attitude in which the psychoanalyst is focussed on the needs and wishes of his patient and not on his own needs. Next to that, the psychoanalyst must take care of the parameters in which the treatment takes place. In this he must be led by what is good for the patient and not by his own personal aims. The psychoanalyst is responsible for the analytic setting. In case of neurotic pathology, the nature of the relationship is triadic, which means that both patient and psychoanalyst are capable of taking a third position and have the ability to reflect about what happens in the relationship. It is the psychoanalyst who directs this process, by means of interpretations of conflicting mental representations, which will, in the patient, lead to developing an emotionally lived-through insight into his motives. The psychoanalyst aims at encouraging such an inner process. This demands that the psychoanalyst stays in close touch with the ‘experiencing ego’ of the patient. Not merging with it because then there will be no process, but not too far away from it because then he will lose the emotional contact. All this means that the psychoanalyst must be emphatically focussed on the patient, but still able to maintain a certain distance and to follow the process; the form, more than the content.
4.2 Inhibited mentalizing ability
With patients with pathology of the mentalizing process, or structural pathology with deficient mentalizing ability, the psychoanalyst will be more actively present in the treatment. Such patients need a psychoanalyst who offers himself specifically as a new primary object or self object. The psychoanalyst does not function primarily as a transference figure, but much more as a developmental object unto which the stagnated development can be started again. In such situations, the psychoanalyst has to function – temporarily – as an external ego or super ego. Above all, he must represent the function of the observing ego and link behaviour to feelings, intentions, wishes and needs. With this he tries to build up or encourage a certain form of ‘psychological mindedness’. In such cases, the instrument of interpretation is used less than mechanisms such as introjection of or identification with. In case of structural pathology, the patient is unable to take a third position and so the nature of the therapeutic relationship will be more dyadic than triadic. The psychoanalyst will, in such treatments, be much more active and less neutral and abstinent, and concepts such as transparency, congruency and consistency are important. In both treatment varieties there can only be a productive therapeutic process if there is an adequate holding environment and an intersubjective relationship. It will be obvious that what is adequate in case of neurotic pathology is not necessarily adequate with more structural pathology and vice versa.
We will now show a vignette in which we will try to clarify what is meant by the intersubjective character of the therapeutic relationship and discuss the consequences for our thinking about transference.
Tobias is lying on the couch. It is Good Friday, the last hour of the week, the weekend is extra long because of Easter Monday. Tobias has, in the past two months, hardly said a word in the analysis, apart from the necessary things when coming or going. Today it’s different, I don’t know what it is but there is something special. Suddenly he explodes: “You can do whatever you want. You will not change me, I don’t want to give you that”, he says with his jaws clamped together. “You mustn’t think you mean anything. I came to you because X, Y and Z didn’t have time, and so I had to come to you. I know that you are not happy in your body, you’re just as scared as I am, you don’t understand anything about me. I think you should first get your own life in order before you start working with other people. Look, I know you’re clever and you’ve studied, so the fact that you act the way you do these days means that you’re a sadist, a real sadist. You’ve got me squeezed into this tight corner because you were the only analyst available to me and you knew all that. Bullshit! You are so bad! You’re just abusing your position and not taking any responsibility for your behaviour!”
His voice sometimes breaks, is sometimes small and then again fully loud. Tobias is furious. And me? During his outbreak, I almost feel tears coming to my eyes, I am touched and in a split second I get this image of a small, desperate child, completely upset, and how I pick it up and hold it. The furiousness gradually disappears. I gently ask him: “Does it hurt so much, all this fear?” Tobias turns on the couch and hisses “asshole”. He turns round again, dropping his head on the pillow, cries intensely and cries “daddy”. He gets up, sits down again at the end of the couch, shaking his head angrily. “Idiotic. Idiotic for me to cry about that man, the idea!” After some time, he lies down again, telling me, in a quiet voice, about things that have happened between him and his father, from his puberty, his early childhood and, more recently, from the period that his mother, after having been ill for seven weeks, died of a carcinoma in the pancreas area. What struck me in all those memories was the image of a lonely and sad kid, desperately trying to get contact with his father, couldn’t get it but couldn’t or didn’t want to give up the longing for it. His voice had, by now, become warm and sad when he said: “I can see myself sitting on your lap, warm, safe, and sort of totally disappearing in you while you’re reading a book or something like that, something ordinary. But oh, well, I think it’s time, isn’t it”. And I smiled and said “Yes, it’s time, we will continue on Tuesday”.
To be clear: Tobias was a man of about 35 when he came to me, married and building a successful career. However, neither his marriage nor his career gave him any pleasure. So when I say “a successful career” that is more my perception than his. He never understood why people looked up to him, that they thought he had it made, and considered him an authority in his field of expertise. He hadn’t had a sexual relationship for years and said that he didn’t suffer from that. He came from a self-employed middle class family where he was taught that the customer was king. But at the same time he learned that they – his family – were ‘above’ ordinary people, while, in the shop, the ordinary people were the customers and therefore kings. Mother was an ambitious but sensitive lady who managed the shop. Father could only cope with her through much passive resistance and illness, together with a forceful way of demanding attention. Very early on, Tobias was carrying responsibilities he was actually too young for, but he did it well. The fears that went with this were no small matter and could only be borne by becoming depersonalized. He used words for this like: “to walk through the world like in a cocoon”, at home, in the shop and at school. Anxiety was always a kind of muted feeling: “Not that I was sad at the time, but I knew there was a lot of sorrow inside and sometimes when I was walking on the street on my own, I would feel so sad and melancholy. I would wallow in it sometimes and then I would think: “Tonight I will go to sleep and then when I wake up tomorrow, that feeling will be gone, just like that, everything is over and I will be happy”.
At school, Tobias performed reasonably well, although he had to put in a lot of effort. It turned out that he was dyslectic which meant he had to invest a lot and, as he put it, little came out. He was a loner, always had one friend but no girlfriends. He was terrified of girls. In his puberty, he had a lot of psychosomatic anxiety- and tension complaints. He was never angry though at home they thought he was considered hot-tempered. Tobias was more of a thinker than a doer. In his spare time, as a child and in puberty, he withdrew to his room and at night he would put himself to sleep by telling himself extensive fantasy stories that he gained much comfort from.
When Tobias comes into my room the Tuesday after Easter and lies down on the couch, I am struck by how pale he looks. After some silence, he tells me that he has dreamt, this night, not frightening, but a little scary though at a distance, more surreal actually. There were all these shining steel objects, round ones and long ones, parts of spoons and forks, but very much enlarged. They were floating in a space without end and he was walking in between them. It wasn’t that he was trying to avoid them, they just didn’t come close. When asked what he felt he said: “Just frozen”. He tells all this in an almost mechanical way. I have the feeling I don’t have contact with him. I realise that one of his complaints at the start was, as he had said during the first interview: “I can just lose my feeling for people all of a sudden, and then there is nothing left. That it can be gone so suddenly without leaving any trace frightens me. I wonder then what it was that I felt yesterday, what is it I have with people? One moment they’re everything and the next, nothing”.
I say to Tobias that it sounds rather cold and distant, all this, especially after last Friday. I notice, in myself, that I wish to touch him, to make contact with him. He then says that last Friday, he had had a thought that he hadn’t told me at the time, and it had to do with it being Good Friday: “When I was a child, we went to church, they would turn off the lights, and then we would have to come forward. The priest held a big cross, with the body of Jesus, covered by a purple cloth, just the feet were bare and we had to kiss them. In some ways, I hated that. It frightened me terribly, but it also gave me a sort of erection. But it wasn’t nice, it hurt, actually.”
Then, in the same breath, he tells me that, as a 12-year old, he had a room in his grandparents’ house, which was diagonally opposite his own home. The reason that he was given a little room at his grandparents was, that his grandfather had had a brain haemorrhage, and his parents thought it would be a good idea if he, Tobias, would keep an eye on them. When Tobias got up in the morning, at 7 o’clock, he would sneak out of the house, terrified when he passed the open door of his grandparents’ bedroom. He was afraid to look, but had to and then: “That long white head and that open mouth. All those images and memories went through my head when I said that I wanted to sit on your lap, disappearing from the world. And, at the same time, it really doesn’t bear thinking about”.
In the sessions after this one, Tobias shares with me the reason why it doesn’t bear thinking about. On Wednesday he comes in, shakes my hand and looks past me when he does that, lies down on the couch, is restless, starts saying something but doesn’t, then gets up and sits down again at the far end of the couch. He says: “About that sitting on your lap, please don’t take it seriously. It sort of slipped from my mouth, it was more a thought, I saw it in my mind and wondered what it would be like”. The way Tobias says this touches me and, at the same time, I feel uncomfortable. I say: “Tell me, what is the matter, what happened. You’re allowed that thought, that need. It is yours, and yet you seem to be terribly frightened of it”. He looks at me and there is a bit of silence, and then he tells me how years ago, he had sought help during a very turbulent time in his life. In that treatment, at some point, about the same thing had happened as had occurred here on Good Friday. It was Good Friday as well and then, as well, he had shared his need of intimacy, of sitting on someone’s lap, with his psychoanalyst. That psychoanalyst had said that fantasising had for him, Tobias, always been a way to escape from the reality of his life and that, if he really wanted to help himself, he should now do the things he normally fantasised about.
Tobias then tells me, sitting there like a frightened little bird, how eventually he sat on the psychoanalyst’s lap, and how it went further and further. “In that period”, he says, “I walked a thin line. If ever I could have been psychotic, it would have been then, and I think I was close. A terrible time, it was. We talked about sex and masturbating, and then he asked me to do it, there, in his room, and then everything turned in me, just like when water gets really cold, one moment it’s water and pang!, the next it’s ice. Suddenly, all my feelings were gone, my sadness, my fears, everything was gone. I was just really calm, I didn’t feel anything”.
It is difficult for me to keep my tears inside when he tells me all this, I can’t really hide it and I say: “How terrible, and you have been all these years with such a story in you. You want to talk about it, but were afraid to, as well. You feel like you’ve been had and also you feel guilty, you’re ashamed and cannot tell anyone.” He looks at me, cries softly but very intense and says: “I was so stuck; I had this feeling that my body was too small for me”. And I, the psychoanalyst, feel anger, shame and powerless and sad.
Tobias’ story evokes many responses, both in me as psychoanalyst and in Tobias. It is not that in Tobias there were all these things lying in wait, and the words were just the tools that made them get out. His story gets its specific shape and colour within the intersubjective relationship between him and his psychoanalyst. There is no ‘objective’ telling of what happened, the story gets its specific colours and shades within this specific context. Truth is not objective but contextually bound. This also goes for memories: what is remembered is not objective in the sense that it is lying there, all ready, like a picture that can or cannot be taken from the photo album. What and how something is remembered is also determined by the emotional context of the here and now. Memory is interpretation and as such it is contextually determined. My transference feelings are mine, as a psychoanalyst, but they are activated by Tobias and undoubtedly he had his reasons for that. All this resonates in me, it touches my own experiences and I intervene the way I did. Transference and counter transference are inextricably bound; they are part of one intersubjective process.
5.4 Psychoanalytic listening
The psychoanalyst listens with ‘Gleichschwebende Aufmerksamkeit’. He listens to the seductive words of his patients without being seduced. He recognises and feels the seduction, and he responds to them, but at the same time, as it were, he takes a third position, he moves into the story but, again, he doesn’t merge with it. Gratification makes the longing go silent, but the psychoanalyst tries to find and uncover the paths that the longing takes to get gratification. In other words, he tries to feel for the inner working model that the patient uses, to provoke it and then to revise it. The stories of our patients give us a reality, and at the same time provoke us. They cover and uncover many things about our patients. The psychoanalyst speaks, as Lacan calls it, a ‘parole vide’, thus provoking the patient to uncover more. By uncovering, the patient builds up his own identity. It will be obvious that analytic concepts such as transference and counter transference have a different meaning here. It is no longer about pathological misrepresentations from either patient or psychoanalyst; it is about an intersubjective relationship in which both are involved. In the treatment we are not one and not two people, but we are three: the patient, the psychoanalyst, and the interaction. With this, we are back at the ancient discussion between Freud and Ferenczi.
6. Finally: Freud and Ferenczi
Both Freud and Ferenczi were intensely focussed on what was going on within the relationship between patient and psychoanalyst. Freud was focusing more on the transferential aspect of the relation in the psychoanalysis while Ferenczi was focussing on the developmental aspect. Both are there at the same time but in neurotic pathology the transferential aspect is in the foreground while in case of structural pathology the developmental aspect is in the foreground. Ferenczi aimed at revitalising early experiences, with the help of an active, emphatic, accepting technique. His aim was not primarily the reconstruction of the forgotten childhood, as Freud wanted to do, but to give the patient a lived-through corrective experience in the here and now.
Where Freud emphasized the analyst as a transferential object, Ferenczi saw the analyst more as a new primary object. He realised that patients have a sharp eye and ear for what moves the analyst; patients anticipate and respond to it. He therefore emphasized that certain characteristics or traits of the analyst would have their influence on the way in which transference and the connected counter transference were formed. This eventually led to his experiment with ‘mutual analysis’, where both patient and Ferenczi mutually analysed each other. Transference was, to him, not something created exclusively by the patient, but a result of the specific interaction between this patient and this psychoanalyst.
With Ferenczi, this resulted in the fact that the borders between the professional psychoanalyst and the patient became vague or invisible. In other words: with Ferenczi, the transference vaporized in the real aspect of the therapeutic relationship. With Freud, on the other hand, at least in his writings, the real relationship vaporized in the transference. The discussion between Freud and Ferenczi was about the importance of the real relationship and the transference. This was how it was then, and, in some ways, it is still like that.
At first, Freud considered transference to be a characteristic way of acting in which early childhood wishes, developed in the relationship with the primary carers, were transferred from the carer-objects to the person of the analyst. The concept of ‘displacement’ was central in this. Freud wrestled, in his writings about techniques, with the question of whether transference was a form of resistance against the process or the re-experience of a crucial inner object relationship. Next to that, he was confronted with the question of whether transference was purely a repetition of what had occurred previously (1915) or whether it was a new shape of old conflicts (1917).
Sandler (1976) and Wachtel (1997) emphasized, in their respective concepts of ‘role-responsiveness’ and ‘cyclical psychodynamics’ the fact that patients try to elicit certain behaviour from their therapist; thus inextricably linking transference and counter transference. McLaughlin (1991); Chused (1991) and Gabbard (1995) concurred with this through their idea that patients, in the therapeutic relationship, actualise an inner scenario through which the therapist is moved to play a specific role, written down in an inner script of the patient. The development that the Kleinian concept of ‘projective identification’ went through points in the same direction. Patients do not project into an empty container, what they project in the therapist must, somehow, connect to that which is already lying in wait in the therapist (see also Ogden 1979; Gabbard 1995).
Kohut, in his turn, further elaborated on the concept of transference, but from a different perspective. Central in his ideas is the thought that the Self of the patient is not complete, because of the failing of the primary objects, and it is the therapist who must offer himself as a Self object in such a way that the patient can yet become ‘complete’.
So far, it can be said that transference contains two aspects: the aspect of ‘repetition’ and of ‘reparation’. Patients aim to repeat old object relationships in the present, hoping this new version will be different from the old one, in other words, they want both reparation and a corrective experience. In the interactional psychoanalysis, ‘transference’ is considered to be a mutual construction of this specific patient and this specific therapist (Gill 1994; Mitchell 1997; Hoffman 1983). From neurosciences we have learned that transference reactions are not merely determined by experiences from the past, they are activated by things that happen in the present. Occurrences from the past have been registered in the implicit or the explicit memory system. These systems are embedded in neural circuits. To remember or to activate these neural circuits demands a memory password and it is the nature and the colour of this password that determines the nature and the colour of the memory. Next to this, these circuits are mutually connected.
The actual behaviour of the therapist or actual occurrences in the psychoanalytic process determine the nature and the colour of the transference reactions that happen. Transference always has a plausible basis in the here and now of the analytic situation. In other words: ‘transference’ always occurs within a certain actual context. There is not so much a transference, but many with many affectively coloured faces. A specific occurrence in the present hooks up with various neurologically registered networks through which specific occurrences or aspects of occurrences become connected. Transference manifests itself in the moment that aspects of the psychoanalytic relationship activate networks (which exist in a potential condition of activation) through which conscious and unconscious perceptions, emotions, desires, expectations and behaviours are activated.
Such networks can be functional but certainly also dysfunctional, and if the latter is the case, they need exploring and working through. In transference, both the implicit procedural memory and the explicit autobiographic memory, but also affective reactions or implicit resistance mechanisms can be activated. In the psychoanalytic treatment, patients develop, within the relationship with their therapist, new behaviours which will eventually be absorbed in new associative neural networks, which can be activated both within the treatment setting and without it. In other words: in the psychoanalytic treatment, slowly new object relational involvements are being developed and internalized, which will finally be registered in implicit networks.
Also from neurosciences it becomes clear that the subjective and personal characteristics of the psychoanalytic therapist are of fundamental significance in the development of a psychoanalytic process. The way the analyst is involved and lets himself be involved in the process determines the patient’s transference. Every activity of the therapist, verbal or non verbal, the way he has furnished his room, the way he greets his patient, the way he is attuned to the patient’s ‘mental state’, or the way he says goodbye at the end of the session, has meaning to the patient. In other words: everything that is connected with the psychoanalytic setting activates specific memories or experiences of the patient.
Because memories are registered in associative networks which do or do not activate each other, one memory recalls another. It is the actuality of the psychoanalytic relationship which makes the patient remember, consciously and unconsciously, earlier implicitly or explicitly registered experiences. The psychoanalytic treatment does not end with working through transference. Transference is not the activation of an old representation standing waiting, it is about the continuous construction and reconstruction of thoughts, desires, fears, expectations and intentions, of ways people shape relationships and regulate affects (Westen 2001). All this, within the context of a new relationship which can only be understood within the context of old relational involvements. Psychoanalytic treatments are about the actuality of the treatment relationship in which present and previous experiences are integrated within less dysfunctional behaviour patterns. In other words: it is all about internalizing affectively coloured object relational involvements.
M.H.M. de Wolf, Ph.D.