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FROM ID TO INTERSUBJECTIVITY
FROM ID TO
INTERSUBJECTIVITY
Talking About the Talking Cure
with Master Clinicians
Dianna T. Kenny
First published in 2014 by
Karnac Books Ltd
118 Finchley Road, London NW3 5HT
The right of Dianna T. Kenny to be identified as the author of this work has
been asserted in accordance with 77 and 78 of the Copyright Design and
Patents Act 1988.
www.karnacbooks.com
CONTENTS
FOREWORD xi
CHAPTER ONE
Where the talking began: the birth of psychoanalysis 1
CHAPTER TWO
Beyond Freuds psychoanalysis 45
CHAPTER THREE
Dr Ron Spielman: object relations psychoanalysis 99
CHAPTER FOUR
Professor Jeremy Holmes: attachment-informed 143
psychotherapy
CHAPTER FIVE
Dr Robert D. Stolorow: intersubjective, existential, 179
phenomenological psychoanalysis
v
vi CONTENTS
CHAPTER SIX
Professor Allan Abbass: intensive short-term dynamic 213
psychotherapy
CHAPTER SEVEN
Historical continuity and discontinuity in the meaning 251
of key psychoanalytic concepts as revealed in the
transcripts of interview
CHAPTER EIGHT
Commentaries on the transcript of an analytic session 265
CHAPTER NINE
Textual and conceptual analysis of psychotherapists 297
commentaries on the transcript of the analytic session
NOTES 327
REFERENCES 331
INDEX 361
ABOUT THE AUTHOR AND THE PSYCHOTHERAPISTS
The psychotherapists
vii
viii ABOUT THE AUTHOR AND THE PSYCHOTHERAPISTS
who conquered adversity with her indomitable spirit, her Irish humour,
and her generous heart.
In this book Dianna Kenny sets out to discover what remains of Freud
in contemporary psychoanalytic practice. To do this, she engages us
in an intensive dialogue with four eminent practitioners. While no
four people can be said to be representative of an entire community
of practitioners they are each distinctive and different with respect
to their theoretical framework and the cultural milieu within which
they operate. After the interviews, she lets them loose on a therapy
transcript, which acts as a kind of Rorschach inkblot onto which they
project their fantasies about the patient and the therapist.
Before we meet the four clinicians, Professor Kenny sets the scene
with an unusually lucid exposition of the core ideas of Freud and
post-Freudian psychoanalysis. This is an heroic task to accomplish in
two chapters but she achieves it with remarkable fluency. Inevitably
some detail is missing but the core ideas are so clearly enunciated that
these chapters alone will prove to be invaluable to any person seeking
to navigate this complex and jargon-infested territory.
The four interviews that follow are themselves outstanding exem-
plars of psychoanalytic enquiry. I cannot put it more clearly than
Robert Stolorow, who said at the end of the interview Your questions
were very thoughtful and incisive. It is clear that Professor Kenny
xi
xii FOREWORD
had a plan that she brought to each interview. Her plan was informed
by a close reading of the published work of each clinician and curios-
ity about how their ideas and approaches related to other strands of
psychoanalytic thinking. However, she never allowed the plan to get
in the way of the conversation and many of the questions were stim-
ulated by the thoughts of the person she was interviewing. Indeed,
there were times when the questions were as interesting and infor-
mative as the responses.
This is a scholarly work, with all the key ideas assiduously foot-
noted or referenced. The reader will have no difficulty further explor-
ing any of the many thought-provoking fragments that the conver-
sations weave together. However, it is much more than scholarly.
There is an intimacy to the interviews, which enables each clinician to
tell a very personal story. We are constantly reminded that an intel-
lectual journey is shaped by life experience and not just by reading
and ideas. For clinicians this is in part vicarious life experience
through constant engagement with patients. However, through these
interviews we also learn about formative personal life experiences
such as the death of a spouse, working in an overburdened health
system, or the search for a father.
When it comes to the transcripts, each of the therapists adopts the
position of the master clinician or therapy supervisor. Here we
encounter something of the superego of each clinician. They are not
always in agreement as to what the therapist might do better but they
share what might best be described as a clear vision for how the work
should proceed. Stolorow put it most graphically when he said in
response to one of the therapists interventions, The therapist is still
pursuing a cognitive behavioural approach, which is not, at this point,
helpful to the patient. Each of the clinicians felt strongly about both
therapist and patient and were emphatic in their advice-giving to the
therapist which was motivated by an unwillingness to provide tacit
endorsement of interventions that they considered less than ideal
from their perspective.
However, after the thoughtful and sometimes humble communi-
cation in the four interviews, the assumption of the role of expert
came as something of a shock. There is a lot we can learn about ther-
apeutic technique from the responses to the transcript. It also reminds
us how strongly identified clinicians are with the patient and how
FOREWORD xiii
little patience they can have with therapists, who struggle with their
patients down difficult byways.
Those with a more academic orientation will especially appreciate
Professor Kennys textual analysis of the responses of the four clini-
cians to the clinical transcript. She uses a formal text analysis program
as well as a conceptual thematic extraction process to identify both the
distinctive voices of each clinician and some of the communalities that
lie behind these voices. This is an invitation to further research, which
I suspect will be both stimulating and challenging for many readers.
It is also the means by which Professor Kenny draws together some
of the disparate strands that have emerged in the clinical discussions,
and in the analyses of the clinical transcripts, to bring her work to a
conclusion.
I hope you enjoy this book as much as I have. It did not set out to
provide you with a complete or fully integrated picture of contempo-
rary psychoanalytic thinking; it does, however, provide you with an
excellent overview. Furthermore, it will give you more than a glimpse
into the world of the practicing clinician. It may also help you under-
stand something Allan Abbass did not when he said I dont know
what might be happening in psychoanalytic treatments that take so
long . . . I cant see the added valuethe health dollar is so stretched.
Psychoanalysis may not be the most cost effective treatment but the
conversations with Spielman, Holmes, and Stolorow do take us to
where we might find some of the added value.
You cannot explore, you cannot think, you cannot play unless you feel
safe. (Professor Jeremy Holmes, this volume, p. 154)
CHAPTER ONE
. . . he merely told
the unhappy Present to recite the Past
like a poetry lesson till sooner
or later it faltered at the line where
long ago the accusations had begun,
and suddenly knew by whom it had been judged,
how rich life had been and how silly,
and was life-forgiven and more humble,
able to approach the Future as a friend
(Auden, 1939)
1
2 FROM ID TO INTERSUBJECTIVITY
memories under hypnosis of the time at which the symptom made its
first appearance; when this has been done, it becomes possible to
demonstrate the connection in the clearest and most convincing fash-
ion. (Freud (with Breuer), 1895d, p. 3)
None the less, these ideas press for expression and sometimes break
through to the surface, often in disguised form, such as in dreams,
slips of the tongue, jokes, and symptomsmanifestations that Freud
called the return of the repressed (p. 148), a process that today is
called an enactment (Cambray, 2001; Chused, 2003; Eagle, 1993;
Friedman & Natterson, 1999; Ivey, 2008).
Freud later defined the ego in two ways: first, as the structure need-
ing protection from the unconscious; second, as the repressing force
that keeps disturbing material at bay. Since the process of repression
is itself unconscious, there must be an unconscious part of the ego.
With this understanding came a change in the understanding of the
role of anxiety. Freud believed at first that repression caused anxiety;
he subsequently came to the view that it was anxiety that motivated
repression (Freud, 1926d).
Freud at first understood repression to be an attempt to ward off
memories of traumatic experiences:
All the experiences and excitations which . . . prepare the way for, or
precipitate, the outbreak of hysteria, demonstrably have their effect
only because they arouse the memory-trace of these [previous] trau-
mas in childhood . . . (Freud, 1896b, p. 166).
years is only possible for those in whom that experience can activate
the memory-trace of a trauma in childhood. (Freud, 1896b, p. 166)
He later revised this view, believing that it was not traumatic experi-
ences or memories, but conflicted impulses, wishes, and desires, with
their attendant anxiety, that motivated repression, in particular,
. . . the patient had not been cured. Indeed, the famed prototype of a
cathartic cure was neither a cure nor a catharsis . . . Anna Os illness
was the desperate struggle of an unsatisfied young woman who found
no outlets for her physical and mental energies, nor for her idealistic
strivings. (p. 279)
Transference
This transference, alike in its positive and negative form, is used as a
weapon by the resistance; but in the hands of the physician it becomes
the most powerful therapeutic instrument and it plays a part scarcely
to be over-estimated in the dynamics of the process of cure. (Freud,
1923a, p. 247)
I . . . put forward the thesis that at the bottom of every case of hyste-
ria there are one or more occurrences of premature sexual experience, occur-
rences which belong to the earliest years of childhood but which can
be reproduced through the work of psycho-analysis in spite of the
intervening decades. I believe that this is an important finding, the
discovery of a caput Nili in neuropathology. (Freud, 1896a, p. 203)
for contact and attachment is born of fear and is, thus, a secondary
instinct. This position has been subsequently challenged (Bowlby,
1958).
Although Freud perceived sexuality as the dominant determinant
of psychological functioning in his early writings, his realisation of a
more fundamental instinct, self-preservation, created a problem for
the role of sexuality in his theorising. He concluded subsequently that
resolving issues in infantile sexuality, such as the Oedipus complex,
represented a simultaneous working through of the primitive anxi-
eties that are linked to the traumatic loss of the object (Van Haute &
Geyskens, 2007, p. xx). In this regard, Freuds theorising was greatly
affected by his observations of the post traumatic stress disorders in
soldiers returning from the First World War. Prior to 1920, Freud
believed that most neurotic symptoms were related to the repressed
experiences of infantile sexuality. After this time, Freud gave primacy
to the experience of trauma, a position that became a central tenet of
subsequent psychoanalytical theorising and speculation (Miliora,
1998; Mills, 2004; Muller, 2009; Naso, 2008; Oliner, 2000). The traumas
of war and the constant imminent threat to survival must surely come
closest to repeating the feeling of helplessness of the infant and the
associated anxiety. The proximal trauma triggers the distal archaic
infant anxieties, resulting in a traumatic neurosis. Freud understood
the symptoms, including repeated nightmares and reliving of the war
trauma, as an attempt to master the trauma psychologically. Freud
had identified the phenomenon of the compulsion to repeat (Freud
(with Breuer), 1895d, p. 105) both in actual life and in the transference
relationship with the analyst in his earliest cases and understood this
as a form of remembering. In Remembering, repeating and working-
through, Freud (1914g) came to the conclusion that psychopathology
(neuroses) is a magnification of universal human phenomena (Van
Haute & Geyskens, 2007, p. 33). The helplessness and dependency
that we all experience as infants are reactivated in subsequent experi-
ences of threat, anxiety, and loss.
The id . . . has no means of showing the ego either love or hate. It can-
not say what it wants; it has achieved no unified will. Eros and the death
18 FROM ID TO INTERSUBJECTIVITY
instinct7 struggle within it; we have seen with what weapons the one
group of instincts defends itself against the other. (Freud, 1923b, p. 59)
The adults ego, with its increased strength, continues to defend itself
against dangers which no longer exist in reality; indeed, it finds itself
compelled to seek out those situations in reality which can serve as an
approximate substitute for the original danger, so as to be able to
justify, in relation to them, its maintaining its habitual modes of reac-
tion. Thus we can easily understand how the defensive mechanisms,
by bringing about an ever more extensive alienation from the external
world and a permanent weakening of the ego, pave the way for, and
encourage, the outbreak of neurosis. (Freud, 1937c, p. 238)
The super-ego retains the character of the father, while the more
powerful the Oedipus complex was and the more rapidly it suc-
cumbed to repression (under the influence of authority, religious
teaching, schooling and reading), the stricter will be the domination of
WHERE THE TALKING BEGAN: THE BIRTH OF PSYCHOANALYSIS 21
Once the patient has been able to accept the reality of the here-and-
now thoughts and feelings that occupy the second system, particularly
the thoughts and fantasies that arise in the transference, and his
second censorship resistance has fallen away in that . . . context, it is
appropriate to reconstruct what has happened in the past . . . in the
knowledge that such reconstructions have as their main function the
provision of a temporal dimension to the patients image of himself in
relation to his world, and help him to become more tolerant of the
previously unacceptable aspects of the child within himself. (p. 422)
psychoanalytic theory that was to evolve over the next thirty years.
Briefly, the case involved a mother who, having just given birth to her
second child, was unable to breastfeed her newborn. As she had expe-
rienced the same difficulty with her first child, she was determined to
succeed with her second child. Freud noted with interest that not only
could the mother not breastfeed, but that in order to prevent herself
from vomiting when the baby was brought to her, she had ceased
eating herself, was unable to sleep, and had become depressed.
Freuds first hypnosis focused on suggestions about the success she
would have in feeding the baby, and how she would experience none
of the worrying symptoms associated with her inability to sleep and
to eat without vomiting. This intervention led to a day of successful
breastfeeding, following which the young mother relapsed. Freud was
called back the next night. On the second occasion of hypnosis, Freud
was bolder in his hypnotic suggestions, which focused on the
mothers need to be fed before she could successfully feed her baby.
Freud suggested to her that when she awoke, she would demand her
dinner from her mother before having her infant brought to her for
feeding. This treatment resulted in a permanent cure and the mother
was able to breastfeed her baby for eight months. From this case,
Freud posited the notion of the antithetic idea, which, through a
process of dissociation, becomes unavailable to conscious awareness
but acts against ones conscious intentions as a counter-will against
which the patient feels powerless. What appears to have occurred in
this intervention is that Freud mobilised the anger in the mother about
an (unconscious) experience she herself had had as an infant of not
being sufficiently fed and encouraged her to express that anger to her
own mother over not being given her dinner before commencing to
breastfeed.
Although Freud had not yet formulated his theories of uncon-
scious action or catharsis/abreaction that he documented in Studies on
Hysteria, it is likely that the clinical success of this case was due to just
such a cathartic process. Thus, the concept of the unconscious appears
early in his work and is later to become one of the foundational
concepts of psychoanalysis. In A note on the unconscious in psycho-
analysis (1912g), Freud offered this definition of the unconscious:
Free association
Free association was not Freuds invention. It has a long history in the
arts, beginning with its first recorded appearance in a comic play (The
Clouds) by the ancient Greek playwright, Aristophanes, in which the
subject was instructed (by the character playing Socrates) to lie on the
couch and say whatever came into his mind (Rogers, 1953). Other
appearances of the technique are noted in Hobbes Leviathan (1651) in
which he describes trayns of thoughts . . . unguided, without design
. . . as in a dream . . . [a] wild ranging of the mind . . . (McAlpine &
Hunter, 1956). Freud (1920b) frequently mentions the work of
Friedrich Schiller, a German poet, philosopher, and historian, who
proposed a theory of animal (forerunner to Freuds sexual instinct),
spiritual (forerunner to Freuds ego instinct), and play drives (fore-
runner of free association), which Schiller believed stimulated crea-
tivity. Freud was also aware of the work of Ludwig Boerne (1823),
including The Art of Becoming an Original Writer in Three Days, which
extols the virtues of free association in enhancing creativity. Frances
Galton (1879) (in Zilboorg, 1952) also explored free association, which
he called associated ideas.
Free association became the first fundamental rule of psycho-
analysis (Freud, 1914g, 1923b).9 In the second stage of technique
development, Freud abandoned both hypnosis and abreaction, replac-
ing them with a new focus on free association and the analysis of the
resistance. The German freie Einflle has the meaning spontaneous
thoughts, by which Freud meant utterances that were not goal-
directed or self-critical (Lothane, 2006). The analysand is instructed to
allow a free flow of associations, emotions, and images to emerge.
When a defensive blocking of those associations occurs within the
analysand, this blocking is called repression. When it is motivated by
the analystanalysand dyad via the transference, it is called resistance.
28 FROM ID TO INTERSUBJECTIVITY
The task became one of discovering from the patients free associa-
tions what he failed to remember. The resistance was . . . circumvented
by the work of interpretation and by making its results known to the
patient. The situations which had given rise to the formation of the
symptom and the other situations which lay behind the moment at
which the illness broke out retained their place as the focus of inter-
est; but the element of abreaction receded into the background and
seemed to be replaced by the expenditure of work which the patient
had to make in being obliged to overcome his criticism of his free asso-
ciations, in accordance with the fundamental rule of psycho-analysis.
(Freud, 1914g, p. 147)
Free association required the patient to say whatever came into his
mind, with no attempt to censure or organise his thoughts, thereby
becoming a passive observer of his own stream of consciousness.
Freud instructed his patients to Act as though . . . you were a trav-
eller sitting next to the window of a railway carriage and describing
to someone inside the carriage the changing views which you see
outside (Freud, 1913c, p. 135).
It was Anna Freud who identified the need to expose and interpret the
defences of the ego in order to reduce the psychic discontinuities.
Interpretation
Guntrip (1993), who commented that Psychoanalytic interpretation
is not therapeutic per se, but only as it expresses a personal relation-
ship of genuine understanding (p. 140), highlights the importance of
a genuine personal relationship between analyst and analysand as the
bedrock of the psychoanalytic process, without which psychoanalytic
technique cannot be effective. Interpretation constitutes the verbal
30 FROM ID TO INTERSUBJECTIVITY
Dealing with resistance is a relentless and often thankless task for the
analyst, who must repeatedly point out/interpret these resistances
throughout the entire course of the analysis before they actually take
hold. Both resistance and content appear in the transference relation-
ship and this will need to be interpreted when it arises. Daily events
that occur in the lives of patients during their analysis call forth old
responses and defensive patterns.
Transference interpretations are directed to the unconscious, with
the aim of making unconscious sources of pain conscious and, thus,
available for scrutiny. Freud believed that the emotional aspects of
insight and working through could only be developed and interpreted
in the transference, in the immediacy of the here-and-now, which,
during the course of the analysis, becomes a condensed, co-ordi-
nated, and timeless version of past and present (Schafer, 1982, p. 77).
The concept of counter-transference, defined as the effect of the
patient on the analysts unconscious feelings (Armony, 1975), consid-
ered such a centrally important part of the analytic relationship today
(Bernstein, 1993; Opdal, 2007), was infrequently mentioned in the
writings of Freud. However, Freud was aware of its existence; his
recommendation that all analysts undergo both analysis and self-
analysis implies that the analysts self can intrude on the therapy in
unhelpful ways. He was reminded of its significance in his therapeutic
encounters, particularly in his analysis of Dora. In his subsequent
32 FROM ID TO INTERSUBJECTIVITY
Resistance
Freud was intrigued by the phenomenon of resistanceit appeared
early and frequently in his writing. For example, in 1900, in Dream
of Irma, Freud observes:
The adoption of the required attitude of mind towards ideas that seem
to emerge of their own free will and the abandonment of the critical
function that is normally in operation against them seem to be hard to
achieve for some people. The involuntary thoughts are liable to
release a most violent resistance, which seeks to prevent their emer-
gence. (1900a, p. 102)
. . . and so it happens that anyone who tries to make [the patient] well
is to his astonishment brought up against a powerful resistance, which
teaches him that the patients intention of getting rid of his complaint
is not so entirely and completely serious as it seemed. (p. 43)
this there results a new sort of division of labour: the doctor uncovers
the resistances which are unknown to the patient; when these have
been got the better of, the patient often relates the forgotten situations
and connections without any difficulty. (Freud, 1914g, p. 147)
Freud recognised early that the treating physician was not immune
from the vicissitudes of resistance:
The length of the road over which an analysis must travel with the
patient, and the quantity of material which must be mastered on the
way, are of no importance in comparison with the resistance which is
met with in the course of the work . . . The situation is the same as
when to-day an enemy army needs weeks and months to make its way
across a stretch of country which in times of peace was traversed by
an express train in a few hours and which only a short time before had
been passed over by the defending army in a few days. (Freud, 1918b,
p. 11)
I determined but not until trustworthy signs had led me to judge that
the right moment had come that the treatment must be brought to an
end at a particular fixed date, no matter how far it had advanced. I
was resolved to keep to the date; and eventually the patient came to
see that I was in earnest. Under the inexorable pressure of this fixed
limit his resistance and his fixation to the illness gave way, and now
in a disproportionately short time the analysis produced all the mate-
rial which made it possible to clear up his inhibitions and remove his
symptoms. (p. 11)
While not all analysts take such an extreme view, most agree that
regression involves a period of induced ego disorganisation and
reorganisation, during which the analyst becomes a new object or
(secure base, in attachment theory terms) that emboldens the patient
to dare to take the plunge into the regressive crisis of the transference
neurosis which brings him face to face again with his childhood
anxieties and conflicts (Loewald, 1960, in Menninger & Holzman,
1973, pp. 5152). Loewald (1960) used the following analogy:
As far as his relations with the physician are concerned, the patient
must have unfulfilled wishes in abundance. It is expedient to deny
him precisely those satisfactions which he desires most intensely and
expresses most importunately. (Freud, 1919a, p. 164)
Once this point in the analysis has been reached, the working through
phase of treatment begins. Infantile feelings and goals become less
compulsive and the patient starts to feel freer to develop more adult,
adaptive means of relating to self and others.
It is interesting to observe that psychoanalysis as a therapeutic
technique emerged in the process of trying to understand current,
mostly hysterical or psychogenic, symptoms in light of current events
in a persons life. However, the importance of infant and childhood
experiences in the aetiology of the disorders that Freud treated in late
nineteenth- and early twentieth-century Vienna quickly became
apparent both theoretically and therapeutically. Even in the earliest
works, there are frequent references to the origin of hysterical symp-
toms in traumas that occurred earlier in life, often in childhood.
However, most of these experiences occurred in the post-verbal
period, were accessible to memory (often under hypnosis), and could
be verbalised. What is remarkable about the case study of the new
mother described earlier is Freuds intuition regarding the aetiology
of her presenting difficulties in some unresolved experience during
her own infancy, although clear articulation of such links was several
years away. When they did appear, however, their character had
changed to a focus on infant sexuality, as opposed to the implied
experience of either maternal neglect or misattunement, as in this
young mothers infancy. In the preface to the second edition of Studies
on Hysteria, published in 1908 thirteen years after the first, Freud adds
infantilism to his original theory of catharsis.
The patient comes into the analytic setting and goes out of it, and
within that setting there is no more than interpretation, correct and
penetrating and well-timed . . . [However,] [w]hat could be more reas-
suring than to find oneself being well analysed, to be in a reliable
setting with a mature person in charge, capable of making penetrating
and accurate interpretation, and to find ones personal process
respected? It is foolish to deny that reassurance is present in the clas-
sical analytic situation . . . The whole set-up of psycho-analysis is one
big reassurance, especially the reliable objectivity and behaviour of the
analyst, and the transference interpretations constructively used
instead of wastefully exploiting the moments passion. (p. 25)
Winnicott argued that in the transference, the past comes into the
present of the analytic relationship; in regression, the present becomes
the past. For other writers, regression signals the need for a change in
psychoanalytic technique, such as a withdrawal from active interven-
tion and interpretation in order to give the patients self-experience
sufficient time and space to unfold (Spurling, 2008, p. 527). Similar
descriptions of this process appear in, for example, Ferenczis princi-
ple of relaxation, Winnicotts regression to dependence, Balints
notion of life becoming simpler and truer (Balint, 1968, p. 135),
Slochowers (1996b) holding in which the otherness of the analyst
is minimised in order to prevent impingement on the patients unfold-
ing process, or Bollass (1987) use of the analyst as a transformational
object (p. 247) rather than a transference object that facilitates the
patients struggle to know his true self. The purpose of this process of
regression is to provide the basis for the emergence of hope and a new
beginning (Winnicott, 1955).
Spurling (2008) challenged the apparent excesses of previous ther-
apists who stepped outside the analytic frame for patients in a
regressed state, including the hand and finger holding of Winnicott,
who allowed regular out of session contact or actually assisting some
patients with life tasks. Masud Khan went even further and engaged
in sexual relationships with some of his patients, behaviour that today
would be considered a serious boundary violation. Spurling argues
that the concept of a therapeutic regression is vague and carries multi-
ple meanings. It privileges a particular state in analysis (that in some
cases might even be iatrogenically induced), which he contends prop-
erly belongs to the analysis as a whole.
42 FROM ID TO INTERSUBJECTIVITY
Termination
We will complete this overview of classical Freudian theory and tech-
nique with a few words about termination of the analysis. This is a
very vexed issue, even today (Hill, 2011), and although many areas of
psychoanalytic theory, technique, and practice are heavily contested,
issues related to termination remain among the most problematic.
Woody Allen makes a humorous and ironic allusion to the problem of
termination in this interaction between Annie and Alvy in Annie Hall:
Klein (1950) believed that the analysis was not complete until the
persecutory and depressive anxieties had been reduced, and the nega-
tive and positive transference analysed. Others were less optimistic
about the final outcome of psychoanalysis. For example, Ekstein
(1965) felt that
Our aim will not be to rub off every peculiarity of human character for
the sake of a schematic normality, nor yet to demand that the person
who has been thoroughly analysed shall feel no passions and
develop no internal conflicts. The business of the analysis is to secure
the best possible psychological conditions for the functions of the ego.
(Freud, 1937c, p. 250)
Freud (1933a) had a certain wry sympathy with Woody Allens char-
acter, Alvy, in Annie Hall,
I do not think our cures can compete with those of Lourdes. There are
so many more people who believe in the miracles of the Blessed Virgin
than in the existence of the Unconscious. (p. 152)
CHAPTER TWO
45
46 FROM ID TO INTERSUBJECTIVITY
the field gradually diverged; concepts were introduced that did not
form part of the original theory. Failure to achieve consensus with
respect to basic concepts compromises the scientific status of a disci-
pline. Rangell (2006) summed up the concerns of many in the field of
psychoanalysis today: Do we have many theories, hundreds of
psychoanalyses or even in the opinion of some, guided by the demo-
cratic ideal, a theory for every analyst or even for every patient?
(p. 218).
There have been many attempts to integrate and clarify psycho-
analytic concepts into a coherent theory. Kernberg (1969, 1974, 1976,
1995, 2001; Kernberg, Yeomans, Clarkin, & Levy, 2008) proposed a
synthesis of instinct theory and the structural model with object rela-
tions theory and ego psychology. Sandler (Sandler & Freud, 1980)
clarified the use of the terms id and impulse and how they might
be reinterpreted:
. . . changed first of all the terms I was using; what I had called
psychological analysis, he called psychoanalysis; what I had called
psychological system, in order to designate that totality of facts of
BEYOND FREUDS PSYCHOANALYSIS 55
For both Freud and Stolorow, therapeutic action occurs in the in-
vestigation of the patients experience of the transference relationship.
This process requires the analyst to continually reflect on his or her
own personal subjectivity (countertransference). The individual
subjective worlds of the participants in the analytic dialogue and the
intersubjective world co-created by both parties are, thus, the subjects
of investigation.
Evidence is, however, lacking for the translation rules for moving
from psychological theory to clinical practice (p. 24). Freud would
have had no argument with this position:
. . . the most successful cases are those in which one proceeds . . . without any
purpose in view, allows oneself to be taken by surprise . . . and always meets
them with an open mind, free from presuppositions. The correct behaviour
for an analyst lies . . . in avoiding speculation or brooding over cases
while they are in analysis, and in submitting the material obtained to
a synthetic process of thought only after the analysis is concluded,
(Freud, 1912e, p. 114, my italics)
. . . reconcil[ing] the search for meanings and reasons through the indi-
vidual exploration of a unique human life with the effort also to fit the
findings derived from that search into the explanatory constructs of a
general theory of the mind . . . (p. 307)
In the following extract, Mitchell (2004) addresses the psychic and co-
constructed realities described by Rosegrant (2010).
The past and dynamics to which Mitchell refers include our infancies.
How do we know and understand infant experience? What aspects of
that experience inform our adult relationships, including the transfer-
ence? Stern (1985) identified two types of infantthe observed infant
and the clinical infant. The observed infant has been constructed from
precise observations and recordings of those observations in
controlled conditions in scientific settings; the clinical infant has been
constructed, or rather co-constructed, retrospectively in clinical
(mostly psychoanalytic) settings with mostly adult patients. Until the
BEYOND FREUDS PSYCHOANALYSIS 61
Some writers (e.g., Wolff, 1996) have argued that infant research is not
relevant to psychoanalysis because the data of psychoanalysis is
language, a capacity that has not yet been acquired by the infant. This
is a specious argument, because infants develop knowledge about
themselves, their world, and their relationships non-verbally, non-
symbolically and implicitly and this knowledge forms the basis of
their object relationships (Kenny, 2013), which later become accessible
through language in the transference (Lecours, 2007b; Talberg, Cuoto,
De Lourdes, & ODonnell, 1988; Talvitie & Ihanus, 2002). This brief
discussion on psychoanalytic reality highlights another major ques-
tion in psychoanalysis, that is, the role of language, given the empha-
sis in current psychoanalytic therapies on infant states of mind
(Madigan, Moran, & Pederson, 2006; Muscetta, Dazzi, De Coro, Ortu,
& Speranza, 1999; Wrye, 1996). It is to this topic that we will now turn
our attention.
I mention this here briefly because Freud revered the poets, both for
their insights into human nature and their ability to express the inef-
fable. Freud brought his literary sensibilities to bear on his struggle to
develop a language that could adequately characterise his emergent
theorising. Freud (1923c) described psychoanalysis as the art of inter-
pretation and noted strong affinities between poetry and his own
endeavours: (Everywhere I go I find that a poet has been there before
me;15 Poets are masters of us ordinary men, in knowledge of the
mind, because they drink at streams which we have not yet made
accessible to science16). Eliot (1975) also exalted the poet who, like the
psychoanalyst, . . . is occupied with frontiers of consciousness
beyond which words fail though meanings still exist (p. 111). Akhtar
(2008) argued that poetry arises from the preverbal era of infantile
experience and can therefore assist us to mentalise the unspoken
substrate of subjectivity.
Holmes (2010a) (see Chapter Four) has also drawn compelling
similarities between psychoanalysis and poetry.
. . . the metaphor takes flight and then while in flight it loses its status
as a metaphoric extension, and becomes . . . a new reality, a co-
constructed reality, spiralling outward as if it were now solid and
confirmed. We go from airy metaphor, to data that seem poetically
consistent, to a sense of a grounded reality. Often I was not
convincedthis is someone elses religious conviction . . . (p. 1046)
I will defer to Winnicott (1955) for the last word on this subject:
Almost from the outset, there were disagreements between Freud and
Breuer about how to articulate and interpret their clinical observa-
tions, as this comment on their competing interpretations of the clin-
ical facts in the early case studies attests:
Breuer, in his case history of Anna O, stated that when Anna experi-
enced . . . a string of frightful and terrifying hallucinations . . . her
mind was completely relieved, when, shaking with fear and horror,
she had reproduced these frightful images and [gave] verbal utterance to
them. (Breuer, in Freud, 1895d, p. 29, my italics)
Later, Breuer commented that her
Finally, all her symptoms were talked away (p. 34, my italics). Freud,
similarly, had great respect for the power of language to communicate
literally and symbolically. He observed how symptoms in his hyster-
ical patients were a symbolic expression of the actual trauma, that the
hysterical symptoms restored the original meaning of the words
because . . . the description was once meant literally (Freud, 1895d,
p. 181).
As Freuds psychoanalytic techniques and methods unfolded, the
verbal communication between analyst and patient was privileged
over other forms of communication, leading him to conclude that a
correct verbal interpretation was both curative and transformational
because it had the capacity to make the unconscious conscious. In his
Preliminary communication (Freud (with Breuer), 1895d), Freud
discussed the proposed mechanism of cure in hysteria in these terms:
It brings to an end the operative force of the idea which was not abre-
acted [discharged as emotion] in the first instance, by allowing its stran-
gulated affect to find a way out through speech; and it subjects it to
BEYOND FREUDS PSYCHOANALYSIS 67
These early case studies were written in a clear and compelling way,
firmly grounded in clinical observation and introspection. They repre-
sent intriguing phenomenological narratives that invite the readers
participation, empathy, and understanding because the humanity of
both the patient and the analyst is compelling in the written record.
Freud (1895d) himself noticed the poetic and narrative quality to his
early writing:
. . . even I myself am struck by the fact that the case histories which I
am writing read like novels . . . a detailed discussion of the psychic
processes, as one is wont to hear it from the poet . . . allows one to gain
an insight into the course of events of hysteria. (p. 50)
Eliots (1933) view about the function of poetry resonates with Freuds
intuitions about his poetic prose.
[Poetry] may make us a little more aware from time to time about the
deeper, unnamed feelings that form the substratum of our being, to
which we rarely penetrate; for our lives are mostly a constant evasion
of ourselves . . . (p. 55)
. . . there emerges from time to time in the creations and fabrics of the
genius of dreams a depth and intimacy of emotion, a tenderness of
feeling, a clarity of vision, a subtlety of observation, and a brilliance of
wit such as we should never claim to have at our permanent command
in our waking lives. There lies in dreams a marvellous poetry, an apt
allegory, an incomparable humour, a rare irony. A dream looks upon
the world in a light of strange idealism and often enhances the effects
of what it sees by its deep understanding of their essential nature
(Freud, 1900a, p. 62).
model of the id, ego, and superego (Brenner, 2003; Sandler, 1974).
Theorising subsequently became more dense and jargonistic, prompt-
ing Stein (2001) to comment:
Our minds are not static structures that we carry around for display
in different contexts. What we carry are potentials for generating
recurrent experiences that are actualized only in specific contexts, in
interpersonal exchanges with others . . . [O]ur very thought processes are
composed of language and interiorized conversations with others. Therefore,
we are embedded, to a great extent unconsciously, in interpersonal
fields, and, conversely, interpersonal configurations are embedded, to
a great extent unconsciously, in our individual psyches. (p. 539, my
italics)
This process does not constitute the entire therapy and the goal
remains the establishment of a collaborative relationship between
analyst and patient.
We have learnt a great deal from infant observation research about
the nature of experience as it unfolds from birth. This literature is
reviewed in detail elsewhere (Kenny, 2013), but, for now, the conclu-
sions drawn by Stern (2010) seem apposite. Although psychoanalysis
is a talking therapy and necessarily privileges linguistic processes
such as narrative and interpretation, the deepest level of meaning
derives from
What is essential for Winnicott is that the baby invents its own mother,
indeed makes her come alive . . . the baby turns the mother into a
series of verbal nouns: milk-giver; warm body-holder; smiling face-
maker; the mother becomes an action the baby needs and over time
these action states coalesce into a being the baby creates as mother.
(p. 36)
act [out] and dramatize their thoughts and phantasies . . . [words are]
the bridge to reality which the child avoids as long as he brings forth
his phantasies only by playing . . . [It] always means progress when
the child has to acknowledge the reality of the objects through his own
words. (p. 314)
Freud cannot escape the fate of most of the great scientists, that of
becoming also a philosopher . . . This philosophizing of Freud which
BEYOND FREUDS PSYCHOANALYSIS 77
In discovering that the symptom had meaning and basing his treatment
on this hypothesis, Freud took the psycho-analytic study of neurosis out
of the world of science into the world of the humanities, because a
meaning is not the product of causes but the creation of a subject. This
is a major difference; for the logic and method of the humanities is
radically different from that of science, though no less respectable and
rational, and of course, much longer established. (p. 43)
Psychological trauma
The more subtle shift within this refocus on the external relational
environment has been the changing view of what experiences consti-
tute trauma. As with many complex psychological issues, Freud
(1926d) presaged this difference, although his original conceptualisa-
tion of trauma was event based (e.g., death of a parent; sexual abuse).
However, he later revised his theory of anxiety, distinguishing
between traumatic (primary) anxietywhich he defined as a state of
psychological helplessness in the face of overwhelmingly painful
affect, such as fear of abandonment or attackand signal (secondary)
anxiety, which is a form of anticipatory anxiety that alerts us to the
danger of re-experiencing the original traumatic state by repeating it
in a weakened form so that measures to protect against retraumatisa-
tion can be taken. You will notice that in these definitions of anxiety,
Freud is not talking about single, discrete events that cause the
trauma, but about a generalised fear of an anticipated experience, a
position much closer to post-classical Freudians, attachment theorists,
and relational and intersubjectivist theorists (Diamond, 2004).
In The First Year of Life, Spitz (1965) said, I cannot emphasize suffici-
ently how small a role traumatic events play in [infant] development
82 FROM ID TO INTERSUBJECTIVITY
The worlds finest tennis players train five hours a day to eliminate
weaknesses in their game. Zen masters endlessly aspire to quiescence
of the mind, the ballerina to consummate balance; and the priest
forever examines his conscience. Every profession has within it a
realm of possibility wherein the practitioner may seek perfection. For
the psychotherapist that realm, that inexhaustible curriculum of self-
improvement from which one never graduates, is referred to in the
trade as countertransference. (Yalom, 1989, p. 87)
Freuds discovery of the transference and his assumption that this was
the sole relationship to the analyst served to deny unbearable reality.
Actually, the analyst must function as both real and transferred object for
the patient and these distinctions must be kept clear by both of them;
otherwise analysis is impossible. (pp. 308309, my italics)
Much of the data on which theories are based derive from individual
relationships between patient and analyst. Confidentiality and privacy
are certainly important issues, but what happens to a science when few
data are directly shared with others? A scientific community becomes
more illusion than reality unless a considerable amount of significant
data is shared, not just the conclusions. (Kirsner, 2004, p. 341)
Table 1. (continued).
Kleinians/ Reducing splitting and projective identification (Klein,
object relations 1975)
Interpretation of anxiety and the negative transference
(Reich, 1926)
Patients experience of the analyst as a good object and
letting go of the internalised bad object (Fairbairn, 1952;
Ogden, 1983)
Facing emotional truth (Bion, 1970)
At the end of the analysis, the analyst becomes devalued
and useless, i.e., de-idealised, and the analysand accepts his
own incomplete state (Bion, 1965)
Moving from K to
K (Symington & Symington, 1996)
Self Therapeutic action occurs not primarily through self-under-
psychology standing but feeling understoodthrough the feeling of
solidarity (Rorty, 1989) and the empathic bond (Kohut,
1984)
The ability to tolerate the reintegration of previously
rejected or split-off parts of the self (Kohut, 1984)
Attachment- Being recognised and understood by another (Winnicott,
based 1941)
. . . psychoanalysis is no way of life. We all hope our
patients will finish with us and forget us, and that they will
find living itself to be the therapy that makes sense
(Winnicott, 1969, p. 712)
Attachment to the analyst is a pre-condition before
interpretation can be effective; importance of care and
concern (Gitelson, 1962, p. 14)
Learning about ones mind; reflection as a conscious,
cognitive process (Fonagy, 1999)
Containment, insight and new experience (Holmes, 1998a,
p. 230)
Healingmaking wholethe divided self (Holmes, 1998a,
p. 230)
Relational/ . . . the unfolding, illumination, and transformation of the
intersubjective patients subjective world (Stolorow, Brandchaft, &
Atwood, 1987, p. 10)
Corrective relational experience (Mitchell, 1995); patients
introject the structure of the analytic relationship (Loewald,
1960)
(continued)
96 FROM ID TO INTERSUBJECTIVITY
Table 1. (continued).
Relational/ If the analyst cannot be experienced as a new object, the
intersubjective analysis never gets underway; if he cannot be experienced
(cont.) as an old one, it never ends (Greenberg, 1986, p. 98)
. . . the patient [must] experience the analysts mind as a
place within which the patient exists as an internal object . . .
toward whom the analyst relates with agency and freedom
(Spezzano, 2007, p. 1564)
Co-construction of a coherent narrative truth (Emde, Wolf,
& Oppenheim, 2003)
. . . the coming into language of ones emotional
experiences (Stolorow, 2008b, p. 281)
The analyst, through sustained empathic inquiry,
constructs an interpretation that enables the patient to feel
deeply understood. . . . psychoanalytic interpretations . . .
derive their mutative power from the intersubjective matrix
in which they crystallize (Stolorow, 1994, p. 43)
Therapeutic action is the creation of meaning (Stolorow, (2002)
Patient and analyst collectively scan and revise old views of
reality for the purpose of co-constructing new narratives
that change the patients expectations, assumptions, and
decision-making (Renik, 1993)
Lacanian Therapeutic action consists in gently pushing the patient
away from his comforting assumption that he can depend
on the analysts authoritative endorsement, gradually
forcing him to become his own self-sufficient authority
(Lacan, 1976)
At the end of the analysis, the analyst no longer occupies
the place of the subject supposed to know (sujet suppose
savoir) and appears instead as a limited and incomplete
subject (Lacan, 1976)
Integrationist Therapeutic action requires the development of a new
relationship with ones internal (creativity and play) and
external (love and work) worlds (Diamond & Christian,
2011)
Therapeutic action uses a reliable wish that patients have to
understand themselvesa wish they present either at the
outset (Renik) or that is developed in treatment (Lander).
They both suppose that therapeutic action at least partly
piggybacks on that wish (Freidman, 2007)
The subject accepts (without conflict or guilt feelings) the
indelible marks of childhood that have resulted in the
formation of his character (Lander, 2007, p. 1151)
BEYOND FREUDS PSYCHOANALYSIS 97
DK: Thank you for talking with me today about the talking cure.
Could we start by your telling me what professional and personal
experiences directed you into the profession of psychoanalysis?
99
100 FROM ID TO INTERSUBJECTIVITY
about looking at me and that they feel freed by being able to look at
the ceiling or anywhere else rather than me, and that they can say
things that they probably wouldnt say if they were saying it face-to-
face. So it is a freeing experience and it enhances free association,
which is an important part of the method. Its something that Freud
got on to as well, the idea of saying whatever comes to mind, without
censoring, because the theory suggests that one thing leads to another
and you can trace along a chain of associations that become meaning-
ful. You cant always know, by any means, but very often its an
important part of what goes on, that the meaning of D comes from A,
B, C. On its own it wouldnt mean anything and its something about
the unconscious that, in fact, given a fair chance, it will exploit this
phenomenon; the unconscious will make itself heard. Things remind
people of things in the unconscious sense of remind. Since becoming
a psychoanalyst, Ive taken an extra interest in words. Ive always
been interested in words, but I just used the word remind meaning
re-mind. There is folk wisdom in language; words, in fact, contain
very sophisticated psychological concepts. The idea of re-mind is
bringing back to mind again and its in the word itself, in the English
language. There are countless examples of this that come up over and
over again. Our minds, our social minds, our language contain
psychological reality, or psychic reality.
RS: Well, I try to have a balance. Its not one or the other. Its both.
The non-verbal is at a minimum when youre sitting behind the couch,
but its not absent. By non-verbal, Im not talking about body lan-
guage; Im talking about affect. Affect is a very important part of
analytic work, what is felt, not necessarily heard. I pay really close
attention to words, perhaps more so than other people think is neces-
sary, because I can work out some things by the words that are used.
Ill actually even hear a different word in my mind than a word a
patient might say.
RS: A patient was talking about a dream today and he said, I got
a speeding ticket by accident. I listened to the whole dream and
eventually said, How does one get a speeding ticket by accident?
and then he described the dream in ways that he hadnt described the
first time, putting in some more detail. He and his father were both
riding motorcycles. His father had been speeding but the policeman
fined him rather than his father. His father avoided something that
eventually ended up on him. So it was unjust, not accident, but acci-
dent just seemed like the wrong wordit didnt make sense to me.
By questioning it, there was a truth that he was defending against, not
necessarily to deceive me, but unconsciously he used a different form
of words to avoid the emotional impact of having been unjustly
treated by his father. Patients will often use a word that that will
minimise an affect.
A patient yesterday stated, I was shocked when something or
other happened. I thought, Why are you shocked? This is a good
thing. Why were you not pleasantly surprised? because it was a
better-than-usual outcome of a series of events. What was shocked
was an unconscious part of her that prefers destructiveness rather
than constructiveness. Any other person listening wouldve thought,
Why werent you pleasantly surprised? This is nice. But it was
shocking to the part of her that doesnt want niceness.
DK: Would you interpret that immediately?
RS: Id draw attention to it and then we would try to explore along
the lines that we have just discussedI eventually said what Ive just
said. A part of you was shocked because its not the way it wants
things to be. It wants things to be repetitiously self-destructive. On
one hand, thats an intellectual interpretation and its not in the trans-
ference, but I would hope, in due course, to find a manifestation of
that phenomenon in the transferencecountertransference. On their
own, these intellectual insights dont bring about mutative or trans-
formative change, but I would hope to hold that sort of thing in mind
and then try to link it to something thats actually going on in the
room, as I say, between the two of us.
DK: I imagine that it would potentiate it, though. When it does
come up in the transference, its not a completely new or alien
concept.
DR RON SPIELMAN: OBJECT RELATIONS PSYCHOANALYSIS 105
had reasons that you come to understand as to why they were the way
they were, rather than they just got out of bed every morning and
wanted to treat you badly. You know, you come to understand that
they were traumatised too, and troubled, so the objective is to restore
a closer-to-reality version that can be accepted.
DK: That is a very helpful clarification of the work that object rela-
tions psychoanalysts do with the patients internal objects, particu-
larly the parents of ones childhood. Were there any particular
theorists that influenced your thinking and practice?
RS: Freud, of course. Ive been mainly influenced by the Kleinian,
post-Kleinian [Spielman, 2006b] and neo-Kleinian [Lombardi, 2006]
models. The British object relations school includes the Independents,
who are analysts who did not identify with the Kleinians. I certainly
am not a Kleiniandont aspire to be one. The British object relations
group have been most persuasive for me. In America, we have post-
Kleinian theorists like Ogden and Bion [1963] who have also made
contributions. I dont use Bion concepts a lot other than as part of
object relations theory. Latin-American psychoanalysts think similarly
to the British object relations school, but they have come at it their
own way through their own traditions. Not reading Spanish, I havent
been influenced by them as theoreticians, but you come across them
at conferences and we hear their papers being simultaneously trans-
lated and theyre talking the same language as us. People to whom I
can relate are talking British object relations no matter what continent
theyre from. Ive even been to a conference in India where Indian
analysts have presented clinical material and their patients sound like
my patients. Those analysts themselves have been taught by British
object relations analysts, so thats not surprising, but the patients
sound like theyve got the same inner worlds, living in that culture, as
patients here. Theyre very familiar clinical cases and the clinical
discussion is very familiar.
DK: It is interesting that the inner worlds of people are essentially
the same across cultures. This is particularly intriguing given how
apparently different formative experiences are for people from differ-
ent cultural, ethnic, and religious backgrounds. This observation lends
support to an ethological/attachment theory understanding of human
development and human relationships. Do you see any relationship
DR RON SPIELMAN: OBJECT RELATIONS PSYCHOANALYSIS 109
and internally with the internal object mother. There are correspon-
dences between psychoanalytic notions of projection and introjection
and attachment theorys idea of the infant exploring the mental state
of his mother which, if the mother is sufficiently sensitive and
attuned, allows him to find himself reflected as an agentic being in her
mind. Bowlbys attachment theory [Bowlby, 1973] argued that it was
the actual relationships of early childhood and not so much the inter-
nal phantasies about them that shape us. One of the differences
between object relations theory and attachment theory is that attach-
ment theory is not so interested in phantasy per se, as originally under-
stood in early psychoanalytic theorising and as you have just outlined.
RS: Not at all and not in the transference and countertransference
by definition. So I dont really understand what attachment-informed
psychotherapy does. Ive never heard anybody present a case. Addi-
tionally, if you listen to people presenting cases from different
schools, a good clinician is a good clinician no matter what they think
guides them. But when we talk with each other about some of our
theories, some of them are just radically incompatible with each other.
This is the case with psychoanalysis and attachment theory. Peter
Fonagys written a book about it.
DK: Peter Fonagy [Fonagy & Target, 2003] tries to integrate psycho-
analytic thinking and attachment theory. There are significant syner-
gies between the two. However, there are also some fundamental
tensions that appear difficult to reconcile. Take affects and affect regu-
lation, for example. Both theories acknowledge the importance,
indeed primacy, of affect in both the development of the sense of self
and in mutative change in therapy. However, psychoanalytic theory
views affects as bodily experiences that are connected with drives and
instincts, arising within the conflicted mind, whereas attachment
theory argues that infants affective experience and capacity for affect
regulation arises in the interaction with early primary care-givers.
You asked the question, What do people in attachment-based
psychotherapy do? This therapy is informed by the four major types
of attachment and the adult behaviour that arises as a result of a
patients state of mind with respect to attachment that they brought
with them into adulthood. The four attachment types in childhood are
secure, avoidant (insecureavoidant), ambivalent, (insecureresis-
tant), and disorganised. Children internalise their dyadic relationships
DR RON SPIELMAN: OBJECT RELATIONS PSYCHOANALYSIS 111
with their primary care-givers that guide all subsequent ways of relat-
ing to others. That is, they carry a state of mind with respect to attach-
ment that is a template from which they understand and conduct their
relationships. These states of mind are secure (autonomous), preoccu-
pied, dismissing, and unresolved/disorganised. In attachment-based
psychotherapy, the assessment process includes an evaluation of the
persons state of mind with respect to attachmentit rarely falls
exclusively into one of the four main types. There can be significant
overlaps, but they guide the therapists understanding of the patients
expectations of relationships. Attachment types in infancy predict
adult states of mind with respect to attachment. Secure parents have
secure infants; preoccupied parents tend to have ambivalent infants;
dismissing parents, avoidant infants, and disorganised parents, disor-
ganised infants.
RS: So what do you do then?
DK: The attachment style informs the nature of the transference. For
attachment-based psychotherapists, transference is regarded as inte-
gral as it is in psychoanalysis and is considered the locus of mutative
change. That is because patients will repeat their early attachment
style within the therapeutic relationship and in that way it is brought
into the room and worked with directly. Jeremy Holmes, who is also
part of this conversation, put it well when he said, What good ther-
apists do with their patients is analogous to what successful parents
do with their children. The therapist becomes the secure base that
was missing in early development, from which the patient can access
and explore painful affects and split off parts of the self, own them
and integrate them.
RS: Well, its just another way of describing what happens, I
suppose.
DK: It is really, because lets take someone with a dismissing state
of mind with respect to attachment. In the psychoanalytic literature,
this pattern has been described as narcissistic self-sufficiency. Both of
these conceptualisations describe people who have been profoundly
disappointed by their attachment figures and become defensively self-
reliant and distancing in their relationships because their attachment
figures were too unreliable or misattuned to allow them to feel safe
and understood in those early relationships. Both narcissistically self-
112 FROM ID TO INTERSUBJECTIVITY
detached from the herd and any criticism of his performance by the
audience renders him an outcast for his audacity. I wonder if we could
talk about the all-important frame in psychoanalysis. There are a
number of elements involved but I dont want to pre-empt your
response. So lets start with my asking you what elements you would
consider essential in setting up a psychoanalytic frame?
RS: The all-important frame . . . When I teach, I try to liken our
consulting room to a surgical operating theatre, not to make it sterile,
but to say how important it is to keep it clean of contaminants. The
idea is to set up the frame, the milieu, the environment, whatever we
want to call it, within which this work is going to be done. There are
so many variables in any human relationship but we attempt to
minimise them, to rule some variables out.
DK: Can you give an example?
RS: Well, all the variables that theoretically emanate from therapists,
to try and make it as much about the patient as possible. Youve got the
room to be as quiet and bland as possibleyes, this rooms bland.
Theres very little that intrudes on the patient but everything in this
room has meaning to me. Theres a little story attached to everything
except the wastepaper basket and the heater. The only three paintings
on the wall mean a lot to me. These little things on the desk have sto-
ries important to me. The couch belonged to that person whom I told
you influenced me originally. When he went back to America, I inher-
ited his couch because wed become friends, but its basically a bland,
unintrusive room. Theres nothing that really impacts on you although
it is not just bare walls but its kept to a minimum.
DK: Yet you have some very personally important items in here.
RS: Yes, I do, but whatever the patient makes of the objects in the
room is the important thing, even though there are bits and pieces of
me. When a patient comes to the door, Ill open the door; I cant help
smiling but I dont say anything. I dont say, Hello, how are you?
because the focus is on them from the minute that they cross the
threshold to the door. As soon as I hear them enter the building, Im
focused on how quickly they come up the stairs, whether they delay
and what they sound like. Ive got one patient who drags himself up
the stairs; it feels like hes coming to an execution every day. Others
come more enthusiastically. You can get a sense and a feel of whats
DR RON SPIELMAN: OBJECT RELATIONS PSYCHOANALYSIS 115
going on in them before they even come into the room. They go and
lie down and Im sitting behind the couch, and the whole focus is on
them. The main idea is to provide an environment within which
everything that happens theoretically originates from them although
I am, of course, part of it. If I say something early on, Ive become
involved; if I dont say something, that also has an effect on what
evolves. Theres no way that youre not part of what goes on in some
way, and I will discuss with myself in my own mind whether I say
something earlier or later or wait orto try to get more information
from them before I try to make up my mind what is worth saying, but
the focus is really on the patient.
To make this a knowable, predictable and safe space, you have to
have boundaries and thats why we call it a frame. They come in,
theyve got control over when they come in, they can be late if they
want to, they can knock on the door early, but generally speaking, the
expectation is that they dont. If somebody comes markedly early, I
say, Well, its not your time yet. Youll have to go back to the wait-
ing room. Nobody uses the waiting room. They all come in at the
right time, but Ive got control over the end of the session. I own the
end of the session; they own the beginning, even though theyre
invited to come at a particular time. So that plus my dates: I tell them
about my planned breaks within the first few weeks of the beginning
of every year, my plans for the whole year in terms of when Ill be
here and when I wont be here.
DK: So you are in charge of the setting and the timing. What about
payment and payment for missed sessions?
RS: I charge for missed appointments because my commitment is
to be here; their commitment is to come and pay for their session. This
is part of the frame. The holiday dates, number of sessions per week,
the more the better. Its hard these days to get people to come five
days a week, but five is better than four, and four is better than three,
and three is better than two. One is barely worthwhile these days in
terms of psychoanalysis. A lot of people do once-a-week psycho-
therapy. But to call it psychoanalysis, coming five days a week and
having a two-day weekend is the ideal, using the couch. Anything
short of that is resistance. Weve settled on four or five days a week
and these days, we accept four days a week, because in this busy time
and age and it is very costly. Four days in a row and a three-day
116 FROM ID TO INTERSUBJECTIVITY
charge them. But Ive got Medicare here, which I actually find an
intrusion and interference becauseand I envy my non-medical
colleagues in this regardbecause they have a direct financial rela-
tionship with their patient. They charge them and the patient pays.
Medicare supports and subsidises and makes psychoanalysis accessi-
ble to a lot of people who probably couldnt get here otherwise. But it
interferes with this direct relationship of paying for what youre
getting. This is not just a question of economic pragmaticsthat Im
selling my time and Im entitled to be paid. I genuinely think that a
huge amount of work gets done over this issue because it, at base, is
about object relations. Its about regard for the objectthe otherand
concern. Maturity is about being able to have regard for the other and
being able to treat them well and not abuse them, and all these issues
come into payment or not for a missed session.
Patients who pay for missed sessions without question are equally
as problematic as those who dont want to pay, because theyre gloss-
ing over what you quite rightly say are feelings of anger, but this can
be worked through. If you were a landlord and you charge rent and
say, You can come and live here as long as you pay rent or until I sell
the premises, which is the equivalent of my retiring [laughs], if the
patient goes off on a holiday, they dont say, Im not going to pay
you rent for three weeks. Thats the way it is. This is the issuethe
persons asset is their property and they rent it. Compassion doesnt
come into it. You might be happy to say, If you cant pay me this
week, Ill wait til next week. But they wont go as far as saying,
Well, you dont have to pay me at all. A compassionate landlord
might say, All right, I understand youve got some financial troubles
this month and Ill wait til next month, but they cant endlessly say,
Well, you can have the use of my assets and I dont get any return
on it. Thats making it sound callous but what we eventually get to
is how the person regards me and treats me and theyve come to
acknowledge that Im offering this and they have responsibility to pay
for it as much as I have of being here in as good a shape as I can be
and never cancelling, but I regard it as very important that I be here
in as good a condition as I can, and they come to appreciate that. They
marvel that you dont take days off, other than the ones that you
say youre going to. Sometimes you have to give notice and say, I
cant be here on such-and-such a day, unexpectedly, but its been
very rare.
118 FROM ID TO INTERSUBJECTIVITY
Its time for you to think about going. Generally, I wait until they
give me enough indication that their unconscious is ready to go and
then we work on termination. Seven, eight years would be a mini-
mum to do enough work on a not grossly disturbed patient, but really
sick patients need a lot longer.
DK: That is a very long commitment to one patient. How do you
maintain interest over such a long period?
RS: Its endlessly fascinating and boring at the same time [Spielman,
1997a] [laughs]. Once I make a commitment, I hang in there.
If it does get boring or uninteresting or feels unproductive, thats
different from someone whos ready to go. When somebody has done
the work and is ready to go, you then do the work on leaving, which is
interesting in its own right. However, if it grindsnot to a haltbut if
its grinding, its because theres resistance and then you have to try to
figure out whats going on in the transference and the countertransfer-
ence, and work on that. Its endlessly interesting in terms of theres
always something to think about, wonder about, work on, deal with,
and as long as the patients committed to coming and paying and
taking some interest, then its a working partnership. By definition,
part of the patient is resistant from the word go, and you have to accept
that youre working against the resistance all the time. Otherwise they
wouldnt be a patient. Everybody is resisting, to a considerable degree,
knowing themselves in ways that might be better if they did know
themselves. Theres too many ways of avoiding knowing but not
everybody has to know him- or herself if they dont want to. But as
soon as they come across my door, the threshold, thats part of the
deal. We have to know, we have to face whats to be known as best we
can.
DK: Yes, the contract must be fulfilled. What happens at the end
lets say an eight-year, five-times-a-week contact with a personis it
just the end or are there different ways of terminating?
RS: Well, it starts to become the end when theyve got better things
to do with their time than to come here. Thats not meant in a nasty
way. There have been reasons for coming and then they find that out
that there are more things to do and they are now in a position to do
them. So the idea of finishing has got to be because I dont need to
come any more and I can better enjoy my life than I did before. Then
122 FROM ID TO INTERSUBJECTIVITY
the process of letting go becomes an important one. All the issues tend
to get revived and sometimes theres a resistance to go and the patient
will start to become symptomatic again in order to say, You cant
kick me out. Its endlessly variable, but there are lots of commonali-
ties too. Everyones unique with respect to this question of letting go.
So it depends what the model is. The model could be the death of a
parent or the model could be growing up and leaving home, in two
different styles of leaving and reasons for leaving. One patient I
remember vividly, when it came to leaving, said, I want to leave like
a boat leaves, not leaving like an aeroplane leaves, because leaving by
aeroplane, you go through the doors and thats it. With a boat, youre
holding on to the streamer until they go out of sight. So ones a more
a weaning type of leaving and the other one was an abrupt shut-the-
door-and-never-look-back type of leaving. These were the two things
that she had in mind. Weve worked on what both of them meant.
With some of my patients, wed drop sessions before leaving and for
others, wed set a date and wed go five days until the last day. By
choosing when it comes time to leave, it gets talked about how you go
about it. They all imagine that theres the textbook way of leaving,
which there isnt. Youve got to try to tailor it to each individual. Some
wean themselves off me and others say, Well, thats the date and I
will work analytically up until the last day. Ive had both experi-
ences, and theyre both valuable as long as you get the right one for
the right patient. Youre not going to know that until its too late
[laughs]. Some people set a date and revise it.
DK: What about coming back after termination?
RS: That can happen and does happen. Ive had some people come
back and Ill just see them once a week for a while to deal with a
particular issue. Some will come back because it was an unsatisfactory
ending. Well have another go. They leave again andso the idea is
to maintain the frame forever. Once they do leave, Im here in the way
that I always was. Theres no social or getting in touch withon a
casual basis, I try to preserve myself as available if they ever need me
again . . .
DK: As a therapist?
RS: . . . in the cleanest possible way. So theres no never darken
my doorstep again, but many have a fantasy that thats what it is;
DR RON SPIELMAN: OBJECT RELATIONS PSYCHOANALYSIS 123
that once they leave, Ill never want to know about them or have any
contact from them. Whatever the fantasy is, hopefully it gets worked
on before they actually leave. So if somebody wanted to write a letter
and tell me how theyre getting on, that would be most welcome, but
the idea is that they should be able to go and get on with it without
being attached in a way thats shackling to them.
DK: Sure. Would you respond to the letter?
RS: Id say, Thank you for your letter. Thats all.
DK: But you wouldnt respond in a more personal way?
RS: I wouldnt write back and say, How are you and whats going on?
DK: OK, so this minimal responsiveness occurs in the interest of
maintaining the frame, even after patients have left. . . . Can you say
a little bit about dreams and dream analysis?
RS: Freud made a big thing out of it, and rightly so, but dreams are
part of the material nowadays. Its the royal road to the unconscious
in the sense that it tells you things that a conscious account of oneself
wouldnt tell you, but they are not elevated to any special rolethey
are just part of the material and the free association [Spielman, 2001].
Having said that, a dream thats told at the beginning of a session is
different from one thats told in the middle from one thats told at the
end. Patients might say at the beginning of the session, I had a dream
last night, . . ., then its part of the agenda. If youre in the session and
you make an interpretation and they say, Oh, that reminds me of a
dream, thats much more spontaneous and revealing and important,
and if they tell you a dream at the end of the session, then they dont
want you to know about it and interpret it [laughs]. So it depends on
whereabouts in the session it comes, the content, and whats it in
response to. It is a special revealing set of material, but not in any
different way to acting out or acting in or anything else thats driven
by less-than-conscious deliberation.
DK: So psychoanalysis as it is practised today treats dream material
in the same way as any other material that is brought into the session,
like the unusual choice of words that we talked about earlier?
RS: Anything thats determined by something theyre not con-
sciously out to tell you. That can be lots of things. Its one way that the
124 FROM ID TO INTERSUBJECTIVITY
unconscious can have a say and I dont think you can interpret every
dream or every bit of every dream. But I take them seriously and do
my best to hold them in mind through the whole session. I dont do
dream analysis in the sense of question and answer, but it doesnt
mean I dont ask questions. I dont systematically work my way
through a dream in a way that Freud may have done at the beginning.
Its not an expectation, but if a patient doesnt bring dreams, youd
wonder whats going on. So not to dream or not to report dreams is
a resistance because we know everybody dreams, so why arent
they bringing them along and telling them. On the other end of the
spectrum, the record was a patient telling me seven dreams in a row,
which I couldnt possibly work with. I was being overwhelmed with
something for some other reason that day. So everything has to be
taken on its merits on the day. Theres no dream analysis, in
inverted commas, thats elevated above anything else that might
happen in the session, to my way of thinking.
DK: Can you comment on whether oedipal issues are still consid-
ered part of the analytic process?
RS: They are always there. Freud came through the oedipal door-
way and Melanie Klein came through the infantile dependency, need-
iness, envy, destructive baby doorway. Klein was more identified with
the pre-oedipal; Freud with the oedipal, but Freud couldnt do every-
thing. What he did was impressive but a combination of oedipal and
pre-oedipal is necessary. If oedipal issues are dominant at the begin-
ning, theres something wrong, because it indicates that pre-oedipal
issues are likely being defended against. When one comes into analy-
sis, ones coming in as a newborn baby into this relationship, and there
are dependency issues that should take pride of place. If a patient is
excessively oedipal at the beginning, then it means that the oedipal
issues have become intense because the other issues are unbearable.
On the other hand, people can get stuck in their dependency issues
and never get, or dont want to get, to oedipal issues. Thats resistance
as well. If a woman patient is excessively histrionic at the beginning,
Id have no doubt that the relationship with her father has interfered
with her relationship with her mother, and that Im seeing
daughterfather issues as a cover-up for motherbaby issues. So Id be
trying to get hints and clues of the pre-oedipal issues. Likewise, if a
man is excessively rivalrous with me at the beginning, the same
DR RON SPIELMAN: OBJECT RELATIONS PSYCHOANALYSIS 125
applies. Its a cover-up for his dependency and neediness and longing
and yearning for me to be a good mother, even though Im a male.
Regardless of the sex of the therapist, the unconscious drives the
issues. I actually think its easier for a male to be felt as a maternal
object than it is for a female therapist to be seen as a paternal object.
It doesnt mean that a woman doesnt have paternal or phallic aspects
that can be either projected on to them or enacted in their own right.
The gender of the therapist shouldnt matter, but in some sense, it
probably does. It might make it harder for things to come to the fore,
but they inevitably will.
This raises another interesting question about how the Oedipus
complex, which is a three-person phenomenon, gets manifested in a
two-person environment. When I was younger I once had the fantasy
that real analysis would have male and female analysts sitting behind
a one-patient couch and although itd be doubly expensive, youd be
able to project on to the female what belongs to the female, on to the
male that which belongs to the male. Now, of course thats impracti-
cal, but it just highlights for me the question of what the patient does
about the third party in an oedipal conflict. Ogdens been foremost in
writing about what he calls the analytic third [Ogden, 2004].
Sometimes psychoanalytic theory is seen as representing the father.
The Lacanians call it the Law of the Father. I imagine its hovering
in the room in some way. The third persons there in fantasy because
every patient has a fantasy that youre married, whether youre
married or not, and that there are siblings, whether there are siblings
or not, that is, other patients. So theres always the fantasy of the
others. Oedipal issues are terribly important because they are part of
development.
Analysis without addressing oedipal issues is unimaginable. If
oedipal behaviour is used defensively against pre-oedipal issues, then
youd have to try to get to the pre-oedipal first, and then the oedipal
later, but you dont determine the timetable. The unconscious does
that. Whether I think its coming at an appropriate time and in an
appropriate way is something for me to consider, but once its there
in its own legitimate right, its terribly important.
Freud said some amazing things about the importance of the
oedipal complexthat the mind could not develop effectively with-
out resolving this complex; that you couldnt have a mind that could
really know what it needs to know until the two-person world
126 FROM ID TO INTERSUBJECTIVITY
RS: That is there to start with. Thats not something that arises in
the course of the analysis. Thats what a person isa malignant
narcissist.
RS: No, I dont think you do. I dont think you can.
RS: He went. He went, and I must say I was relieved. You always
worry that theyll do something nasty on the way out, but no, he knew
he was a nasty piece of work. Hed talked about it. Once you open
your door to somebody, you take what comes and then you have to
deal with it as best you can. Im not going to put up with being abused
relentlessly if theres no give. If theres not an interest to do something
about it, you understand if a persons doing it defensively. Nobody
does it for fun, although thats probably not true [laughs]. But theyre
not going to come to a therapist for fun and use their time and spend
money. So you can think, all right, the poor fellow is defending
against something even more unbearable. But theres no future in my
subjecting myself to this for years if he genuinely doesnt have some
small desire to be otherwise.
132 FROM ID TO INTERSUBJECTIVITY
DK: These are the really difficult issues that can arise in the analytic
process and they cannot necessarily be forewarned. It takes a great
deal of stamina in the analyst to manage such situations. I guess we
need to move on to other difficult areas [laughs]. For example, weve
touched on the role of sexuality in talking about oedipal issues, but
are there other issues related to sexuality that you think must be
addressed in psychoanalysis?
RS: Yes. Analysis is a sexual encounter in terms of two people
having intercourse. It is, from day oneits intercourse in the Kleinian
sense of a mother and a baby, a breast and a baby, a nipple and a
babys mouth. Thats sexual and its erotic and the interaction is a
manifestation of those unconscious issues, and you look for echoes in
the way ones talked to, whats talked about, the way ones treated,
that have to do with those early things. Likewise, with actual inter-
course, or perverse intercourse, homosexual intercourse; you know,
its not penisvagina, but its intercourse. Its a model that actually can
inform the language of an interpretation, such as our intercourse,
when we have intercourse, with what youre looking for in inter-
course with me, how you treat me during our intercourse. So, its
not an everyday word that youd use, but its certainly a common
enough one. It would guide an understanding of whats going on
between us. Ideally, the relationship would show evidence of how the
person behaves in intercourse or looks to be treated in intercourse;
to be abused, or to be abusive, or to titillate or to tantalise or to be
phobic of being penetrated by a good interpretation. The language
lends itself to trying to see what goes on in the relationship with a
view to it transferring to real life. The intercourse between the thera-
pist and the patient needs to be of a wholesome, mutual, respectful
nature with appropriate gratification, without acting out; its got to be
gratifying to understand oneself, its got to be gratifying to have some-
one trying to understand you. You cant take that out of it. You cant
say its a sterile relationship of just words that are being tossed into
the air. Theres a relationship that theoretically should translate into
the real world. Perverse sexuality finds its way into perversions of
transference and hopefully is experienced, identified, described,
worked through andIm just thinking of a gimmicky thing that
I came up with a few years agowhere I talked about a series of
X-es, you know . . . that the relationship is X-perienced and
X-plored and X-plained.
DR RON SPIELMAN: OBJECT RELATIONS PSYCHOANALYSIS 133
DK: [Laughs].
RS: No, no, there is inevitability. If I ever meet God, I will complain
to him about a design fault in our minds that destructiveness is part
of us, beyond whatever abuses weve suffered. Its not just because
many people get abused that they become abusers, but theres some-
thing about our psychic structure that includes negativity and
destructiveness, which ideally needs to become integrated. We hate
[Spielman, 1997b] before we love and love is a triumphgenuine love
as opposed to pseudo-loveis a triumph over negativity. Is that a
more optimistic way to end our discussion?
DK: It occurred to me as you were speaking that I doubt God would
recognise easily the psychic fault that you describe because we are
created in His image and He would have to recognise the fault in
Himself.
RS: Im sure he does [laughs]. But its intrinsic in a lot of religious
philosophy that we are divided selves. The good and the evilit
wasnt there before we got here, so its just a metaphor for what were
talking about now; an acknowledgement that theres a battle between
good and bad forces. I dont like the concept evil, but certainly good
and bad, constructivedestructive, which were all charged with
trying to harness, integrate, live with, including that were going to
die one day.
DK: Do you find it odd that people talk about a benevolent, munif-
icent God, and yet they fear that theyll be struck down by this same
God for wrongdoing?
RS: Its just a manifestation of projectionprojection of these things
that weve been talking about on to God, on to the external world.
DK: Is God a projection?
RS: Yes, unequivocally. To my credit, when I was young, I had a
book, Man Created God [Sell, 2011], on my shelf that I bought when I
was a teenager. Im proud of myself that I could recognise that as a
reality. Someone wrote it obviously, but when I saw it in the book-
store, I said, Ive got to have that book.
DK: Similarly, I have a book on the sadomasochism of Christianity
[see also Carrette, 2005].
138 FROM ID TO INTERSUBJECTIVITY
other people that Ive worked with. Thats how I got on to thinking
about this. I am a bit more optimistic than I was a few minutes ago.
DK: Yes, yes. But you only have to scratch the surface to get to
pessimism [laughs].
RS: Or realism. If thats the way it is, thats the way it is. We cant
be Pollyanna-ish about it. Theres a difference between being realistic
and pessimistic.
DK: Thats true, but reality can often be quite depressing, cant it?
RS: Well, thats the wrong word to use. Depressing is a pathological
word from my point of view; saddening, maybe.
DK: Saddening, distressing.
RS: Not even distressing. Look, we have to come to terms with our
mortality, we also have to think that the planets going to come to an
end. It is. Its not infinite. It cant go on forever. It wont end in our
lifetime, but theres a reality that there are finite resourcesthis much
oil in the ground or this much carbon in the air or oxygen or un-
polluted water or food. Finity and infinity is another problem we have
to grapple with. Things are finite. Time is finite. Sessions are finite. My
life is finite. My working life is finite. My patients currently have to
come to terms with the fact that Im not going to work forever. I let all
of them know that in the next little while, little being a few years, Im
retiring.
DK: Whats a few?
RS: Dont know, around three to five, something like that.
DK: OK. Well, they cant say they havent had ample notice.
RS: They havent had a figure, but the idea that Im not immortal is
something they have to work with too. This cannot go on forever.
Theyre my last batch of patients. When they go, Ill have retired. Im
not going to shoo anyone away unless someone refuses to go in a
reasonable amount of time, which will be three to five years. They will
have had a significant amount of time already, so its not as if some-
ones being booted out. Its another human issue thats part of the
work, isnt it? Finiteness.
DK: Absolutely. Melanie Klein was devastated when her analyst,
Karl Abraham, died a few months into her analysis.
DR RON SPIELMAN: OBJECT RELATIONS PSYCHOANALYSIS 141
RS: Yeah. Well, fair enough. Thats not part of the deal, to die on
somebody too early. But on the other hand, its a human thing to do
[laughs].
DK: Indeed. I guess this conversation is also finite and although I am
sure there is much more we could have discussed, this is perhaps a
good place to finish, contemplating our finiteness and mortality
[laughs]. I really appreciate your speaking with me about the talking
cure today. Thank you.
CHAPTER FOUR
143
144 FROM ID TO INTERSUBJECTIVITY
DK: Yes, and perhaps these interviews will also be, to some extent,
an oral autobiography! The idea that our developmental history is
fundamental to understanding ourselves is accepted within psycho-
analytic circles but not elsewhere, where the ideas somehow become
disconnected from the thinker of those ideas and his or her motiva-
tions. This is evident in symptom-based treatment approaches like
cognitive behaviour therapy. How do you identify yourself?
JH: I am a psychoanalytic psychotherapist. I am not a member of
the International Psychoanalytic Association (IPA) because I have not
trained as a psychoanalyst. I side-stepped this form of control and this
hierarchybut of course also missed out on the cross-fertilisation and
camaraderie but evaded the necessary submission to the yoke of
authority. I was, of course, influenced by Charles Rycroft, who even-
tually left the IPA, and John Bowlby, who remained a member of the
IPA but was persona non grata for many years within the British soci-
ety. I am also a maverick. Do you know who Maverick was?24 He was
a cattle rancher. In those days, cattle ranchers all branded their cattle
to prove ownership but Maverick refused to brand his cattle. I am a
natural integrative psychotherapist. I have been influenced by a range
of therapies; I have also trained as a family therapist. I am totally anti-
branding.
DK: Your motto is Dont fence me in! [laughs] . . . In your revision
of Storrs Art of Psychotherapy [Holmes, 2012a], you define psycho-
therapy as the art of alleviating personal difficulties through conver-
sation in the context of a personal, professional relationship. Could
you say something more about how you define psychoanalysis and
the nature of the relationship between analyst and patient?
JH: My basic model of the analytic relationship is the parentchild
relationshipsecurely attached children have a different develop-
mental history compared with insecurely attached children. Maternal
sensitivity correlates with security. But there is a transmission
gapthe term sensitivity is vaguewhat is it that makes mothers
sensitive? There is a similar issue with defining the therapistpatient
relationship. We know that therapy works, but still dont know
146 FROM ID TO INTERSUBJECTIVITY
DK: Actually, its a very good example, but I am just hoping that
when you could hear me and I couldnt hear you that I wasnt using
too many expletives, thinking that you could not hear me at your end
either [laughs].
JH: But it doesnt matter how many expletives you used because
thats the whole point. In the consulting room those expletives would
be your way of trying to contain and hold your distress. And the great
thing about the consulting room is it doesnt matter what you say. You
can eff and blind25 to your hearts content if thats what you want
to do because its a hypothetical situation; you can do things there that
you wouldnt perhaps be able to do in real life.
JH: They are at the start anyway. This a very simple attachment
model, but lets say you are a six-month-old or a nine-month-old child
and you have a stressed mother. She may be stressed socio-economi-
cally, she may be wondering where she is going to get her next meal
or how she can pay the mortgage, she may be having marital conflict,
she may not have a partner. But you are an infant, you need your
mothers protection because, as Winnicott says, there is no such thing
as a baby. An infant without her parent or protector will die. You
become distressed for whatever reason; if you express too much affect
your mother, rather than being able to help you with that, soothe you,
may push you away. It may be too much for her. So you learn a
defence mechanism and the defence mechanism here is whats now
technically known in the attachment literature as deactivation.
Basically, you close down your feelings. That way your mother will
protect you but you pay a price and the price is you are not so much
in touch with your feelings; your affective universe is diminished,
your pleasure in life may be diminished, your flexibility may be
diminished. There are always trade-offs, in all aspects of psychologi-
cal life. Here the trade-off is: security takes precedence over affective
expression. Thats looking at a defence mechanism from an interper-
sonal perspective. Attachment research shows that there are continu-
ities between defensive and interpersonal patterns in early childhood
and adult life, which is quite remarkable; Freud predicted it. The child
I have just described will grow into an adult who is dismissive, as
assessed by the Adult Attachment Inventory, somebody who needs
relationship, but when they are in relationship they are unable to
express themselves fully; they are unable to respond to their partners
emotional needs or expect their partner to be responsive to their
emotional needs. They will be relationally compromised, handi-
capped even. If that person then comes into therapy, that relationship
will be reproduced in the therapy situation. The patient will present a
rather affectless account of his or her life. If therapy is successful, the
therapist provides a setting in which it gradually becomes more and
more safe to express the affect which they suppress and that enables
a reworking of the defensive structures and perhaps possibly a move,
using Vaillants model, to a more mature defensiveness. They may be
152 FROM ID TO INTERSUBJECTIVITY
able to make a joke about their feelings, which is better than not
expressing feelings at all. That would be a move from repression to
suppressionto using a mature defence like humour. That is an
attachment perspective on the psychotherapeutic task.
DK: What particular defences in the classic psychoanalytic sense would
parallel with this dismissive, deactivating type of attachment style?
JH: Obsessional defences would be seen that way. One of the crucial
growth points currently in this way of looking at things is the concept
of disorganised attachment and the relationship between disorganised
attachment and psychopathology. Disorganised attachment is rela-
tively uncommon in non-clinical populations but very common in
psychopathology. Where you have highly stressed care-givers, where
you have children who present to clinics with a variety of symptoms,
where there is a history of physical or sexual abuse in the family, then
disorganised attachment seems to be very prevalent. Disorganised
attachment is a very interesting area that needs to be explored more.
Splitting, dissociation, and role reversal are the common defences,
whereby you project your own vulnerability into another person and
look after it over there rather than in yourself. Those are typical pat-
terns you see in disorganised attachment and they are highly relevant
to one of the big issues for psychoanalytical psychotherapy, which is
borderline personality disorder. A cutting-edge area is the attachment
concept of disorganised attachment and how that relates to personality
disorder in adults and how that in turn relates to the kinds of thera-
peutic strategies that are going to be helpful with such people.
DK: In a recent paper [Holmes 2010b] you state that all good thera-
pies share three common features: the work is accomplished via a
secure attachment relationship with the analyst/therapist, meaning-
making, and change-promotion. You state that patients can only
meaning make and risk change when they feel securely attached to
their therapist.
JH: Yes, I also propose that an attachment meta-perspective may
reconcile apparent differences between the different psychoanalytic
schools. In order to promote change we must place our patients in a
benign bind: this involves close engagement, discrepancy between
client transferential expectations and therapist response, and explo-
ration and articulation of the feelings arising from these discrepancies.
PROFESSOR JEREMY HOLMES: ATTACHMENT-INFORMED PSYCHOTHERAPY 153
When that therapist said, You most certainly will not, although that
sounds about as unpsychoanalytic as you can get, she was actually
saying, We are not going to be able to work together unless this is a
safe space and I am going to make this space safe. Without that secu-
rity there can be no mentalising. We are still within the attachment
paradigm and the basis of the attachment paradigm is contained in
the title of my book, Exploring in Security [2010a]. You cannot explore,
you cannot think, you cannot play unless you feel safe. In therapy
there is always an oscillation between dealing with arousal and stress
and fear and helping those feelings to be assuaged so that one can
then begin to start thinking about what is going on. There is the
constant dialectic between the affect and thinking about the affect, and
gradually the capacity to mentalise, to monitor oneself, to think about
oneself becomes internalised. Thats possibly one reason why effective
therapy takes time because that is a complex skill to learn. Its like
learning to play the piano; you cannot learn to play the piano, as you
well know, unless you put in your 10,000 hours. Malcolm Gladwell
[2008] has made the point that no leading musician and no leading
sportsman and no leading thinker has ever got there without putting
in 10,000 hours of practice. Learning the skill of mentalising may not
need 10,000 hours of analysis, but it needs quite a few hundred hours!
Thats possibly what Freud was intuitively getting at when he coined
the phrase working through.
than moving us into some idealised world in which none of that ever
happens. It has to do with the scaffolding, the architecture of the ther-
apeutic relationship and the parallel between that and the parentchild
relationship. Eventually that scaffolding is removed and we are, with
luck, equipped to face the world without it.
DK: You wrote a paper recently on the superego [Holmes, 2011b],
in which you said that the superego is concerned as much with safety
as with sex and that it is heir to the attachment relationship. I
wonder if you could comment.
JH: Well, this is the heretical thing where I dont see eye to eye with
my psychoanalytic colleagues. I dont believe in infantile sexuality; its
a myth. Thats not to say, of course, that infantile sensuality is not
hugely important. Of course, the body of an infant and the body of a
mother and a father are drawn to each other like magnets and the child
seeks warmth and physical protection from her care-givers. When the
child is at the breast, the child is not just having some feeding experi-
ence because we know that infants go on sucking at the breast long
after their need for milk has been satisfied. The whole mouth is drawn
to the breast and presumably achieves or receives sensual satisfaction.
Now, if you want to call that sexuality, fine, but I dont want to call it
sexuality, which I say only kicks in with puberty, and is a separate
behavioural system. Of course there are sexual issues between
parents and children, there is no question about that. Little boys have
erections. Little girls may have sexual feelings that we can detect and
record, and similarly, of course, some women, when breastfeeding,
may experience sexual feelings. Fathers get erections from time to time
when their children are on their knee and I dont think thats necessar-
ily an abusive situation. I am not denying that sex is around, as it were,
in the parenting relationship but I dont see it as central or as primary;
Freud was just plain wrong about this. He was wrong because he
wanted a coherent theory. Since his theory is based around libido or
what drives us, and the glue of relationships, and he sees libido as
essentially sexual, then, without a security motivator, which is what
attachment is, he has to have infantile sexuality. That leads on to the
Oedipus complex. I want to rewrite the Oedipus complex in attach-
ment terms, to look at it from an evolutionary perspective, that is, a
childs need for the parent is not the same as the parents need for the
child. Do you know Hrdys work [Hrdy, 1999]?
PROFESSOR JEREMY HOLMES: ATTACHMENT-INFORMED PSYCHOTHERAPY 157
DK: Yes.
rather than sex; and (b) about how, on the basis of secure attachment,
we can begin to take risks, whether these are sexual risks or risks in a
wider sense. I dont think it is a particularly successful paper; it fell on
deaf earssadly, because my theory of therapeutic action is also
within that paper. A person comes into therapy with a whole set of
defences. If the therapist provides sufficient safety, he can challenge
the person to divest themselves of those defences and move to a less
defended position. I sometimes see this as a very crudeI almost
hesitate to say this especially to an Australian colleaguebut one of
my little metaphors for this is the joey and the marsupial, because, as
I understand the biology, you have got this little tiny creature that
emerges from the womb and then has to climb up the side of the
mothers belly to get into the pouch for further development to take
place. Now, thats a very scary thing to think about because that joey
is incredibly vulnerable at that moment of climbing. In therapy the
patient has to become incredibly vulnerable before the developmental
process can resume. I am also trying to indicate that what one is doing
in therapy is simultaneously giving a message to the patient that it is
safe, that the therapist is going to look after them, he is not going to
push them further than they can tolerate but at the same time will not
collude with them and reinforce the superego, but challenge and
create a different relational environment to what they expect and have
had instilled in them through their developmental experience. So,
therapy is all the time playing with challenge and security.
DK: You have just highlighted an interesting juxtapositionthat to
live fully, we need both challenge and security; the therapeutic situa-
tion is a microcosm and training ground for working with this juxta-
position, which is also somewhat paradoxical. Therapy is, at the same
time, a place where the therapist creates both maximum security and
maximum uncertainty.
JH: Yes, I really believe that. It is a very simple point, but when
you go to see a therapist you absolutely need to know that that person
is reliable; they are as good as their word. If they say they will see
you next week at 10 oclock, they will see you at 10 oclock. You also
need to know that this person isnt going to exploit you sexually,
financially or in terms of gossip, so in terms of confidentiality. That
space, that hour that you are offered is inviolable; people arent going
to intrude on it because it is going to be quiet and comfortable. This
PROFESSOR JEREMY HOLMES: ATTACHMENT-INFORMED PSYCHOTHERAPY 159
that their mind had gone blank, I would definitely make some semi-
helpful remark. So, again, its all the time playing with security and
exploration. If there is a paramount need for security, if the attach-
ment system is activated, no exploration is possible. If I feel a person
is just so anxious that they are in a state of attachment panic then
that has to be dealt with. I might say, It sounds like you are feeling
really panicky, perhaps you are wishing you had never come here in
the first place, so we might focus on that. I tune into the affectthats
what I call the reverie: I feel the patients anxiety and then I give a
logos, I try to give a name to it, and then assess whether the patient
picks up on that logos. I feel that psychoanalytic theory is so far
removed from this kind of issue but this is really where I feel we need
to focus our attention and where we need theoretical models. We need
experimental explorations and thats where the attachment paradigm
provides such a good context for that because its (a) really interested
in the minutiae of relationships, and (b) it has this experimental
empirical culture.
DK: You said in your book, Exploring in Security, that co-constructed
meanings are the only therapeutic truths. This statement is an apho-
ristic way of summarising what you have just been saying.
JH: Yes. It takes us back to Tom Ogden and the psychoanalytic
third and the fact that in the end you are working together with
somebody to try to create something that makes sense to both of you;
its a joint project. Another metaphor that I rather like comes from
Donnel Stern [2006, 2012], who is a relational theorist. He has been
influenced by Daniel Stern [1985, 2004] (they are not related). Daniel
is a giant of child development research, a psychoanalyst and a leader
in the Boston Change Process Study Group [Bruschweiler-Stern et al.,
2010]. Donnel Stern is interested in Hans-Georg Gadamer, who is a
Heideggerian philosopher. Gadamer proposed the concept, fusion of
horizons. He says that all truths are conversational truths. Whether
you are reading Hamlet or talking to someone, you are still having a
conversation. He is saying something and you are seeing whether you
agree with him or whether you understand what he is saying or trying
to visualise what he is saying. Donnel Stern uses this phrase fusion
of horizons, from Gadamer. I like that; the patient comes in with his
world view, the therapist comes in with her world view and then they
have a conversation and attempt to achieve a fusion of horizons in the
PROFESSOR JEREMY HOLMES: ATTACHMENT-INFORMED PSYCHOTHERAPY 161
sense that they are then both looking at the same thing in a way that
satisfies both of them.
DK: I would like to move on to a discussion of some of the key
elements in the psychoanalytic approach and get a response from you
on some of the issues, for example, the use of the couch. I was inter-
ested to read your perspective in Seeing, sitting and lying down
[Holmes, 2012b] that the face is insufficiently theorised in psycho-
analysis. We have spent some time discussing that earlier on in our
conversation. But it is certainly also related to this question about
patients using or not using the couch. Could you say something about
that?
JH: To some extent the couch is a bit like the QWERTY keyboard.
We are stuck with the QWERTY keyboard because the early type-
writers used to jam up if they put the letters in more logical order.
From a logical point of view there is no particular reason why we
should use the QWERTY keyboard because we all use word proces-
sors and computers, but we are just stuck with it. Using the couch is
just what Freud did; it goes back to hypnosis, in fact, and Freuds pre-
psychoanalytic hypnotic arrangements. We are all heirs of Freud, so
we use the couch. There is nothing wrong with the QWERTY
keyboard; we are all used to it and we all use it. I personally dont feel
that one necessarily needs to confine the use of the couch to the more
frequentthree to five times a weekanalyses. Some of my once-
weekly patients use the couch. We need to consider the benefits or
otherwise of the couch, which I try to spell out in that paper. There
are huge advantages. There is a sense in which you are held, you are
lying down, you can dream more easily, daydream, you can pursue
your unconscious more easily. Tom Ogden says there is something
about sitting behind patients and not having to interact with them in
a facial way that enables the analyst to dream their patient and to
pursue their own countertransference. Empathic responses perhaps
follow more easily. From those points of view there is a sense in which
using the couch can foster the psychoanalytic process. There are
disadvantages too. A patient who has been dropped affectively or
emotionally as a child, or who has never been held, may need the reas-
surance of actually seeing a responsive analyst/therapist in front of
them; to feel that they have got someone who is really attuned and
responding in a minute-to-minute way with facial contact. Another
162 FROM ID TO INTERSUBJECTIVITY
downside to the use of the couch is that it may foster dependency and
regression that doesnt actually lead anywhere, so one needs to be
aware of that. I refuse to be pinned down by the concrete, thats why
I dont think psychoanalysis can be equated to the use of the couch, to
five times a week sessions at all. The essence of the psychoanalytic
approach is that it is exploratory as opposed to supportive. There are
various aspects of the couch that foster that exploratory culture but
they may also be inimical to it as well at times. I do use in my prac-
tice a mixture of lying down and sitting up, as indeed I experienced
myself as a patient. So thats my position.
DK: People do fluctuate in the same analysis between using the
couch and sitting up. Most would agree that it needs to be a flexible
arrangement and whichever method allows that freedom of explo-
ration is what would direct the use or the non-use of the couch.
JH: The important thing is the meaning of it. I had a patient whom I
thought would be suitable for the couch, and invited her to use it, and
she said, No way, I can barely get into the room let alone lie down.
Thats the state we are still at but its possible that in a few months or
even years she will feel safe enough to get on to the couch. There are
other patients whom I feel possibly get on to the couch a bit too read-
ily, because they are slotting into a preconceived psychoanalytic model
without actually looking at what the meaning of it might be. If a
patient has been on the couch and then suddenly decides to say, I
dont want to be on the couch any more, I want to sit up, that is not
good or bad; its something to be explored. Maybe they dont really
trust the analyst, or they are terrified of what they might find if they
really regress. Or they feel they have had enough, they need to move
on, they want to have a fair fight with the analyst and get into some
aggressive competitiveness that is really not so easy when you are
lying down and the other person is sitting up. There are 101 different
issues to think about in relation to the couch. Its what we do, what we
feel comfortable with, thats how we have been analysed, and thats
the culture. This is one of the paradoxes that I still struggle with, which
is this idea that I am an integrated, maverick therapist but I also have a
mother tongue. Esperanto and a general language do not really work.
Everyone speaks his own language whether its English or Chinese or
Italian or Dutch. In order to express yourself fully, you have to be
absolutely conversant with the particular, to use Hobsons phrase
PROFESSOR JEREMY HOLMES: ATTACHMENT-INFORMED PSYCHOTHERAPY 163
a good thing to try to contain that within the therapy and I dont think
its really the psychoanalysts job to manage that breakdown. I feel the
case manager has to deal with that. Its the psychoanalysts job to help
the patient look at and understand whatever is going on for them,
including a breakdown that might require them to go to hospital. The
analyst cannot move out of his analytic role into a case-management
role. For psychotherapy to work the patient needs to have a suffi-
ciently functioning ego to get him or herself to therapy, to be able to
talk to the therapist, and in private practice to pay for the therapy. The
regressive aspect needs to be handled by a case manager rather than
the therapist. I am a bit suspicious of regression. Of course, regression
does happen but its in the context of the therapy. The patient needs
to be able to get up off the couch and walk out and continue with their
basic coping, their basic living. Heinz Wolf used to say, Well, its
nearly time to stop now and I am going to have to hand you back to
yourself.
DK: [Laughs] I like that.
JH: Thats like saying OK, regression happens in the session, but
its got to be reversible. If its irreversible, it may sound heroic and
wonderful but I am a little bit sceptical and suspicious.
DK: Yes, thats a nice way of putting itthat it needs to be assessed
on an individual basis. For some patients, there can be a certain
bounded regression but one must be sure that the patient can come
out of it effectively at the end of each session.
JH: Yes, thats right. I dont really believe in heroic psychoanalysis.
One hears about it and people like to write about it but I am sceptical.
DK: Would you call encouraging regression heroic?
JH: We all tell stories; everything everyone writes about his
psychoanalytic work, including myself, is a story. That comes back to
what I was saying earlier about the fly on the wallthe fly on the wall
isnt telling stories, it is actually observing what really goes on. I am
not saying that those of us who write about what goes on in the
consulting room are making it all upand we have a problem with
confidentiality so it all has to be disguised in some waybut we
inevitably choose particular cases that are telling a story that we want
to tell.
PROFESSOR JEREMY HOLMES: ATTACHMENT-INFORMED PSYCHOTHERAPY 165
DK: I have been reading the interviews that Peter Rudnytsky [2000]
conducted with some really interesting people like Enid Balint and
Mary Ainsworth and your analyst, Charles Rycroft. It was fascinating
to me how so many of them were critical of Winnicott. They say there
is a mythology around Winnicottthat he wasnt this huge teddy
bear who was so wonderful and warm. They identify another side of
him that hasnt survived into the history or the mythology of the man.
For example, Enid Balint said that people make him cuddlier than he
was . . . [that] he was actually tough and very hard but absolutely
trustworthy (p. 22). Charles Rycroft was much less flattering. He des-
cribed Winnicott as a prima donna, totally self-absorbed and very
strange (pp. 7274).
has clay feet and he certainly had a few. My main objection to him is
that he was rather unscholarly; he didnt acknowledge anyoneits as
though all his ideas originated with him, whereas in fact, he was the
product of a whole tradition.
DK: You open your paper on the issue of money in psychotherapy
[1998b] with a quote from Freud (1913c): Money matters are treated
by civilised people in the same ways as sexual matters, with the same
inconsistency, prudishness and hypocrisy (p. 131). It is really such a
central issue in psychoanalysis, I think it deserves some air time.
JH: Money is a form of exchange and all human relatedness is
based on exchange. For example, mother and infant exchange smiles,
parents exchange the labour of rearing children for the chance of
genetic survival, a form of immortality. But money also breeds greed
and envy and can be divisive and a source of conflict. Just as patients
need the regulation of time and place to establish their secure thera-
peutic base, in a similar way, financial exchange is an explicit part of
the therapeutic contract. Fenichel (1946) made the brilliant insight that
in the pre-oedipal stage, infants demand unlimited love and avail-
ability from their care-givers, which corresponds to what he called a
pre-pecuniary stage of development. During the oedipal phase,
children learn that they must share mother with father (and other
siblings) and that love and money have demands, for example, for
reciprocation and limits. This is a similar lesson that patients must
learn in therapythat it is a form of exchange between analyst and
patient, and that neither love nor money is unlimited.
DK: I know we have touched on the oedipal issues but I would be
interested in hearing your perspective on whether the integration of
attachment and sexual feelings towards ones partner is an indication
of the resolution of oedipal conflicts and attachment insecurities. You
were saying earlier that psychoanalysis is not very good at defining
its aims, or what would constitute a positive outcome, or what mental
health is. I was interested to read Peter Lomass view on the aims of
psychoanalysis. He says that the concept of health or being restored
to health does not cover its aims. Rather, he invokes a moral dimen-
sion and says that psychoanalysts are trying to help patients to
become better people, to live a good life in the Aristotelian sense, so
I am wondering about your perspective on these issues and how
attachment and sexuality figure.
PROFESSOR JEREMY HOLMES: ATTACHMENT-INFORMED PSYCHOTHERAPY 167
does that couple and that family cope with that? This may be a rather
sexist way of looking at itbut is the father able to switch off and say,
OK, babys distress takes precedence over my sexual needs. My
partner has got to be available for our babys security and that is more
important than my sexual need. Now, if children have had develop-
mental experiences in which they are simultaneously allowed to let go
of their parents, they cannot feel so driven by envy and rivalry and
exclusion and fear that they have to intrude on their parents sexual
relationship. This will happen if they know that if there were a crisis
the parents would respond to them.
JH: Maybe there is some truth in that, but I dont really agree
because the main negative emotion that attachment theory writes
about and Bowlby was interested in was anger. Whether or not that is
a negative emotion might be open to debate, but obviously envy and
rivalry can manifest themselves as anger. If you discover your partner
is having an affair, you respond to that with anger, but underneath the
anger may lie Oedipal insecurity, envy, and rivalry. I would say that
attachment theory does have something to say about negative emotion
but it sees them in terms of attachmentthe primary function of anger
is to activate attachment behaviour. It works both waysif the child
feels angry, he will activate the care-giver to attend to him. The first
thing that happens if you feel threatened and the parent isnt there, is
that you get angry. I sometimes give an example from adult life: if you
arrange to meet your partner at a certain place and time for coffee and
they dont turn up, or they turn up half an hour late, and you say,
Where the hell were you? you are expressing anger but that anger is
actually fuelled by an attachment dynamictheir non-appearance
activates your attachment needs and in order to re-establish contact
with your secure base you express anger. Its about rupture and repair.
Ill give another example from the developmental origins of attach-
ment. I remember as a child when I was probably aged about eight. I
grew up in London and there was a big main road near where we lived
and my mother was very keen on walks so we used to go to the park a
lot. On the way back, we had to cross this main road. I was with my
170 FROM ID TO INTERSUBJECTIVITY
mother and she would have been pushing a pram with my younger
sister. Anyway, I ran ahead across the main road and when she caught
up with me she hit me and said, Dont you ever do that again. Maybe
this is why I became a psychotherapist! I thought, I dont get this, why
is she hitting me? She should be pleased that I am here and I am still
alive and we are reunited. But of course, by hitting me she was ensur-
ing that it didnt happen again; I would think twice about running
across the road if I thought I was going to get a slap for doing so. So
going back to the question, does attachment theory theorise negative
emotion: I would say yes. Now, how does this relate to envy and jeal-
ousy or the oedipal situation? Well, lets go back to a pathological
scenarioa couple with a new baby and the baby cries while the
parents are having sex. One or other of the parents might get very
angry with that child and that can be understood in terms of attach-
ment rivalry. The father is saying to or about his wife, You belong to
me. What the hell are you doing disrupting our sex life by going off to
look after your crying baby? If the parents dont come, the baby says,
Look, I am going to die in here if you dont come soon. In both cases,
the negative emotion is attachment-related. I am very interested in the
neo-Kleinian model of the Oedipus complex, which is quite relevant to
mentalising. Ron Britton is probably the best exponent of the neo-
Kleinian model. He recasts Oedipus in mentalising terms. He argues
that the oedipal child, the three-year-old child, whose parents are off
behind the bedroom door having sex, will feel excluded and has to
experience loss and loneliness. But in that process, that child also
acquires a mind of his own. He thinks, Well, I am free, I can think my
own thoughts. I am no longer so dependent on my mother; I am an
independent being. These are the beginnings of mentalising. The
beginnings of thinking your own thoughts can be seen in terms of the
oedipal dynamic. Here we are moving away from a concrete infantile
sexuality model to a much more metaphorical one that includes this
attachment aspect and mentalising.
DK: Your reference to the metaphorical just now leads us nicely into
the next discussionon language. You have written a lot about the
use of language in psychotherapy and psychoanalysis. You have a
strong interest in literature and poetry and you understand the thera-
peutic relationship in terms of metaphor and analogy. So I was
wondering if you could bring all of those interests together in a
comment about language in psychoanalysis.
PROFESSOR JEREMY HOLMES: ATTACHMENT-INFORMED PSYCHOTHERAPY 171
resonates with your own. For example, a patient might say something
like, I have had a really rough day today. Now, that actually is a
dead metaphor. So the therapist might say, Well, rough in what way?
Was it like walking through a ploughed field or walking on glass? I
am just making this up now . . . Then the patient might say, Oh, yes,
it was really like wading through a ploughed field, my legs felt heavy,
and then the therapist might say, Well, how are we going to get the
mud off those boots today? I feel that that kind of communication is
an integral part of good therapy. Dream analysis is really metaphor
work because a dream is a kind of metaphor. Mmm . . . Do I give this
example? I am slightly hesitant but I will. I had a dream the night
before last in which I was being captured by the Nazis. I woke up and
thought, now why did I dream that? Then I remembered that I had an
invitation to speak in Germany at a conference, so that was an obvious
link. Then I started to think, well, I am actually quite frightened of
exposing myself in that environment. So the dream was like a
metaphor that led me both to my preoccupation, the days residue, but
it also led me to the affective world of anxiety and fear and competi-
tiveness. Every dream analysis to me is metaphor work. I suppose the
final point about language is a research study I recently read that
suggested that there was a correlation between good outcome in ther-
apy and the therapists use of metaphor. We are usually taught to play
with the patients metaphors, but sometimes therapists come up with
something that really strikes home to the patient and makes the patient
feel that they are understood. The difference between saying to a
patient, Well, it seems as though you suffer from anxiety, thats the
kind of thing a psychiatrist might say, vs. saying, Well, sometimes it
feels as though you are a frightened child and havent got anyone there
to protect you. That metaphor of a frightened child is a clich but its
still a metaphor. Then the patient may be able to build on that and they
might say . . . let me give you an actual example of my father-in-law,
now dead, but when the First World War was over he was five years
old and he was at school and the entire school left to go and celebrate
the end of the war and he was forgotten; he was stuck in the school and
he was obviously completely terrified. The patient might then come up
with a memory like that. I feel this metaphorical way of working is
absolutely integral with what we are trying to do as therapists and its
something to do with empathy. That empathic resonance is communi-
cated via metaphor. This also happens in literature and poetry.
PROFESSOR JEREMY HOLMES: ATTACHMENT-INFORMED PSYCHOTHERAPY 173
this is what death is like. You can no longer look after your loved
ones. You are alone; you are cut off from your attachments. It would
be an interesting study to relate a persons attachment style to their
fantasy of the nature of death. My wife visualises herself surrounded
by her loved ones.
I dont believe in infantile sexuality and I dont believe in the death
instinct. From the psychoanalytic point of view, existential anxiety
relates to the death instinct and it would be something to do with how
one comes to terms with ones rage, ones destructiveness, ones
murderousness. I see rage and destructiveness and murderousness as
all perversions of attachment. Rage and destructiveness are ways of
trying to establish a connection with the object, with the inaccessible
object. Rage, rage against the dying of the light is Dylan Thomass
model. Thats an attachment rage that is saying, Where are you? I
need you. I need you to be with me. From an attachment point of
view, if you have come to terms with existential anxiety, you know
that there is a good object inside you so the security is there; you dont
need to rage against the dying of the light. From a psychoanalytic point
of view you are raging against the dying of the light because you are
owning your death instinct manifestation. In a way, Dylan Thomas is
praising this protest against the dying of the light, thats healthy anger,
healthy aggression: why have I got to die? I suppose the only other
point that I would make about dying and death is the question, If I
could lead my life again, would I make the same mistakes? From a
Buddhist perspective I suddenly realisenot that I believe in any
literal way in reincarnationbut the knowledge that you have
acquired through learning from your mistakes isnt completely lost;
its passed on to the next generation (admittedly with a lot of the
mistakes too!). One way of dealing with ones existential angst is the
idea of the next generation and your legacy to your children, your
grandchildren, your friends, all our relationships, brothers, sisters,
spouses, which is a completely relational picture. One might say the
psychoanalytic model is a much more individualistic oneeach of us
must come to terms with our death instinct. Anyway, I dont know, its
a really interesting issue that I had never thought about before in this
context.
Another existential issue that is very relevant to psychotherapy
is the extent to which one is master of ones destiny, or driven by
unconscious psychobiological forces. At an experiential level, psycho-
176 FROM ID TO INTERSUBJECTIVITY
analysis does empower people, so that they feel less at the mercy of
their unconscious; at another level, possibly an existential one, it can
help its subjects to accept and come to terms with the fact that they
are probably far less in control of things than they like to think. That
paradox could be called existential. Im not sure that attachment
theory has any more to say about that than mainstream psycho-
analysisbut the idea of mentalising, which has come out of an
attachment approach, is relevant here. Finding a safe place from
which to view ones feelings and actions leads on perhaps to the capa-
city to see ones life in a less attached (in the Buddhist sense) way
and to accept life in all its varietyabsurd, vain, beautiful, transient,
ultimately perhaps from a human perspective, meaningless, but
locally hugely meaningful and significant.
JH: Mmm.
DK: Do you feel that your attachment figures will not look after
you, will not be with you in the moment of your death or that you
cannot be with them in the moment of their death?
Dr Robert D. Stolorow:
intersubjective, existential,
phenomenological psychoanalysis
179
180 FROM ID TO INTERSUBJECTIVITY
RDS: Thats great. I am glad to hear that; glad you feel that way.
DK: Yeah . . . I would like to ask you about Winnicotts notion that
when we experience as an adult what feels like an overwhelming
crisis or trauma, it is a repetition of a past, developmental loss that has
not been fully processed or integrated. Im wondering if that has
perhaps been your experience.
RDS: Well, I think it can bean adult onset trauma can be a retrau-
matisation. But that was not the case for me. I had never experienced
a traumatic loss before of the magnitude that I experienced when my
late wife died. However, if you look at it more existentially, rather
than adult trauma being a repetition of a particular childhood trauma,
I would say human existence, stripped of its sheltering illusions, is
inherently traumatising. In Heideggerian jargon, we might say were
always already traumatised. Because of our finitude and the finitude
of those we love, trauma is built into the structure of our existence.
Even if we havent been previously traumatised, any trauma brings us
face to face with the traumatising dimension of finite human existence
itself.
with other people, partly because it brings them into contact with their
own finitude and their own vulnerability to trauma. Thats another
reason why traumatised people often feel alienated and alone,
because no one wants to get near their experience of traumatisation.
DK: So what happens for some traumatised people is that they do
not experience attuned relationality, which you define as the others
attunement to and understanding of ones distinctive affectivity, and
that such contexts are necessary to sustain ones sense of mineness.
In its absence, the experience becomes doubly traumatising because
the experience of trauma itself can be alienating and place one outside
of this illusion of security and certainty of the absolutisms of every-
dayness, and secondarily traumatising because no one wants to move
with them into that space.
RDS: Thats exactly right. And a lot of therapists dont want to go
there either.
DK: Indeed.
RDS: But they must try.
DK: Yes, yes, we all try. You talked earlier in our discussion about
the pre-reflective unconscious. In your writing you discuss other
forms of unconscious, such as the unvalidated unconscious and the
ontological unconscious, as well as the better understood dynamic
unconscious. Can you talk more about these different ways of under-
standing the unconscious and how they are related within intersub-
jective psychoanalysis?
RDS: They have one thing in commonthey are all constituted inter-
subjectively [Stolorow & Atwood, 1999]. The pre-reflective uncon-
scious is a system of organising principles, formed in a lifetime of rela-
tional experiences, that pattern and thematise our lived experience.
These principles are not repressed as such, but they operate outside of
reflective self-awareness. We have reconceptualised the dynamic
unconscious as those affect states that are barred from coming into
language, coming into discourse, because theyre perceived to be too
dangerous and unwanted. The contents of the dynamic unconscious
have been met with massive malattunement [Stolorow, 2008a] and
thus came to be perceived as threatening to needed ties to care-givers.
In this context, we understand repression as a negative organising
DR ROBERT D. STOLOROW: INTERSUBJECTIVE . . . PSYCHOANALYSIS 189
DK: Yes, to some extent. Thank you. Can we return to the question
regarding the movement from the couch to the chair with the patient
whom you described? Was that movement related to the loss of the
accurate empathic immersion of the therapist in that patients subjec-
tivity?
RDS: There are many things that can produce a shift like that, one of
which is bad, unattuned, unempathic interpretations. Other things
that could produce a shift like that are silences, the meaning given to
silences by the patient, anticipating the endings of sessions. Ending of
sessions for some patients can be retraumatising. In between sessions
can be retraumatising. A patient can leave a session in a wonderful,
expansive, developmental transference, but when the patient comes
back the next time after the separation having been experienced as
traumatising, they come back into therapy behind a brick wall. All
kinds of things, including unempathic interpretations can cause a shift
towards the repetitive, retraumatising dimension of the transference.
DK: You have just been describing the developmental transference
and the experience patients have of being held, or sitting in mothers
lap. As an intersubjective psychoanalyst, would you work with what
is commonly called infant states of mind?
RDS: I call them archaic states of mind and the answer is yes, I
work with archaic states of mind.
DK: OK. Is there a difference between archaic and infant states of
mind?
RDS: I dont think so.
DK: How do you work with archaic states of mind?
RDS: As with any emotional experience, I would try to dwell in them
with the patient and try to grasp them in their formative contexts, past
and present.
DK: What about the notion of resistance in psychoanalysis from an
intersubjective perspective? Im wondering whether you view the
concepts of impasse and resistance as similar.
RDS: No, resistance comes from the danger dimension, from the
repetitive part of the transference. Freud published a marvellous
paper in 1926[d], Inhibitions, Symptoms and Anxiety. In that paper, he
196 FROM ID TO INTERSUBJECTIVITY
organised so closely to that of the therapist, the therapist may miss the
psychologically important material to be investigated there. This leads
to a stalemate. The analysis goes on but not much is happening.
An unrecognised disjunction can have very dramatic effects. This
may be what you had in mind when you asked me your question. In
this situation, the analysts interpretations are being directed to a
subjective situation that from the patients standpoint doesnt exist, so
the patient is being relentlessly misunderstood. Those experiences can
be extremely retraumatising for the patient. There are certain inter-
pretive approaches that regularly do thatthose that come out of the
classically Freudian and Kleinian traditions.
DK: Im interested in whether intersubjective psychoanalysts do
any diagnostic work. Theres been a lot of recent literature on work-
ing with, for example, people diagnosed with borderline personality
disorder, or, to use the more correct terminology, borderline states. Do
you undertake any diagnostic formulation with people when they
first come to see you?
RDS: Neverbecause I am among a growing group of people in
the United States who are very critical of the whole DSM [Diagnostic
and Statistical Manual (American Psychiatric Association, 2013)]
enterprise. Heres the way I characterise it in a blog that I wrote. The
DSM is the pseudo-scientific manual for diagnosing sick, isolated,
Cartesian minds [Atwood & Stolorow, 1997] that fails to take into
account the context embeddedness of emotional experience and all
forms of emotional disturbance. This is covered in the early work we
did on so-called borderline statesone can describe a borderline state
but not a borderline patient. My friend and collaborator, Bernie
Brandchaft, and I wrote a paper that had a rather subversive subtitle
Pathological character or iatrogenic myth? (Brandchaft & Stolorow,
1984]. It was on borderline states, in which we argued that the so-
called borderline character is an iatrogenic myth. Bernie had also
written about impasses, along the lines that we have just been talking
about. What we found when we were first starting to write this paper,
is that if you took a very vulnerable, archaically organised patient
and worked with that patient according to the theoretical ideas and
therapeutic recommendations of Otto Kernberg, pretty soon that
patient will start showing all the features of a so-called borderline
personality [Brandchaft & Stolorow, 1987]. The pages of Kernbergs
198 FROM ID TO INTERSUBJECTIVITY
books will come alive right before your eyes. On the other hand, if
you take that same vulnerable, archaically organised patient and treat
him or her according to the theoretical ideas and technical recom-
mendations of Heinz Kohut, that patient pretty soon is going to look
like a severe narcissistic personality. The pages of Kohuts books will
come alive right before your eyes. Until theres a severe disruption
in the therapeutic relationship, the patient will start to look like
Kernbergs patient again. I think borderline states are not only prod-
ucts of the psychological structures within the patient, they are co-
constituted in an intersubjective field by the patients psychological
structures and the way these are understood and responded to by
the analyst. We extended that idea to all forms of manifest psycho-
pathology, from the psychoneurotic to the overtly psychotic. They all
have to be understood as being constituted, or rather, co-constituted
within an intersubjective context. This holds for every form of manifest
psychopathology.
DK: You are proposing that the so-called borderline pathologies can
be reproduced in therapeutic relationships that are not properly
attuned to the emotional states of the patient. You use the terms co-
constituted or co-created to describe this intersubjective process. It
is a cornerstone of your theory. Im wondering how you situate the
concept of countertransference within that conceptualisation.
RDS: Its not a concept that I use any more [Stolorow & Atwood,
1994]. Originally, the term countertransference was used because
Freud wanted to distinguish between the patients transference and
the analysiss transference. He viewed the analysts transference as a
reaction to the patients transference. This is silly. There is no differ-
ence between the analysts transference and the patients transference.
They are the samethey are both transference. I think we can expunge
the concept of countertransference and talk about the patients and
analysts organising principles and how they interacthow the
analysts unconscious organising principles interact with the patients
unconscious organising activity. This constitutes the intersubjective
system. Hopefully, the analyst, having been analysed, has more reflec-
tive awareness or can readily reach reflective awareness about his or
her organising activity; if not, the analysis would be a disaster.
DK: So the idea of countertransference is not required in intersub-
jective psychoanalysis. You do not see the need to make a distinction
DR ROBERT D. STOLOROW: INTERSUBJECTIVE . . . PSYCHOANALYSIS 199
RDS: I am not sure that I can answer that, but I would not use the
phrase empathic immersion because that still has a Cartesian qual-
ity that one mind can become immersed in another mind. I prefer the
phrase empathic introspective enquirya tracking of my experi-
ence along with the experience of the patient and how the two are
influencing each other. Anyway, what this work aims at, I would call
intelligibility, sense making. When someone can understand the
others emotional experience, in particular, the principles or themes
that are helping to shape the patients emotional experience, the
patients experience gradually becomes more intelligible to the
patient. Its that intelligibility or that understandability, I think, that
the patient gradually takes possession of as part of the patients own
expanded psychological organisation. My friend, Donna Orange, uses
a phrase that I think is a good way of describing the therapeutic
process. She refers to it as making sense together.
DK: OK. So you are not sympathetic to concepts like internalisa-
tion or identification as a way of conceptualising the therapeutic
process.
RDS: No, I am not sympathetic to these concepts. The question
becomes, What is internalised and what does it go into? Into what
is something internalised?
DK: I suppose ones mind [laughs] . . . I realise this is a Cartesian
concept [laughs]in fact, one of the central constructs of Descartess
dualism is the mind.
RDS: Yes, Descartess mind is a structure. His mind is an entity, a
container of contents. Descartes called it a thinking thing which is
ontologically separate from the rest of reality. You have this isolated
mind which is res cogitansthe container of contents. There is no
extension, so how does it make contact with the rest of reality? Youve
got this mind with its inner contents. But the question is, how does
this thinking thing thats a container of contents make contact with
the rest of reality? Locke and others have argued that it makes contact
by forming ideas that are contained within the thinking thing that
more or less correspond to external reality. Then you get the whole
question of epistemology. How do you determine whether the ideas
contained within the isolated mind are accurately representing enti-
ties in external reality?
202 FROM ID TO INTERSUBJECTIVITY
issues arent importantthey are, and they are going on all the time.
But all of it needs to be brought into language and made intelligible.
DK: When youre working intersubjectively to bring the patients
emotional experience into language, Im wondering what language
patients will end up speaking, and whether they will speak an inter-
subjective language with you?
RDS: I hope not. What I try to do is speak the patients language.
DK: Yes. But what Im asking is not so much about the words that
they choose, but whether it takes on an intersubjective flavour in the
way that those analysed by Klein take on a Kleinian perspective and
understand their emotional processes using Kleinian concepts and
language?
RDS: Yes and no. One of the big differences between intersubjective-
systems theory and every other psychoanalytic framework is that we
dont prescribe any universal contents of experience. It is not a content
theory. Freuds was a content theory. The Oedipus complex was at the
centre of everything: all roads led there. Melanie Kleins was a content
theorythe paranoid position, the depressive position; she left out the
missionary position. Kohuts was a content theory, with his trinity of
selfobject needsidealising, mirroring, and twinship. Ours is not a
content theory. It is a process theory. Our two basic tenets are first,
experiencethat is, investigating the unique themes and principles or
meaning structures that take shape in a persons unique developmen-
tal history. There is no prescribed content; and second, contextall
these principles and structures always take form within an intersub-
jective or relational context. So my patients take on those broad
process principles, but they are not content principles.
DK: I understand. In terms of therapeutic action, it could be des-
cribed as experience that becomes conscious, able to be articulated,
brought into language, intelligible, and then becomes second
nature.
RDS: I would say that something is becoming mine. It is not going
inside of me. It is just becoming mine.
DK: OK. This notion of becoming mine implies to me a form
of integration so complete that it becomes a seamless, that is,
DR ROBERT D. STOLOROW: INTERSUBJECTIVE . . . PSYCHOANALYSIS 205
RDS: Freud had some good ideas about working with dreamsto
ask for associations to elements of the dream, to look at what he called
the day residue, what happened during the day, which I call the inter-
subjective context of the dream. He also asked about the affect in the
dream, because he felt that this was the least distorted part of the
dream. There are two things that I would add to the Freudian way of
working with dreams. One is that Freud denigrated the manifest
content of the dream, the dream story, because he felt that it was the
last phase of dream distortion. The last phase of dream distortion was
that the mish-mash created by the primary process has to pass an
aesthetic requirement, had to make sense, to be a coherent story. But
for Freud, the coherence in manifest dreams was the most distorted
part of the dream, so he would not do much with the manifest content.
He would take the fragments or elements in the story and get associ-
ations to those details or fragments. However, I think the manifest
story is very helpful because it contains direct encoding of the
206 FROM ID TO INTERSUBJECTIVITY
213
214 FROM ID TO INTERSUBJECTIVITY
and see what emotions were going on in me. Quite quickly, early on,
what started to happen was when the patient would have break-
through of feeling, I would also have a parallel experience. Id be
having a breakthrough of feeling and the patient would be having a
breakthrough of feeling. So I got the therapeutic benefit out of all that,
just by tuning into the patient and sticking to the process of engaging
with him, not defending, being present and encouraging that person
to be present with me and to feel emotions that were being activated
by sitting with me, and then tying it altogether, and remembering
that. So therapy with my patients was having a therapeutic effect on
me; a lot of my colleagues reported the same experiences as me.
DK: You dont feel concerned about these breakthrough feelings or
the effect they might have on your patients?
AA: When a therapist is really stuck and blocked in one place with
the same thing happening patient to patient and its not getting
dislodged or cleared out by a supervision process, then he or she
might have a trial therapy of a few sessions or more. I guess it goes
against the theory that absolutely everyone has to have therapy, or has
to have years of therapy, or has to go to treatment in order to be able
to provide treatment. Im one example, and I know others too, for
whom it just wasnt required, and we can still provide high quality
therapy.
DK: So you virtually learnt on the job from patients and through the
supervisory process. I think more conservative psychoanalytic thera-
pists would be concerned that this represents a significant departure
from basic minimum requirements in more mainstream psycho-
analytic training.
AA: Im sure it is. I have had the same events happen that patients
have described during my training and supervision. It was the same
process. The stimulus was deciding to be present with the patient and
to let things happen, not to avoid things.
DK: So you were feeling parallel experiences with the patient. For
example, if the patient were having a breakthrough of grief, would
you experience grief as well?
AA: Sometimes. I was more thinking of the complex emotions of
rage and guilt, because grief would pass on its own without it being
218 FROM ID TO INTERSUBJECTIVITY
because, first, they dont feel alone with their emotions. Second, it
gives me confidence that theyre actually feeling rather than just intel-
lectualising about it, and talking about it, which we want to help them
not do most of the time. They can intellectualise and talk about things,
but the work is actually feeling the feelings, experiencing them, not
just chatting about them. Were not just intellectualising and tying
things together, but going through the next step of experiencing
emotionsdealing with unresolved pain, rage, guilt about the rage,
and then being kind to themselves and stopping the anxiety and
defences from wrecking their lives any more. We want this to occur
as efficiently as possible.
DK: Do you consider those parallel feelings that you have while
working with a patient to be countertransference?
AA: Initially, I would call those feelings complex countertrans-
ference feelings. I was having a breakthrough of complex counter-
transference feelings, meaning that they were related to my own
attachments, pain, rage, guilt about the rage, grief, loving feeling.27
All these feelings were being mobilised by the process of engaging
and working with the patients. However, in recent years when Im
talking with my patients, Im usually having a parallel experience
that has to do with empathic attunement, allowing me to resonate
with their emotions. I dont consider this to be countertransference in
the classical sense because these feelings are not linked to anything in
my unconscious from the past. They are just an empathic experience
with my patient, a mirroring event. For us, countertransference is
used very rigidly to define transference of unconscious, unresolved
emotions from the past to the present. Some therapists and models
define countertransference as any feeling that comes up in the thera-
pist. But we try to separate the two; one is related to unconscious
feelings and secondary unconscious anxiety being triggered by the
patient, and the other is not primarily linked to unconscious anxiety
and feelings. Those feelings are related to tuning in to the patient.
To engage a patient with intense therapeutic pressure and challenge
will activate unresolved emotions in the therapist and can then
produce anxiety and defence against these feelings, sabotaging treat-
ment.
Were a herd species. When someone is alarmed, we all have our
receptors on and we can all become alarmed at the same time. Thus,
220 FROM ID TO INTERSUBJECTIVITY
clutter of our past getting in the way and distorting the read. We can
then engage with our patient distinct from our own past complex feel-
ings and anxieties. Otherwise we are stuck, detached, anxious, or
defending. The therapist can end up sabotaging the treatment process,
being critical of the patient and not explaining what theyre doing,
getting misaligned.
DK: I can imagine that some therapists might have more difficulty
than you have had in finding that clear space in the unconscious.
AA: Perhaps. If we look at the average of five trainee residents in
psychiatry Ive had over the past seventeen years, on average, there is
one resident in each year who seems to be able to grasp the process
efficiently with good anxiety tolerance, typically a warm, likable,
sociable person. There are three who struggle with learning the
methodtheyre blocked up to some extent. They cant see things too
well, and they have some process to go through. The fifth is usually a
fragile person, meaning their anxiety interrupts their cognitive
perceptual function. They cant see or hear or think when they start to
engage a patient. They cant sit in the interview very well at all. So a
longer process is required for them to get used to working in this way,
to desensitise to their own anxiety, and start to be aware and start to
feel emotion. There is an extra added training phasea desensitisa-
tion phasewhere the anxiety tolerance increases.
DK: Are these fragile trainees eventually able to become ISTDP
therapists?
AA: They are if they persist in the training. But if a person has
significant fragility, theyre not going to be learning in the first months
because they wont be able to remember any of it. It all disappears
every week because the anxiety blocks it out. But if they persist, then
by six months to a year of training, they start to be able to focus in the
first fifteen to twenty minutes of the interview. Other than that,
they dont get anything much done in the interview. Its very flat and
intellectual. All theyre really doing is trying to keep their own anxi-
ety down, just trying to hold themselves together. They have got to
get used to that; its more about capacity building. For the three
trainees in the middle, its more about building awareness of emotion,
understanding tactical defences [Davanloo, 1996a,b]. Theyre not as
burdened by anxiety or defence. It is more about interrupting their
222 FROM ID TO INTERSUBJECTIVITY
own defences, tuning into emotions, staying focused, using the inter-
ventions. The fifth person can actually sit in on the interview and
apply elements of ISTDP almost immediately. So, on average, there
are one-fifth of trainees with good capacity. This is from a pool of
people the university has recruited far and wide, who are thought to
have good interpersonal skillsthat is, above average to start with.
DK: OK, so it is really quite difficult to identify people who are suit-
able for this kind of work. What ongoing training have you had
beyond your training during your residency?
AA: I am continually training and learning case by case. Last year,
I went to an immersion course. I go almost every year. In addition, I
had supervision with Davanloo in blocks for several years to 2001. In
the block training from 1991 upward, there were different foci for each
training block. It all occurred on video [Abbass, 2004]the teaching
and the supervision. This allows us to look back and see whats going
on, how we felt, to review it, to allow transmission of the information
to other colleagues and learners. The video is the partner in the devel-
opment and dissemination of Davanloos method.
DK: The transparency with which ISTDP is practised and taught is
in sharp contrast to the secrecy in which psychoanalysis is conducted.
I wonder if I could turn your attention to the core skill set that you
teach your residents undergoing ISTDP training?
AA: Sure. The first is ability to provide the central technical inter-
vention, which is called pressure [Davanloo, 1999a], although the term
is a misnomer. What we mean by this is encouraging our patients to
be present with us, to identify emotions, and not to defend; to do
something good for themselves. Pressure interventions include ques-
tions such as: Can you tell me about your problems? Can you give a
specific example? Can you tell me how you feel? How do you experi-
ence those feelings? These questions support the therapeutic attach-
ment and begin the process of building an unconscious therapeutic
alliance in order to start to reach the persons defences. To do that, one
has to be comfortable to be with another person, to be engaged and
present with them, and to have emotions ourselves. Otherwise we
wont do the pressure, we wont want the person to be open with us;
we would want to keep them far away. For about one third of
patients, all you require are pressure interventions.
PROFESSOR ALLAN ABBASS: INTENSIVE SHORT-TERM DYNAMIC PSYCHOTHERAPY 223
Patient: My father died when I was fourteen and Im having trouble deal-
ing with it.
AA: So the problem has to do with your father, pertaining to your
fathers death?
Patient: Well, it might be a little bit about that [using her defences]. Im
not sure.
AA: But when you came in you said you thought that it was about
your fathers death.
Patient: Well, I think it must be.
224 FROM ID TO INTERSUBJECTIVITY
that really wasnt what I was intending to do. So, yes, Ill acknowledge
that I wasnt intending to do it and that will bring back the anxiety
and defences. They might come back to the next session and say, You
know, Im really [sighs] . . . [theyre all anxious], something
happened last session. Im not sure I liked it [sighs] . . . Ill say, Can
we look at how you felt with me? Youre tense when you are talking
about it. There is something happening. Can we look into it? Thus,
in this case, rather than apologise, the best move is to see what
complex feelings are being mobilised as the patient is talking about it.
If they didnt have a positive feeling about what I did and truly felt
it was something negative I did to them, then they wouldnt be
anxious any more. They would not be tense. They would not be
defending. They would be telling me that they didnt like it without
any unconscious signals. When thats happening, I know that theres
something that I messed up, missed, misunderstood, or just transmit-
ted wrongly.
We have so many cultures and languages here in Canada, things
can easily become misunderstood. You can be having a bad day, your
intervention was mistimed or any combination of factors can produce
a misalliance. The therapeutic decision the therapist makes is always
based on unconscious signals. Unconscious anxiety in the voluntary
muscles is a solid positive marker to keep going and focus on whats
going on emotionally under the tension. Its important not to get hung
up on words too much at that point, but just to go with the feelings.
Many patients defences centre around creating misalliances, debates,
and arguments with others to keep a distance, so a patient simply
saying the words you did something wrong does not necessarily
mean much!
DK: What are the major diagnostic indicators you use to place
people on the spectrum of resistance and fragility?
AA: This is a central skill set in ISTDP, namely, doing a psycho-
diagnostic evaluation of the anxiety and defensive patterns and levels
in patients. I have already mentioned voluntary muscle tension. Then
there is anxiety discharged in the smooth muscles like the bowel,
airways, and blood vessels. This anxiety pathway goes with depres-
sion, irritable bowel, and migraine; the person flattens out. The third
dimension is cognitive perceptual disruption where the person loses
vision or it gets blurry, or they lose hearing, or feel numbness; they
PROFESSOR ALLAN ABBASS: INTENSIVE SHORT-TERM DYNAMIC PSYCHOTHERAPY 229
can even black out or faint. With motor conversion, there is no tension
in the voluntary muscles at all and muscles in one part of the body are
weak.
Davanloo identified three types of major resistance. The first is
isolation of affect, where the person intellectualises but does not feel
anything. The second is repression, which goes with smooth muscle,
conversion, and major depression. The emotions get repressed and
they go into those body systems. The third is projection and projective
identification. When projection is occurring, there is no unconscious
anxiety, but when you interrupt it, these patients tend to go to cogni-
tive disruption first. A person with striated (voluntary) muscle anxi-
ety will often report fibromyalgia and pain in the body, as well as
intellectualisation and emotional detachment. These tend to cluster.
All of these factors are assessed in the first minutes of the first inter-
view. We assess the level of resistance, the degree to which emotions
are mobilised, and the degree to which the patient sees their defences.
If you add these parameters together, it tells you which way to go.
You can really make a decision based on a few algorithms.
DK: Do you see patients with simultaneous striated and smooth
muscle tension?
AA: Not in the same second; theres a transitional period where
they might have some smooth muscle firing but the striated muscle is
relaxed. Research shows that people with irritable bowel and high
blood pressure look more relaxed than normal controls, because they
dont have voluntary muscle tension. Most patients have a threshold
above which they have smooth muscle anxiety, although when it is at
a lower level, they get voluntary muscle tension anxiety. So they can
have fibromyalgia, a whole lot of pain in their body, but when they
are coming to your office, they get diarrhoea just by getting out of the
house. Once in the office, they have a migraine and look flat. They
dont have any tone. Their stomachs cramping. When theyre at
home, theyre relaxed but tense, that is, relatively calmer.
If a person with cognitive disruption comes into your office and
they cant see well and theyre confused and cloudy, when theyre at
home at night, theyre scared someones going to come in and attack
them. Theyre really projecting a lot. They cant take a shower because
they cant hear the sounds and theyre scared. A different level of rise
occurs when theyre at home compared with when theyre out. It
230 FROM ID TO INTERSUBJECTIVITY
changes its manifestation also. Some people start with a low level
where they can have striated muscle tension, then they have a higher
rise and the anxiety goes into the smooth muscle. At an even higher
level, they get cognitive disruption. So, on a bad day, theyre really
flustered and cloudy-headed; on a medium day, their stomach cramps
and they feel a little sick. On a really good day, theyre just tense.
Tension is best because at least theyre not in the bathroom feeling
weak and vomiting.
The transcript you presented for comment reminds me of a patient
of mine who had suffered depression for five years and was off work.
He said, My problem has to do with my childhood. He was tense
with sighing respirations and was ruminating in an intellectual way.
I said, I see you are anxious. Can we look into what feelings you have
coming in here? He said, Yeah. My childhood was difficult . . . I
said, But right now, in here with me, do you notice that youre really
tense? What is coming up here with me? I didnt go into the child-
hood rumination. The guy had had therapy for years and he still
wanted to talk about his childhood in a detached way. I opted to
mobilise the unconscious to look at what was driving all this uncon-
scious anxiety. So thats what we did for the first fifteen minutes.
There was a nice breakthrough, with complex feelings with me. In the
midst of the passage of feelings, including rage and guilt, he was
seeing a visual image of the face of his father. He had five sessions and
returned to work after being off work for so long. So, you can have a
lot of conversations, but if theyre all tensed up and defending against
the emotions, there is little value in that because people are already
able to intellectualise.
Were interested, as a dynamic psychotherapy, in helping our
patients to feel their actual emotions, not just to know them, but to expe-
rience them. Feeling the emotions is the key. They must first have the
capacity to tolerate emotions and then to feel emotions that cause
anxiety and defence. That process helps the vast majority of patients
with a broad range of problems86% of referred psychiatric patients
can benefit from this approach, that is, five of the six people coming into
a psychiatrists office in Canada were candidates for this approach.
DK: I was astounded when you told me that you have seen 2,000
patients in your career so far because a psychoanalyst would only see
between seventy to 100 patients in a whole career.
PROFESSOR ALLAN ABBASS: INTENSIVE SHORT-TERM DYNAMIC PSYCHOTHERAPY 231
AA: The majority of all interventions are reaching for the person
stuck underneath the anxiety and defences. We consider this effort, as
expressed by pressure interventions, to be a central key. They have to
know we really want them to be present with their horrendous stories
and emotions. The only way we can communicate that is by reaching
to them with pressure, with interventions. Its not enough to say, I
really want to know you and I want to know your terrible stories.
Weve got to show it by our actions. Our actions are really actively
trying to encourage the person to be present with us. So the level of
activity and the central focus on emotional experiencing is what
distinguishes ISTDP from some other models. Psychoanalytical thera-
pies have these same foci when the process is going efficiently. But we
actively make those things happen; we dont wait for the patient to get
there before we intervene.
DK: I notice also that there is much less focus on history taking in
ISTDP. I recall Winnicott saying that psychoanalysis can be viewed as
PROFESSOR ALLAN ABBASS: INTENSIVE SHORT-TERM DYNAMIC PSYCHOTHERAPY 233
one very lengthy history taking. You often dont have too much detail
at the point where you get the breakthrough of feeling about the key
people in the patients life. Even then, there is no pursuit of an almost
forensic history taking that occurs in other therapies.
AA: ISTDP with resistant patients is all about process, which means
opening the unconscious and helping the patient feel the emotions
and work through them. Up to that point in time, we dont care about
content. Content-based review can itself become a resistance and
delay access to the unconscious in resistant cases. In more fragile cases
and those with repression, there is more history taking and develop-
ing of the whole narrative as part of building psychic integration and
structure to be able to access the unconscious safely.
AA: Yes, it is all about process and what is happening in the room
right now. We work purposely to establish the unconscious thera-
peutic alliance; this is the alliance thats buried in the unconscious that
allows the patient to bring the images and the linkages and all the core
content clearly into the present. We aim to help get this unconscious
alliance dominating over resistance; getting the memory banks to fire,
to move beyond the frontal inhibitory systems in the brain. We want
to activate the emotional centres and emotional memory systems to
fire up louder, or at higher volume, whatever it needs to do, to go
beyond the inhibitory system. Until that happens, thats all were
focused on. We dont care what words are said, largely. This may
sound like a terrible thing to say. Sometimes we get patients who want
to beat around the bush for ten sessions or 100 sessionsthe patients
life is passing and we will interrupt this rumination for his or her own
sake. Likely the patient has already previously done that for hundreds
of hours and it didnt go anywhere, so we are not going to allow that
situation to repeat itself. If a patient comes in and tells me his father is
really nasty and starts to go into detail with ranting about his father, I
will cut across that and say, Right now, you are anxious; can we look
at that? Then we start to get a breakthrough of the complex feelings.
The rage is coming and then he is looking at the image on the floor
the damaged body there. I say, Looking down there, what do you
234 FROM ID TO INTERSUBJECTIVITY
see? You would think he would see his father, but no, he sees his
mother. On the surface, he thought it was all about his father, but
actually in the unconscious at that point it was about his mother.
Often, feelings towards one parent are defended against by ruminat-
ing defensively about the other parent. For example, the patient was
angry with his father because his mother died and his father became a
drinker and virtually abandoned him, but the feelings related to his
mother dying were avoided. So when we achieved the breakthrough,
it was all about his mother, and he couldnt believe he had those feel-
ings about her. That changed everything for him. His annoyance with
his father was conscious and was defensive, too. This is why were
more interested in establishing the unconscious therapeutic alliance
and not getting hung up on the ruminations of the resistance in
anxious resistant patients. Thereafter, the content becomes central; the
patient starts speaking eloquently, even poetically about his life, with
imagery and emotion. Thats because the resistance has really been, to
some degree, either reduced or removed by the process.
DK: So you are saying that once you reduce the resistance, relevant
parts of the personal history follows, such as, for example, in the case
you just described, you learnt that the patients mother died and his
father fell apart emotionally, leaving the patient as a boy abandoned
by both parents.
AA: Thats right. I dont need to know the persons childhood.
When the alliance is established, they will tell me whats going on,
and I follow them. All I need to know is how to help them to be with
me. When that happens, the emotions emerge and everything else I
just follow and underscore and recapitulate. If defences return, Im
back on process again. Im back to helping them be back with me, to
beat down their defences. Then I am following again, following the
alliance, underscoring and so on.
DK: I imagine that this process would be especially important in
resistant patients because they will not respond until work has been
done on reducing their resistance.
AA: Yes, thats right. Here is a big difference between ISTDP and
psychoanalysis. Interpretation in resistant patients is actually
contraindicated. We use pressure, and challenge and head-on colli-
sion. An interpretation is only given after breakthrough. In the case
PROFESSOR ALLAN ABBASS: INTENSIVE SHORT-TERM DYNAMIC PSYCHOTHERAPY 235
Guilt has its own somatic pathway and so does grief. These are
different emotional somatic pathways. We have been teaching
emotion physiology in our new medical curriculum for a number of
years to all the medical students, and the medical and surgery resi-
dents at our university too. We want a literate medical system, doctors
who can understand the emotional effects on the body and how to
pick these things up. We want our doctors to be more self-aware.
DK: Can you say a bit more about these different pathways for the
different emotions?
AA: Yeah. The somatic pathway of rage starts in the bottom of the
body, feet and lower body, with heat, energy, or a fireball moving
upward. It moves upward and as it does, it displaces any tension and
anxiety all the way up as it passes up. So the tension stops when the
heat and anger come up. It goes up to the neck, down the arms to the
hands with an urge to clench and express aggression, and in some
people it then goes to the jaw, with an urge to bite. So rage moves
from the lower spinal levels upward.
Unconscious anxiety moves from the top spinal levels downward.
It starts in the middle of the neck and goes south. The emotions are
going north, upward, and pushing outward the unconscious anxiety
all the way up. Thats the somatic pathway of rage. There is an urge
and some thoughts about aggression. It has a wave that comes and
goes like a sine wave.
The somatic pathway of guilt involves upper body constriction
and pain when the person experiences remorse looking at the dead
person. Its guilt about rage and often is accompanied by the pain of
grief as well. It has a wave that comes and goesa solid wave. During
the middle of it, the person cant talk. There is too much pain and
theyre immersed in it.
Grief is not so much a solid wave. Its not as painful in the same
physical sense as guilt is. It comes and goes, and the core content is
loss; there are also loving feelings and feelings to attach. There is also
a moving warmth in the body, mid-body, chest and an urge to em-
brace or reach toward a person.
These things are physiologic events but we dont talk about or
think of them that way. I think psychology has missed this in almost
all textbooks. The literature there is confused because they usually
238 FROM ID TO INTERSUBJECTIVITY
confuse rage with anxiety, the behaviour, the defence, and the body
experience. When you look at books on emotion, its confusing.
When you understand emotion the way Davanloo does and work
with the emotions in this way, you get directly to childhood issues
and all the painful feelings and trauma. Before then, the anxiety and
defence cover all the feelings up, and thats why people appear in
your office.
DK: Do you draw on Steven Porges polyvagal theory to under-
stand these physiological pathways of the emotions that you have just
described? The polyvagal theory [Porges, 2001, 2007] explains how an
increasingly complex neural system developed in order to regulate
the different neurobehavioural states needed to deal with environ-
mental challenges. Porges argued that the physiological states under-
lying all survival-related behaviours are associated with one of three
neural regulation pathways or circuits. The three circuits and their
associated behavioural strategies are the freeze response or playing
dead, which is the most primitive circuit, the fight/flight response,
and the communication/social engagement circuit. The theory states
that under increasing levels of threat, people move to circuits that
have an older evolutionary history. I have read some papers on ISTDP
that refer to Porges theory with respect to these neuro-emotional
pathways that you have just described. This leads me into my next
question.
I work with musicians with severe music performance anxiety.
These musicians often report bizarre experiences; for example, when
they start to play their instruments under conditions of social threat,
they report that their limbs feel as if they do not belong to them, or
theyll look at the music but feel unable to read it. Others report
explosions going off in their brains and so on. How would you
understand such symptomatology?
AA: You are describing a person with fragile character structure that
is associated with depersonalisation, derealisation, and dissociation
under the burden of the anxiety. For musicians, it is likely connected to
the assessment people are going to make of their performance. It has to
do with being scrutinised, which is related to the trigger of a trauma
response that mobilises a lot of painful feelingrage, and guilt about
the rage. Usually its very heavy rage, and that leads to cognitive
perceptual disruption. They dont notice these feelings. If you have a
PROFESSOR ALLAN ABBASS: INTENSIVE SHORT-TERM DYNAMIC PSYCHOTHERAPY 239
make sure I had time with the patient and had time to do what we
could do. I was having about two hour sessions. But everythings
gone shorter over time. As far as a trial therapy, I average about ninety
minutes. When I first started out, I would leave a whole afternoon and
take several hours to do a trial therapy. Now, its more efficient.
However, sometimes, people need a series of sessions before you can
tell if they are likely to benefit or not, because patients often have a
broad range of problems to deal with. Some have bona fide medical
conditions; others live in really bad social situations. Serious medical
or social problems can interrupt therapeutic efforts.
DK: In very fragile patients whom youre only seeing once a week,
would there be a risk of major attachment crises occurring between
sessions?
AA: Even with fragile patients, it is very rare for them to go into
crisis between sessions. We just dont see it. Once we get the ball
rolling with a good trial therapy, the patient feels contained between
sessions. I dont get the phone calls, desperation emails; that is very
rare. The therapy has a containing effect on patients from the outset.
The person is doing hard work in the session, and theyre the first to
tell you, this is hard. If the person has been projecting his or her whole
life and blaming everybody else, and youre sitting there helping them
stop doing that, thats hard. So they know its hard work, but it gives
them something to chew on in between sessions, and they feel like its
going in the right direction. So their hope goes up and theyre acting
out goes down. I have heard of only a very few suicides that have
happened in relation to this form of therapy, and typically those
people were not attending therapy at the time of the suicide and had
major psychological problems, including histories of psychosis and
repeated suicide attempts.
DK: How do you manage those people whom you find unsuitable
for this approach?
DK: How do people respond when you tell them that you think the
best course of action is to refer them somewhere else?
DK: Many studies internationally show that the bulk of the medical
costs for any one person occur in the proximal years before death, so
there is greater potential to reduce these costs because of the initially
higher medical costs in this age group.
AA: Thats right, but we are seeing this cost reduction, sustained in
long-term follow-up, as the patients become even older.
DK: ISTDP grew out of classical Freudian psychoanalysis. There are
both commonalities, for example, mobilising the positive transference
(Davanloos unconscious therapeutic alliance) and removing the
major resistances, and differences between Freudian psychoanalysis
and ISTDP. For example, ISTDP does not use the couch, free associa-
tion or a passive therapist. Can we look at each of these? I gather
that everyone sits up for ISTDP.
AA: Yes, thats right. We want to use chairs with arms, so that we
can follow the rise of striated muscle anxiety and to be face-to-face,
squared up to maximise eye contact. Eye contact is important in terms
of early attachment because the early bond is through the eyes, so we
are really interested in having eye contact.
DK: We have touched on free association, which is the cornerstone
of classical psychoanalysis, but do you have any other comments on
it here?
AA: We dont use free association and I believe that in many or most
cases, it sets the stage for a victory of the resistance, through delaying
therapeutic ingredients. Our goal is to mobilise the unconscious thera-
peutic alliance and access the pathogenic emotions as rapidly as the
patient can bear. To do this we actively work on the resistance in order
to reach to the patient stuck underneath the resistance.
DK: Because the ISTDP therapist is so active, silence occurs less
frequently in ISTDP compared with other therapies that use silence as
a therapeutic tool. How does ISTDP view the function of silence? Is
there a place for silence in ISTDP?
AA: Yes. There is a place for silence. When a person sits there
passively, I might go silent as a way to use pressure to encourage the
patient to become more active. So Ill sit and wait, thereby exerting
pressure. This is one situation, by the way, where an analytic stance
may be quite effective.
244 FROM ID TO INTERSUBJECTIVITY
AA: The reality is that the patient is likely to want to murder the
same sex parent because that parent interrupted the relationship with
their opposite sex parent. For example, if a father keeps thwarting the
efforts of his son to attach with his mother, the boy is going to start to
feel jealousy and rage toward his father, and then guilt about the rage
towards his father.
AA: Yes.
AA: I dont do any touching; its not in the realm. I might shake
hands after a session if the patient offers a hand but I dont offer a
hand. I dont put a hand on their shoulder or offer a hand as a gesture
of comfort, although I know that some colleagues do.
PROFESSOR ALLAN ABBASS: INTENSIVE SHORT-TERM DYNAMIC PSYCHOTHERAPY 245
the guilt and the rage will bring character change. It brings a soften-
ing of the interpersonal space. Theyre not afraid of killing anybody.
Theyre not on a guilt trip interrupting all their relationships. Thats
an important change agent in this approach. Thats when you see
interpersonal problems changing and this improvement in interper-
sonal relationships strongly correlates with cost and service use
reduction. To be clear about total removal, in the real world, we do
many partial courses in which the depths of pain, rage, and guilt are
not fully worked through in highly resistant and fragile cases. In
moderate and low resistant cases, the bulk of the unconscious is exam-
ined and worked through.
DK: Davanloo states that many patients have experienced major
trauma early in life, which is associated with primitive, unconscious,
murderous rage, guilt, and grief in relation to early attachment figures
and that these factors give rise to major resistance and major charac-
ter disturbances. What advice does ISTDP offer with respect to child
rearing practices to help prevent such disturbances?
AA: If parents project on to the child, that will agitate the child, so
when we treat a parent, were treating their child too. How many
times do you see children improve when you treat their mother and
father? For example, a mother comes in complaining, My childs in a
terrible shape. Hes got ADHD, conduct disorder and obsessive com-
pulsive disorder. Hes on all these pills. Then you treat the mother,
and they say, Oh, whats happened? My sons got better, doing so
much better in school, is so much easier to manage. We havent
treated the child but we have reduced the parents projection on to the
child and when we can do that, it takes the burden off the child and
the parent can then be more attuned to the child.
DK: What about our world which is continually in crisis and
conflict?
AA: Id say the commonest threats are projective processes and
herd mentality that comes out in people who feel attacked, and who
react as a herd and declare the other side an enemy. It becomes herd
versus herd, and the projection sticks there; it becomes a way of
reducing anxiety for people who have neurosis. In some conflict situ-
ations, people experience less anxiety and depression because they
have an external threat to deal with.
PROFESSOR ALLAN ABBASS: INTENSIVE SHORT-TERM DYNAMIC PSYCHOTHERAPY 247
worried and tense and anxious. Soon, the symptoms and worries and
phobias will start melting down. In patients who are highly resistant,
we are uninterested in content until the unconscious therapeutic
alliance is activated. In low resistant patients, the content is already
there; they are already open, but those people are really rare in the
clinical world. Ive only seen six or seven out of approximately 2,500
patients. I havent even seen ten low resistant patients with no rage in
the unconscious. Thats probably because Im a psychiatrist and its
harder to get to me. But there are people out there who have no buried
rage. They just have grief related to specific losses and my role is to
help them feel the grief. It doesnt take much since they only have
minor defences. However, for the highly resistant patient, where there
is rage and guilt, it takes much more work.
DK: How does ISTDP understand fundamentalism? For example,
there was an incident in Denmark in which Muslims rioted because a
cartoon depicted the prophet Mohammed in a disrespectful light. We
had a similar incident in Australia in which a riot broke out as a result
of a video clip that was posted on the Internet being interpreted as an
insult to the prophet. In that demonstration there were children as
young as three years old who had been given placards to hold in
the street that said, Behead all infidels who insult the prophet,
Mohammed.
AA: I think many religious structures can become an element of
resistance. Also, within these structures can also be elements of
alliance. The worlds major religions support positive regard for
others. If you think about it, what is it that prevents people from doing
that with each other and having a high regard for each other, and
furthering the development of one another? The answer is resistance.
Its like jealousy. If a person is developing and someone doesnt want
them to develop, they feel jealous about it and want to thwart the
efforts of the person who wants to develop. Parents can do it with their
children, but so can neighbouring communities or countries. If one
country has more money or resources, this can produce envy in their
neighbours and lead to attempts to undermine them in some way. The
same thing can happen within different religions. Simplistically, this
type of behaviour can be understood as a defensive structure, which
also contains elements of alliance (the herd mentality). Societies and
cultures shape both health and pathology of all its members.
PROFESSOR ALLAN ABBASS: INTENSIVE SHORT-TERM DYNAMIC PSYCHOTHERAPY 249
abused him. But when he had murdered the child in his head and he
felt the rage, he was looking at the image and saw the eyes of his
father. The guilt started pouring out. Every one of the children whom
he assaulted was his father. Instead of murdering his father, he abused
children, in an attempt to prevent himself from committing murder,
but he was burying his feelings. He was also self-destructing to avoid
perpetrating more harm. He was transferring his feelings from his
father on to the children whom he abused.
DK: If we distil your key message, I think it would be that herd
behaviours and the response to the environment you have described
all have similar roots within the unconscious experience of individ-
ual members of a social group, and until these are understood and
addressed, we cannot expect to see positive changes in our world of
conflict and strife. Would this be an accurate summary of your posi-
tion?
AA: I think that among several psychosocial factors, unconscious
rage and guilt drive much of the self-destructive and other-destructive
conduct we see in the world today. Ive seen many people go from
harming to helping others when they have better anxiety tolerance
and a better regard for themselves through working through under-
lying rage and guilt. It is obvious to me that this is a key factor. The
good news is it can happen through psychodynamic psychotherapy
and need not take years or tens of thousands of dollars in the vast
majority of cases.
CHAPTER SEVEN
The unconscious
251
252 FROM ID TO INTERSUBJECTIVITY
account of oneself wouldnt tell you, but they are not elevated to
any special rolethey are just part of the material and the free asso-
ciation . . .
JH: . . . Unconscious forces influence our conscious thoughts . . .
Bowlbys idea was that infants were not going to survive in the
primitive savannah unless adults were highly protective of them. So
stage one is this primary attachment relationship. Its a little bit like
Winnicotts notion of primary maternal preoccupation, which is
unconscious, not in the classical psychoanalytic sense, but in the sense
that it is biologically programmed.
There is a sense in which you are held, you are lying down, you
can dream more easily, daydream, you can pursue your unconscious
more easily. (Comment related to using the couch).
[An] existential issue that is very relevant to psychotherapy is the
extent to which one is master of ones destiny, or driven by uncon-
scious psychobiological forces. At an experiential level psychoanalysis
does empower people, so that they feel less at the mercy of their
unconscious . . .
RDS: . . . phenomenology as a philosophical discipline has always
been concerned with investigating and illuminating structures of
consciousness that are pre-reflective. We call them the pre-reflective
unconscious. Philosophical phenomenology, starting with Kant and
Husserl, sought to identify the universal structures of experience,
whereas psychoanalytic phenomenology wants to identify those
structures that take form within the individuals unique intersubjec-
tive history, much of which is unconscious.
[There are many forms of the unconscious]the pre-reflective
unconscious, the unvalidated unconscious, the ontological unconscious
and . . . the dynamic unconscious. They have one thing in common
they are all constituted intersubjectively. The pre-reflective uncon-
scious is a system of organising principles, formed in a lifetime of
relational experiences, that pattern and thematise our lived experi-
ence. These principles are not repressed . . . but they operate outside
of reflective self-awareness. . . . the dynamic unconscious is those
affect states that are barred from coming into language, coming into
discourse, because theyre perceived to be too dangerous and unwan-
ted. The contents of the dynamic unconscious have been met with
massive misattunement and thus came to be perceived as threatening
254 FROM ID TO INTERSUBJECTIVITY
* * *
All four clinicians understood the unconscious in much the same way
as Freud, that is, as a reservoir of unconscious ideas and feelings that
influence behaviour, ideas that align with Freuds notion of the
dynamic unconscious (which Freud also described as the repressed
unconscious), and which Dr Stolorow defines as . . . those affect
HISTORICAL CONTINUITY AND DISCONTINUITY 255
states that are barred from coming into language . . . because theyre
perceived to be too dangerous and unwanted, a definition most
would agree constitutes repression. Dr Stolorows pre-reflective
unconscious (a system of organising principles formed in a lifetime of
relational experiences, that pattern and thematise our lived experience.
These principles are not repressed . . . but they operate outside of
reflective self-awareness) is akin to Freuds Preconscious, but with a
stronger relational component that maps onto Sterns (1985) concept of
RIGs (representations of interactions that have generalised), a concept
from attachment theory to which Professor Holmes alluded. Freud,
however, conceived an additional dimension to the pre-conscious that
has perhaps been lost in current conceptualisations. Freud explored
the relationship between jokes, dreams, and the unconscious (Freud,
1905b). He argued that the comic process forms part of the pre-
conscious, and that . . . such processes . . . run their course in the
pre-conscious, but lack the cathexis of attention with which consciousness is
linked (p. 220, my italics); that is, they operate outside reflective self-
awareness. Note, however, the understanding of dreams in Dr
Spielmans and Professor Holmess commentsboth explicitly agree
with Freud that dreams may provide an entre into the Unconscious.
Dr Stolorows phenomenological perspective on the nature of the
unconscious has broadened and more clearly explicated several facets
of the unconscious, in particular with the distinction between danger
(dynamic unconscious) and emotional impoverishment (unvalidated
unconscious), for which I could find no parallel concept in Freud.
Further, the concept of the ontological unconscious, although presaged
by Winnicott, Kohut, and others, is one of the clearest expositions of
the existential dimension of the Unconscious to date.
Affect
Freuds affect-trauma model was his first coherent theory of the origin
of psychopathology. It was primarily focused on the role of affect, and
its abreaction and catharsis as the means of cure. Below are some of
Freuds (and Breuers) comments about the role of affect in aetiology
and treatment. These are followed by statements from the interviews
of the four psychotherapists on the meaning of affect in their psycho-
analytic thinking and how they apply that thinking in clinical practice.
256 FROM ID TO INTERSUBJECTIVITY
Defences (resistance)
In Freudian theory, the idea of the unconscious, affect, defence, and
resistance are closely intertwined. The patient is invariably defending
against painful affect, and will resist that affect coming into awareness
through the employment of a range of defence mechanisms that
generally operate unconsciously. There are many examples in Freuds
writing of this close inter-connectedness as the following examples
show. I will discuss transference and defence together in the follow-
ing section on synthesis to avoid repetition.
Compare Freuds (and Breuers) view on the role of resistance and the
use of defences with the four clinicians accounts.
JH: The role of the analyst isnt just to interpret the defence mech-
anisms; it is simultaneously to rework the defence mechanisms while
becoming aware of and commenting on them at the same time . . . I
sometimes use a French proverbreculer pour mieux sauter (you run
back in order to jump better). So in order to progress . . . you need to
be able to divest yourself of your habitual defences in order to move
to a more mature and sophisticated use of defences. In that sense,
effective therapy is inherently somewhat regressive.
and others, for example, Green (1997), have cut a swathe through the
metapsychology and minutiae of psychoanalytic theory in order to
identify the heart of a psychoanalytic process, . . . as a form of organ-
ization . . . of the internal development of the patients psychic
processes, or as exchanges between patient and analyst (p. 9).
While there have been shifts, rifts and developments in psycho-
analytic theory and practice over the past 120 years, the nature of this
shift is more evolution than revolution. Freud offered a Kuhnian para-
digm shift (Kuhn, 1962) regarding the way in which we construct
human subjectivity and intersubjectivity by his discovery of the
unconscious and all the concepts that flowed from that discovery. This
summary and its conclusions in no way seek to minimise the signifi-
cant contributions of subsequent theoreticians, but to place psycho-
analytic theory and practice into a continuous historical framework
that includes commonsense folk psychology whereby we try to
understand each other by ascribing to ourselves and others intentions,
reasons, desires, and wishes . . . and Aristotles syllogism (Eagle,
2011, p. 43), in which the unconscious remains the sun around which
the planets of the transferencecountertransference and its dynamic
forces of resistance in the form of defences revolve. Indeed, Eagle
(2011) argued that much of the history of psychoanalytic interven-
tions and techniques can be seen as constituting various means to
uncover and identify unconscious motives (p. 42).
Freud began with the affect-trauma model, to which contemporary
psychoanalysis now essentially subscribesin which external trauma
and not internal (instinctual) conflict, lies at the heart of psychopathol-
ogy. Object relations theory identifies both actual experience and
phantasy (fantasy) as causes of trauma:
265
266 FROM ID TO INTERSUBJECTIVITY
Patient: I found out on Friday evening that I did not get the job.
RS: I am now quite sure that this opening material does have to do
with the weekend. This is not merely an automatic analyst response,
but early infantile issues notably express themselves around week-
ends and this binge eating does seem to have to do with filling the
emptiness of the weekend. From the little history available, this
patient does have relevant emotional deprivation in early life, and
feels mother was misattuned.
So . . . I would be prepared to say something like You feel you
lose your position with me here on the weekend and needed to fill
yourself with junk food to deal with the emptiness. [I have changed
job to position for the purposes of this interpretation.]
Patient: I used to binge a lot when I was younger. It started after I got
married. I remember once my mother had upset me terribly. It
was around Christmas time and I had just prepared the
Christmas cakesthey were ready to go into the oven. I just sat
down with a teaspoon and ate the raw cake mixture out of one
of the cake tins.
Therapist: I think you are terribly upset about not getting this job [Yes,
THIS job], but you dont allow yourself to really feel the upset.
You do that a lot, not allowing yourself to feel your feelings. So
268 FROM ID TO INTERSUBJECTIVITY
Patient: I would advise him to keep his options open and to cast a wide
net.
Therapist: But you do not do that for yourself. You are not really aware of
this part of you that must have things just so. It constrains you
in your thinking, prevents you from thinking more creatively
about issues.
Patient: I was wondering how I would be coping with this work crisis
had I not been coming here, because it seems to me that I am
not coping very well with it, even though I have had three
years to prepare for it and have been coming here the whole
time.
Patient: I am concerned about these things; that is partly the reason that
I keep a diary . . . I do like to remember what happens and what
we discuss here. At the same time, it worries me that when a
crisis turns up, I am as dysfunctional as ever in trying to deal
with it. I have always put the blinkers on and not wanted to
know about difficult issues or difficult decisions to be made. I
tend to pretend that it isnt happening, but it seeps in some-
where. I will get a migraine, or become flat and listless and feel
like all the life has drained out of me. I feel like a draft horse
with blinkers on such that it can only see in one direction and
does not have to think about the twists and turns in the road.
Therapist: Is that how you see yourself? As a draft horse who has to
produce 1,000 words a day to justify its existence?
Patient: I have always had this feeling that I have to justify my exis-
tence; that I must always have something to show for every
day. My motto is carpe diem. Goethe said that there is nothing
more precious than this day. Thinking about losing my job
through no fault of my own makes me feel very panicky, unfo-
cused, unmotivated, without direction . . .
Therapist: What is the panic about?
RS: I would rather try to talk about losing me; again, not for knee-
jerk weekend reasons . . . but to access feelings of loss which are
inevitably relevant in one form or another.
Carpe diemseize the daycould be an encouragement by the
analysand of the analyst to seize the opportunity to address these
painful issues of deprivation (too many children and not enough
of anything) and being overlooked by the analyst-mother who is
confronted by the needs of so many other children: the analysts other
patients and the analysts own real life.
Therapist: All this when you said that nothing need change once your
employer stops paying you. You have said that you will not be
financially stressed when they stop paying you. You also said
that you still had a great deal of work to complete . . . Is this so?
Therapist: I asked you whether your work will change after your contract
ends and whether you will have any financial stress and you
avoid the question and tell me about your inconsistencies.
COMMENTARIES ON THE TRANSCRIPT OF AN ANALYTIC SESSION 271
Patient: The answers to your questions are no and no, the work will
not changeI still have at least a years work to do, and no,
I will not be financially stressed if I dont get another job
immediately.
Therapist: So what is this panic about having to find another job right
now?
[pause . . . silence]
Therapist: What did you think of your mothers comment that he should
get a job?
Therapist: Are you worried that your mother would think less of you if
dont have a job?
Patient: No, not in the same sense as my brother, because I have never
been dependent on anyone. I have always worked and carried
my weight my whole life. What worries me is who or what I
will be when I leave work. I will feel like nothing, that I dont
have a place on this earth. I may as well be dead.
Therapist: If you are only Dr X and have no other identity, then when you
leave your job, you will feel that you do not exist, that you are
nothing.
Patient: When I was young, I felt such a burden to my mother. The only
thing I could do to ease her load was to do things for her, to
pull my weight, to do chores. It didnt make a difference, of
course, nothing could make her happy, but that is where my
work ethic comes from. Also from my father . . . he worked
sixteen hours a day just trying to keep body and soul
togetherto feed the family and put clothes on our backs.
Therapist: This view of yourself as a draft horse with blinkers on, work-
ing, producing things, justifying your existence.
Patient: I have never not worked. I cannot imagine not working; the
word retirement freaks me out. I cannot imagine doing noth-
ing. I would sink into a deep depression and not be able to
move.
Patient: I used to binge a lot when I was younger. It started after I got
married. I remember once my mother had upset me terribly. It
was around Christmas time and I had just prepared the
Christmas cakesthey were ready to go into the oven. I just sat
down with a teaspoon and ate the raw cake mixture out of one
of the cake tins.
Therapist: I think you are terribly upset about not getting this job, but you
dont allow yourself to really feel the upset. You do that a lot.
So you go on a binge to comfort yourself. We really need to
attend to this part of you.
Therapist (cont): There is a part of you that has to have things just so
like this job, you had to have this job; there is no other
suitable job, even though you gave me several really
good reasons as to why this job would probably not suit
you. What would you say to your son if he came home
and said that he could only work for one companyit
had to be that company and no other?
Patient: I would advise him to keep his options open and to cast a wide
net.
Therapist: But you do not do that for yourself. You are not really aware of
this part of you that must have things just so. It constrains you
in your thinking, prevents you from thinking more creatively
about issues.
Patient: I was wondering how I would be coping with this work crisis
had I not been coming here, because it seems to me that I am
not coping very well with it, even though I have had three
years to prepare for it and have been coming here the whole
time. I have had a horrible couple of weeks raging and stress-
ing about this. I got the impression that you were very frus-
trated with me as well. It felt like I was sinking into a quagmire
. . . [pause . . . silence]
JH: Id rather say something like I wonder what you think about
that in relation to what goes on in here . . .? That puts the patient at
the zone of proximal development rather than the analyst (a) asking
direct questions, (b) telling him that he is worrying. Or, take another
tack: one might say Hmmm . . . perhaps you are wondering whether
you might give me the sack, and give the job of analysing you to
someone more organic and incremental . . . Then you might really
get through to me just how awful it feels to be summarily dismissed,
and see ones lifes strategy go up in smoke.
Patient: I am concerned about these things; that is partly the reason that
I keep a diary . . . I do like to remember what happens and what
we discuss here. At the same time, it worries me that when a
COMMENTARIES ON THE TRANSCRIPT OF AN ANALYTIC SESSION 277
Therapist: Is that how you see yourself? As a draft horse who has to
produce 1,000 words a day to justify its existence?
Patient: I have always had this feeling that I have to justify my exis-
tence; that I always must have something to show for every
day. My motto is carpe diem. Goethe said that there is nothing
more precious than this day. Thinking about losing my job
through no fault of my own makes me feel very panicky, unfo-
cused, unmotivated, without direction . . .
JH: Here, assuming we are nearing the latter third of the session
(which in my experience is the best place for such things), I would
278 FROM ID TO INTERSUBJECTIVITY
JH: The message here is: try as one might, nothing really helps,
including analysis. Id have said, It sounds as though you are verg-
ing on despair, including feeling a bit hopeless about what we might
achieve here . . .
Therapist: All this when you said that nothing need change once your
employer stops paying you. You have said that you will not be
financially stressed when they stop paying you. You also said
that you still had a great deal of work to complete . . .
Therapist: I asked you whether your work will change after your contract
ends and whether you will have any financial stress and you
avoid the question and tell me about your inconsistencies.
Patient: The answers to your questions are no and no, the work will not
changeI still have at least a years work to do, and no, I will
not be financially stressed if I dont get another job immedi-
ately. And yes, I have work to finish.
Therapist: So what is this panic about having to find another job right
now?
[pause . . . silence]
JH: So what were really looking at here iswho are you? Do you
have an inner core identity apart from your work? Thats an issue for
anyone who retires or is made redundant, but maybe has an extra
poignancy for you because . . . (Here I would need some biographi-
cal/developmental data to provide chapter and verse.) The basic
message is that the current trauma is a repetition of previous loss/
stress/developmental difficulty. As Winnicott, quoting Nietzsche,
said, the dreadful has already happened.
Therapist: What did you think of your mothers comment that he should
get a job?
JH: Thats certainly one strategy, and not far from the one I have
been advocating in that the therapist wants to help the patient think
about his own thinking (i.e., to mentalise better). But it is a bit too
focused. I would have rather said something like, How did you react
to that . . .? In fact I think its an opportunity to go further: Well,
280 FROM ID TO INTERSUBJECTIVITY
youve been coming here for three years, and it hasnt been cheap; I
wonder if you arent feeling pretty frustrated with me and our work
together and would like to throw my Freudian book at me and storm
out . . .? Maybe thats what you really wanted to do to those bastards
who didnt give you the job. Tell them to stuff their bloody jobthat
way maybe the bingeing might not have been necessary. Or am I
diverting aggression away from me (the putative analyst) by bring-
ing in the job at the end like that?
JH: I really dont think patient and analyst are on the same
wavelength. It feels like parallel lines, each pursuing their separate
agenda. Id be wondering if something is being enacted herea de-
activated attachment where real engagement (which might entail
anger and despairbut also hope and love) is sacrificed for the sake
of a modicum of secondary security.
Patient: No, not in the same sense as my brother because I have never
been dependent on anyone. I have always worked and carried
my weight my whole life. What worries me is who or what I
will be when I leave work. I will feel like nothing, that I dont
have a place on this earth. I may as well be dead.
Therapist: If you are only Dr X and have no other identity, then when you
leave your job, you will feel that you do not exist, that you are
nothing.
Patient: When I was young, I felt such a burden to my mother. The only
thing I could do to ease her load was to do things for her, to
pull my weight, to do chores. It didnt make a difference, of
course, nothing could make her happy, but that is where my
work ethic comes from. Also from my father. He worked
sixteen hours a day just trying to keep body and soul
togetherto feed the family and put clothes on our backs.
Therapist: This view of yourself as a draft horse with blinkers on, work-
ing, producing things, justifying your existence.
Patient: I have never not worked. I cannot imagine not working; the
word retirement freaks me out. I cannot imagine doing noth-
ing. I would sink into a deep depression and not be able to
move.
JH: Are therapist and patient doing nothing? Can they conjure a
something out of that nothing? Can liveliness and meaning erupt
into the vacuum: anger, rage, fear, vulnerability, longing, love . . .?
Can the analyst provide primary security, rather than reinforcing and
repeating secondary security strategies such as hyperactivation and
disorganisation and self-soothing, including the self-soothing of
nihilism?
After the commentary was concluded, JH sent the following post-
script:
Your bio of the patient did not reveal his/her sex. That I unquestion-
ingly assumed the patient was male stands out for me. I thought it was
an interesting example of what is too easily glibly passed off as coun-
tertransference, without really dissecting what that consists of. From
a relational, and I would say attachment perspective what matters is
the therapistpatient fitjust as the motherchild fit is what matters
in attachment. Secure mothers can cope with a range of infant tempera-
ments and still provide secure attachments. For insecure mothers, the
fit is what determines the outcome. Here, my slightly skewed assump-
tions about maleness (scientists tend to be male; men binge and cook as
well as women) meshed with the patients masculine identification and
obsession with work to the exclusion of all else. I think we need to get
those thoughts or something like them into the commentary.
Patient: I found out on Friday evening that I did not get the job.
Therapist: How did you feel about that?
COMMENTARIES ON THE TRANSCRIPT OF AN ANALYTIC SESSION 283
RDS: I might have said, Tell me what you were feeling just before
you started to eat.
Patient: I used to binge a lot when I was younger. It started after I got
married. I remember once my mother had upset me terribly. It
was around Christmas time and I had just prepared the
Christmas cakesthey were ready to go into the oven. I just sat
down with a teaspoon and ate the raw cake mixture out of one
of the cake tins.
Therapist: I think you are terribly upset about not getting this job, but you
dont allow yourself to really feel the upset. You do that a lot,
not allowing yourself to feel. So you go on a binge to comfort
yourself. We really need to attend to this part of you. There is
a part of you that has to have things just solike this job, you
had to have this job; there was no other suitable job, even
though you gave me several really good reasons as to why this
job would probably not suit you. What would you say to your
son if he came home and said that he could only work for one
companyit had to be that company and no other?
RDS: After commenting that the patient doesnt allow himself to feel
upset, the therapist does not wonder out loud, as I would do, about
why this is so. Instead, the therapist challenges and tries to correct the
patients need to have things just so, rather than enquiring into what
makes that necessary.
Patient: I would advise him to keep his options open and to cast a wide
net.
Therapist: But you do not do that for yourself. You are not really aware of
this part of you that must have things just so. It constrains you
284 FROM ID TO INTERSUBJECTIVITY
Patient: I was wondering how I would be coping with this work crisis
had I not been coming here, because it seems to me that I am not
coping very well with it, even though I have had three years to
prepare for it and have been coming here the whole time.
RDS: There is therapeutic gold here that the therapist doesnt mine.
I would have asked, How am I making you feel worse?
RDS: The therapist is not helping the patient dwell in and integrate
painful affectnot very surprising given the therapists unwelcoming
COMMENTARIES ON THE TRANSCRIPT OF AN ANALYTIC SESSION 285
Therapist: Is that how you see yourself? As a draft horse who has to
produce 1,000 words a day to justify its existence?
Patient: I have always had this feeling that I have to justify my exis-
tence; that I must always have something to show for every
day.
Patient: My motto is carpe diem. Goethe said that there is nothing more
precious than this day. Thinking about losing my job through
no fault of my own makes me feel very panicky, unfocused,
unmotivated, without direction . . .
Therapist: What is the panic about?
RDS: Great! An enquiry about painful affect! And the patient res-
ponds to the enquiry by disclosing below that he is experiencing a
state of world-collapse and self-lossi.e., a state of psychological
annihilation! This is extremely important!
Patient: The answers to your questions are no and no, the work will not
changeI still have at least a years work to do, and no, I will
not be financially stressed if I dont get another job immediately.
Therapist: So what is this panic about having to find another job right
now?
RDS: The patient might interpret this comment about his panic as
shaming.
Patient: When the end date arrives, I will be a pretender in a sense,
hanging on to the institution even though I am not really a part
of it any more.
[pause . . . silence]
Patient: I was speaking to my mother on the weekend and she told me
that my brother had come to visit. He was sitting at the table
reading the newspaper when my mother said that he should
think about getting a job, given that he has been seven years
out of work and he has exhausted most of his wifes financial
resources. He became extremely angry and threw the newspa-
per at her and then got up from the chair and threw the chair
at her. He then stormed out and has not been in touch since.
Therapist: Are you worried that your mother would think less of you if
dont have a job?
Patient: No, not in the same sense as my brother, because I have never
been dependent on anyone. I have always worked and carried
my weight my whole life. What worries me is who or what I
will be when I leave work. I will feel like nothing, that I dont
have a place on this earth. I may as well be dead.
Therapist: This view of yourself as a draft horse with blinkers on, work-
ing, producing things, justifying your existence.
Patient: I have never not worked. I cannot imagine not working; the
word retirement freaks me out. I cannot imagine doing noth-
ing. I would sink into a deep depression and not be able to
move.
RDS: For the patient, not working = doing nothing = falling into a
state of non-being.
AA: The first thought in trying to review this transcript from the
perspective of Davanloos model is that it is impossible to make a
treatment decision based on text, or words alone. In ISTDP, decisions
are informed on the gestalt of verbal, but more so non-verbal, con-
comitants of unconscious anxiety and defence. Thus, the model
requires seeing a patient and activating the attachment system to
determine a road map for the process of moving to the unconscious.
It is for this reason that all training and supervision in ISTDP are
conducted via videotape review.
For me to comment on this case, I will make an assumption that
indeed there are actually unconscious emotions that are not resolved
as part of this patients problems. If there are unresolved unconscious
emotions covered with defence, then these will be visible as much
through indicators such as rate and pace of speech, non-verbal
gestures, posture, and quality of eye contact, as they will by words.
Patient: I found out on Friday evening that I did not get the job.
Therapist: How did you feel about that?
AA: The primary focus in ISTDP would not be the description of the
binge; rather the feelings the person has mobilised by the current
event, or better, the emotions mobilised in the transference while
reviewing the story. The main point here is that content exploration is
contraindicated as it is seen as prolonging treatment and augmenting
defences in all cases except those with poor anxiety tolerance, disso-
ciation, or major depression. If we assume this is a highly resistant
(character neurotic) patient, then content exploration is equal to
dialoguing with the resistance and protracts the treatment, making
transference neurosis possible to probable.
Patient: I used to binge a lot when I was younger. It started after I got
married. I remember once my mother had upset me terribly. It
was around Christmas time and I had just prepared the
Christmas cakesthey were ready to go into the oven. I just sat
down with a teaspoon and ate the raw cake mixture out of one
of the cake tins.
Therapist I think you are terribly upset about not getting this job, but you
dont allow yourself to really feel the upset. You do that a lot,
not allowing yourself to feel. So you go on a binge to comfort
yourself. We really need to attend to this part of you. There is
a part of you that has to have things just solike this job, you
had to have this job; there was no other suitable job, even
though you gave me several really good reasons as to why this
job would probably not suit you. What would you say to your
son if he came home and said that he could only work for one
companyit had to be that company and no other?
Patient: I would advise him to keep his options open and to cast a wide
net.
Therapist: But you do not do that for yourself. You are not really aware of
this part of you that must have things just so. It constrains you
in your thinking, prevents you from thinking more creatively
about issues.
Patient: I was wondering how I would be coping with this work crisis
had I not been coming here, because it seems to me that I am
not coping very well with it, even though I have had three
years to prepare for it and have been coming here the whole
time. I have had a horrible couple of weeks raging and stress-
ing about this. I got the impression that you were very frus-
trated with me as well. It felt like I was sinking into a quagmire
. . . [pause]
Therapist: Are you wondering what you are getting out of your analysis
or worrying that you might not remember everything that
happens here?
Patient: I am concerned about these things; that is partly the reason that
I keep a diary . . . I do like to remember what happens and what
we discuss here. At the same time, it worries me that when a
crisis turns up, I am as dysfunctional as ever in trying to deal
COMMENTARIES ON THE TRANSCRIPT OF AN ANALYTIC SESSION 291
with it. I have always put the blinkers on and not wanted to
know about difficult issues or difficult decisions to be made. I
tend to pretend that it isnt happening, but it seeps in some-
where. I will get a migraine, or become flat and listless and feel
like all the life has drained out of me. I feel like a draft horse
with blinkers on such that it can only see in one direction and
does not have to think about the twists and turns in the road.
Therapist: Is that how you see yourself? As a draft horse who has to
produce 1,000 words a day to justify its existence?
Patient: I have always had this feeling that I have to justify my exis-
tence; that I must always have something to show for every
day. My motto is carpe diem. Goethe said that there is nothing
more precious than this day. Thinking about losing my job
through no fault of my own makes me feel very panicky, unfo-
cused, unmotivated, without direction . . .
Therapist: What is the panic about?
Patient: About my world coming to an end . . . the loss of my job . . . the
loss of myselfthe same old, same old . . . it is like the dreaded
292 FROM ID TO INTERSUBJECTIVITY
carbon tax that everyone has been gloom and dooming about.
The reality is that nothing changed on Monday when it was
introduced . . . I am, like the Australian media, an inveterate
catastrophiser.
AA: Again it is hard to know from text alone, but this patient may
have fragile character structure where the underlying intense
emotions interrupt cognitive functioning. These same patients can
have somatisation and depression. If this be the case, then the process
indicated is to build structural capacity to tolerate unconscious anxi-
ety through a specific process Davanloo called the graded format.
Cycles of pressure to feelings followed by intellectual recapitulation
build capacity to self-reflect. This process can be optimised by keep-
ing as high a rise in unconscious anxiety as the patient can tolerate.
Therapists typically underestimate these patients capacity and end
up with prolonged, intellectualised treatments that become difficult or
impossible to terminate.
Therapist: All this when you said that nothing need change once your
employer stops paying you. You have said that you will not be
financially stressed when they stop paying you. You also said
that you still had a great deal of work to complete . . . Is this so?
AA: Again this is a form of challenge where the risk is of the patient
feeling criticised and put down. Challenge in ISTDP is reserved for
when resistances are crystallised in the room creating an obstacle to
mobilising the unconscious. If done too early, it risks misalliance,
dependency, transference neurosis, and delayed rise in the uncon-
scious alliance.
Patient: The answers to your questions are no and no, the work will not
changeI still have at least a years work to do, and no, I will
not be financially stressed if I dont get another job immediately.
Therapist: So what is this panic about having to find another job right
now?
AA: Here it makes me think that the patient feels criticised in the
way his mother criticises the brother.
Therapist: What did you think of your mothers comment that he should
get a job?
Patient: I thought it was fair enough. He has no shame; he has been
depending on his wife all these years and contributing nothing.
I have never heard him express gratitude to her.
AA: Here I think his comment about his brother is equal to self-
criticising, having internalised the punitive mother. And this punitive
294 FROM ID TO INTERSUBJECTIVITY
Therapist: Are you worried that your mother would think less of you if
dont have a job?
Patient: No, not in the same sense as my brother, because I have never
been dependent on anyone. I have always worked and carried
my weight my whole life. What worries me is who or what I
will be when I leave work. I will feel like nothing, that I dont
have a place on this earth. I may as well be dead.
Therapist: If you are only Dr X and have no other identity, then when you
leave your job, you will feel that you do not exist, that you are
nothing.
Patient: When I was young, I felt such a burden to my mother. The only
thing I could do to ease her load was to do things for her, to
pull my weight, to do chores. It didnt make a difference, of
course, nothing could make her happy, but that is where my
work ethic comes from. Also from my father . . . he worked
sixteen hours a day just trying to keep body and soul
togetherto feed the family and put clothes on our backs.
AA: This suggests that the patient transfers all the complex
emotions from parents on to others, including the therapist. In the
ISTDP frame, we would facilitate the experience of these emotions
directly in the room: this would serve as a gateway to these emotions
and also as a vehicle to cutting down the anxiety, building anxiety
tolerance, and building the power of the unconscious therapeutic
alliance.
Therapist: This view of yourself as a draft horse with blinkers on, work-
ing, producing things, justifying your existence.
Patient: I have never not worked. I cannot imagine not working; the
word retirement freaks me out. I cannot imagine doing noth-
ing. I would sink into a deep depression and not be able to
move.
Therapist: What is wrong with doing nothing?
Patient: Everything is wrong with doing nothing. Doing nothing is like
death.
COMMENTARIES ON THE TRANSCRIPT OF AN ANALYTIC SESSION 295
297
298 FROM ID TO INTERSUBJECTIVITY
Results
Figure 2 displays the concept map for the most prominent themes and
concepts arising in the four commentaries on the transcripts and the
locations of the four psychotherapists (RS, JH, RDS, AA) in conceptual
space, in relation to those themes and concepts and to each other.
The thematic summary includes a connectivity score that indi-
cates the relative importance of the themes.
In this map, the largest and most densely populated theme (red
text) can be described as the elements that are required to establish a
300 FROM ID TO INTERSUBJECTIVITY
Dr Stolorow did not use any of the words in the concept analy-
sis.
With respect to the second principal theme, Professor Abbass used
the concept unconscious eighteen times in his commentary com-
pared with very low usage by the other three therapistsDr Spielman
(1), Professor Holmes (1), and Dr Stolorow (0). Examples of Professor
Abbasss five uses of the concept unconscious include:
Figure 3. Quadrant report showing strength and relative frequency scores for
the main concepts used for each psychotherapist.
Figure 4. Ranked concepts for each psychotherapist, with relative frequency and
strength expressed in percentages and prominence ratings expressed as bar charts.
308 FROM ID TO INTERSUBJECTIVITY
accounting for 23% of the total usage. Professor Holmes used it once
explicitly (I would venture a complete interpretationone that, la
Strachey, tries to bring together present, transference, and past),
although it is implied in his comments regarding the therapist becom-
ing a secure base for his patient, suggesting that the development of
a positive transference is seen as necessary for a good therapeutic
outcome in attachment-based psychotherapy. Dr Stolorow used it
twice (the therapist does not appear to investigate the impact of his
style on the patients transference experience; the patient is experi-
encing the therapist as a shaming mother in the transference).
Professor Abbass used the concept seven times, accounting for 57% of
all usages. Below are four examples:
Dr Ron Spielman
. . . implicit criticism of not having had enough from mother,
and the quagmire experience of not having been able to be
understood as an infant . . .
. . . the analyst appears not to take up the transference commu-
nications which . . . are . . . likely to be the core of the unconscious
communication.
Dr Robert Stolorow
This association indicates clearly that the patient is experiencing
the therapist as a shaming mother in the transference. I would
ask, Did I just shame you?
I am being critical of the analyst in a similar way to how the
analyst seems to be handling the patient (i.e., critically).
Dr Ron Spielman
Carpe diemseize the daycould be an encouragement by the
analysand of the analyst to seize the opportunity to address these
painful issues of deprivation (too many children and not enough of
anything) and being overlooked by the analyst-mother when he/she
is confronted by the needs of so many other children: the analysts
other patients and the analysts own real life.
Dr Robert Stolorow
There is therapeutic gold here that the therapist doesnt mine . . . The
therapist is not helping the patient dwell in and integrate painful
affect . . . [From his interview: I am most interested in enquiring
about those organising principles that shape the patients emotional
experience and how those show up in the interaction with me in the
form of the transference.]
Dr Spielman:
. . . early infantile issues notably express themselves around
weekends and this binge eating does seem to have to do with filling
the emptiness of the weekend; I would be prepared to say some-
thing like you feel you lose your position with me here on the week-
end and needed to fill yourself with junk food to deal with the
emptiness. [I have changed job to position for the purposes of
this interpretation.] We really do need to attend to this bingeing to
comfort behaviour.
Professor Holmes:
The horrid pain of the job rejection, the need for comfort and
soothing, and then the blow-out . . . (the latter a more vernacular
phrase than bingeing). I would see binge eating as a self-soothing
318 FROM ID TO INTERSUBJECTIVITY
Dr Stolorow:
. . . the patient has to continue to dissociate and somatise the
emotional pain that the therapist is not helping him to bear.
Professor Abbass:
The primary focus in ISTDP would not be the description of the
binge, rather feelings the person has mobilised by the current event or
better, the emotions mobilised in the transference while reviewing the
story.
Dr Spielman:
Yes, doing nothing is like death . . . this session has been about
unmet dependency needs and loss . . . and the analysands character-
istic manic style of defence against this by working. To be out of a job
is to expose the analysand to the threat of feeling dead.
Professor Holmes:
I would . . . pick up on the word dead, partly as an actual suici-
dal feeling, partly as a description of the session itself which feels
TEXTUAL AND CONCEPTUAL ANALYSIS OF . . . COMMENTARIES 319
Dr Stolorow:
. . . the patient is in terror of falling into a state of psychological
annihilationof world-collapse and self-loss.
Professor Abbass:
This suggests that the patient transfers all the complex emotions
from parents on to others, including the therapist. In the ISTDP frame,
we would facilitate the experience of these emotions directly in the
room: this would serve as a gateway to these emotions and also as a
vehicle to cutting down the anxiety, building anxiety tolerance, and
building the power of the unconscious therapeutic alliance.
There are several interpretations to the theme of feeling dead in the
transcript, and each therapist highlights a different constellation of
meanings. The key themes are:
Dr Spielman:
Weekend breaks are manifestations of maternal misattunement
by the very nature of the break: the analysand feels the absence of the
320 FROM ID TO INTERSUBJECTIVITY
Professor Holmes:
So what were really looking at here iswho are you? Do you
have an inner core identity apart from your work? Thats an issue for
anyone who retires or is made redundant, but maybe has an extra
poignancy for you because . . . (Here I would need some biographi-
cal/developmental data to provide chapter and verse.) The basic
message is that the current trauma is a repetition of previous
loss/stress/developmental difficulty. As Winnicott, quoting
Nietzsche, said, the dreadful has already happened.
Dr Stolorow:
Doing nothing is like deaththat says it all. The therapist really
needs to understand this catastrophic feeling in the patient and dwell
in that together rather than try to change the patients faulty cogni-
tions at this point in the therapy.
Professor Abbass
If [the patient] has capacity . . . in the ISTDP frame, strong encour-
agement to be present in the room, identify and experience the
emotions that still go to repression, self-criticism, detachment, and
intellectualisation are called for in order to accelerate the psychody-
namic process.
Three of the four therapists stated their therapeutic interest in
uncovering some aspect of early developmental trauma that they
believed underlay the patients current catastrophic reaction to the job
loss. This was expressed as accessing . . . early infantile feelings
(RS), the current trauma is a repetition of a previous loss/stress/
developmental difficulty (JH), and identify[ing] and experienc[ing]
the emotions that still go to repression (AA). Although Dr Stolorow
did not explicitly state that this was his therapeutic task and evinced
a much more present-focus, it would be inevitable that the process of
dwelling in painful affect would eventually connect the patient with
early trauma and the unconscious. In his interview, he stated that:
TEXTUAL AND CONCEPTUAL ANALYSIS OF . . . COMMENTARIES 321
323
324 FROM ID TO INTERSUBJECTIVITY
327
328 NOTES
7. Freud rarely referred to the death instinct after its appearance in Beyond
the Pleasure Principle (1920g). He conceived of it in the context of his
observation of the compulsion to repeat in the war neuroses following
the First World War, a phenomenon that could not be explained by the
pleasure principle. The concept is both theoretically and clinically redun-
dant in Freudian psychoanalysis (van Haute & Geyskens, 2007) and will
not be discussed further here.
8. http://www.kheper.net/topics/psychology/Freud.html. Accessed 24
March 2011.
9. Robert Stolorow makes an interesting comment on free association in his
interview (see p. 193), describing it as an oxymoron.
10. Primary process is defined as the logic and rules of the unconscious
(Brakel, Shevrin, & Villa, 2002).
11. The patient experiences the analysis as if it were an erotic experience
deriving from infantile wishes relating to his/her parents. The analytic
relationship may be sexualised (eroticised) in any of the ways that the
developing child experienced physical pleasureoral, anal, phallic, geni-
tal (Opdal, 2007).
12. Secondary process is defined as rational thought, the egos reality-testing
capacity (Rycroft, 1956).
13. The perfect Freudian man has the following characteristics: heterosexual
potency, and capacity for love, object relationships, and work (Menninger
& Holzman, 1973).
14. Selfobjects are defined as the experience of essential psychological func-
tions that sustain the self, and which are experienced as part of the self,
although the functions are provided by another (Kohut, 1971, 1984); that
is, selfobject needs are satisfied (or not) by external figures in ones life.
15. This is a caption on a wall of the Freud Museum in Vienna and is attrib-
uted to Freud.
16. www.age-of-the-sage.org/famous_familiar_quotes.html
17. A metaphor is a poetic substitution of an uncommon word for a more
ordinary one and, thus, has the capacity to connect elements on the basis
of their relatedness (metonymy) or equivalence (metaphor).
18. The first recorded use of a metaphor is found in the poem, Epic of
Gilgamesh, in the Sumerian language (Damrosch, 2007).
19. It is not correct to assign the origin of these terms to Freud, who used the
everyday German words, das Ich I (I), uber-Ich (over-I) and das Es (It) to
describe these concepts in his structural metapsychology. It was, in fact,
A. A. Brill, one of Freuds English translators, who introduced the words
id, ego, and superego.
NOTES 329
20. Sadism means love of cruelty, derived from the French word sadisme,
which originated from Count Donatien A. F. de Sade (17401815), who
earned notoriety for the cruel sexual practices he described in his novels.
21. More recent CBT models are increasingly including an emotional
processing component.
22. There are now schema-focused CBT approaches, which address internal
representations of ones reinforcement history.
23. For a definition and discussion, see Klein (1923), and Laplanche and
Pontalis (1973).
24. Samuel Maverick (18031870) was a Texan lawyer, politician, rancher,
and signatory to the Texas Declaration of Independence. The word maver-
ick came to denote independence of mind.
25. This is a euphemistic expression for fuck and blimey (may God blind
me).
26. The concept of the portkey is found in Freuds (1900a) Interpretation of
Dreams:
331
332 REFERENCES
Glocer Fiorini, L., & Canestri, J. (2009). The Experience of Time: Psycho-
analytic Perspectives. London: Karnac.
Gramzow, R. H., Sedikides, C., Panter, A. T., Sathy, V., Harris, J., & Insko,
C. A. (2004). Patterns of self-regulation and the Big Five. European
Journal of Personality, 18(5): 367385.
Green, E. J., Crenshaw, D. A., & Kolos, A. C. (2010). Counseling children
with preverbal trauma. International Journal of Play Therapy, 19(2):
95105.
Greenberg, J. R. (1986). The problem of analytic neutrality. Contemporary
Psychoanalysis, 22: 7686.
Greenberg, J. R., & Mitchell, S. A. (1983). Object Relations in Psychoanalytic
Theory. Cambridge, MA: Harvard University Press.
Greenson, R. R. (1965). The working alliance and the transference neuro-
sis. Psychoanalytic Quarterly, 34: 155181.
Grotstein, J. (2009). But at the Same Time and on Another Level. Vol. 1:
Psychoanalytic Theory and Technique in the KleinBionian Mode. London:
Karnac.
Guntrip, H. (1975). My experience of analysis with Fairbairn and
Winnicott(How complete a result does psycho-analytic therapy
achieve?). International Review of Psycho-Analysis, 2: 145156.
Guntrip, H. (1993). My experience of analysis with Fairbairn and Winni-
cott. In: D. Goldman (Ed.), In Ones Bones: The Clinical Genius of
Winnicott (pp. 139158). Northvale, NJ: Jason Aronson.
Hartmann, H. (1939). Ego Psychology and the Problem of Adaptation. New
York: International Universities Press.
Havens, L. (1986). A theoretical basis for the concepts of self and authen-
tic self. Journal of the American Psychoanalytic Association, 34: 363378.
Hegel, G. W. F. (2010). Encyclopaedia of the Philosophical Sciences in Basic
Outline: Part I: Science of Logic, K. Brinkmann (Ed.), D. O. Dahlstrom
(Trans.). Cambridge: Cambridge University Press.
Heidegger, M. (1962). Being and Time, J. Macquarrie & E. Robinson
(Trans.). London: SCM Press.
Heidegger, M. (1998). What is metaphysics? In: W. McNeill (Ed.),
Pathmarks (pp. 8296). Cambridge: Cambridge University Press.
Heisenberg, W. (1958). The Physicists Conception of Nature. New York:
Harcourt, Brace.
Hill, C. A. S. (2011). What Do Patients Want? Psychoanalytic Perspectives from
the Couch. London: Karnac.
Hinshelwood, R. D. (1997). Therapy or Coercion: Does Psychoanalysis Differ
from Brainwashing? London: Karnac.
REFERENCES 345
Stolorow, R. D. (1992). Closing the gap between theory and practice with
better psychoanalytic theory. Psychotherapy: Theory, Research, Practice,
Training, 29(2): 159166.
Stolorow, R. D. (1994). The nature and therapeutic action of psycho-
analytic interpretation. In: R. D. Stolorow (Ed.), The Intersubjective
Perspective (pp. 4355). Lanham, MD: Jason Aronson.
Stolorow, R. D. (1999a). The phenomenology of trauma and the abso-
lutisms of everyday life: a personal journey. Psychoanalytic Psychology,
16(3): 464468.
Stolorow, R. D. (1999b). Antidotes, enactments, rituals, and the dance of
reassurance: comments on the case of Joanna Churchill and Alan
Kindler. In: A. Goldberg (Ed.), Pluralism in Self Psychology: Progress in
Self Psychology (pp. 229232). Mahwah, NJ: Analytic Press.
Stolorow, R. D. (2001). What in the (experiential) world is an internal
couple? Psychoanalytic Inquiry, 21(4): 530535.
Stolorow, R. D. (2002). Meaning is where the action is: response to
Summers (2001). Psychoanalytic Psychology, 19(2): 378379.
Stolorow, R. D. (2005a). The contextuality of emotional experience.
Psychoanalytic Psychology, 22(1): 101106.
Stolorow, R. D. (2005b). Pre-reflective organizing principles and the
systematicity of experience in Kants critical philosophy. Psychoanalytic
Psychology, 22(1): 96100.
Stolorow, R. D. (2006). Heideggers investigative method in Being and
Time. Psychoanalytic Psychology, 23(3): 594602.
Stolorow, R. D. (2008a). Review of subjectivity and selfhood: investigating
the first-person perspective. Journal of the American Psychoanalytic
Association, 56(3): 10391043.
Stolorow, R. D. (2008b). Autobiographical and theoretical reflections on
the ontological unconsciousness. In: K. J. Schneider (Ed.), Existential
Integrative Psychotherapy: Guideposts to the Core of Practice (pp. 281290).
New York: Routledge/Taylor & Francis.
Stolorow, R. D. (2008c). The contextuality and existentiality of emotional
trauma. Psychoanalytic Dialogues, 18(1): 113123.
Stolorow, R. D. (2009). Individuality in context. International Journal of
Psychoanalytic Self Psychology, 4(4): 405413.
Stolorow, R. D. (2011a). World, Affectivity, Trauma: Heidegger and Post-
Cartesian Psychoanalysis. New York: Routledge/Taylor & Francis.
Stolorow, R. D. (2011b). Toward greater authenticity: from shame to exis-
tential guilt, anxiety, and grief. International Journal of Psychoanalytic
Self Psychology, 6(2): 285287.
REFERENCES 357
361
362 INDEX
regulation, 48, 52, 110, 148, 150, anxiety, 47, 15, 20, 43, 50, 74, 81, 83,
153, 274, 305, 312, 318 95, 100, 107, 148, 159160, 172,
signal, 20 196, 214216, 218221, 224230,
states, 79, 88, 184, 186, 188, 192, 232234, 237238, 245248, 254,
253 256, 259, 265, 273, 294, 303, 305,
strangulated, 14, 66, 256257, 263, 317, 319, 325, 327 see also: death,
327 existential, primitive,
terrifying, 134 unconscious(ness)
tone, 66, 256 anticipatory, 20, 81
-trauma model, 5, 1314, 81, 255, 262 associated, 15
universe, 151 attendant, 8
unpleasant, 148 childhood, 36
aggression, 19, 35, 49, 135, 237, 280 depressive, 43
competitiveness, 162 discharge, 295
drive, 20, 47, 83 ego, 83
energy, 17, 19, 29 infant, 15
healthy, 175 moral, 20
impulse, 17, 48, 53 muscle, 229, 243
individual, 19 pathway, 228
origins, 46 patterns, 225
repressed, 3 performance, 113, 154, 238
urges, 53 providing, 225
Aguillaume, R., 30, 332 signal, 20, 81
Ainsworth, M. D., 109, 146, 165, 332 stranger, 47
Akhtar, S., 2, 62, 77, 332 tension, 229
Alexander, F., 49, 54, 76, 94, 332 theory of, 81
Allen, W., 42, 44, 159 tolerance, 221, 239, 245, 249250,
American Psychiatric Association, 289, 294295, 303, 317, 319
197, 332 traumatic, 20, 81
American Psychological Association, underlying, 275
191 Appelbaum, J., 58, 80, 332
anger, 24, 34, 3637, 85, 117, 169, 220, Appignanesi, L., 10, 332
236237, 249, 280282, 303, Aristotle, 6263, 262, 332
314315, 319, 321 Arlow, J. A., 30, 332
healthy, 175 Armony, N., 31, 332
pervasive, 37 Aron, L., 86, 332
self-directed, 236 attachment (passim)
somatic, 220 approach, 176
unexpressed, 319 aspect, 170
angst, 175, 182185, 187, 247 behaviour, 109, 167, 169
Antia, S. X., 90, 335 bonds, 245
Antonaci, F., 23, 332 crises, 240
INDEX 363
function, 44, 164 existential, 2, 36, 48, 77, 90, 93, 135,
ideal, 18, 44 175176, 183, 185, 247, 253, 255,
instinct, 27 282, 297, 303, 311, 317
observing, 38, 44, 89, 94 anxiety, 174176, 182, 184
overwhelmed, 38 Ezriel, H., 231, 339
psychology, 47, 5153, 83, 89
regressive, 44 Fairbairn, W. R. D., 48, 52, 70, 83, 95,
resistance, 35 339340
super, xii, 1718, 2021, 35, 38, 44, Fairholme, C. P., 38, 359
6364, 68, 83, 89, 94, 107, fantasy, 50, 80, 8485, 107, 122123,
156158, 181, 247, 252, 125, 129, 176, 181, 202, 262
328 see also: sexual
waking, 252 -driven, 18
Ehrlich, F. M., 86, 339 objects, 52
Eissler, K. R., 20, 339 of death, 174175
Ekstein, R., 43, 339 original, 176
Eliot, T. S., 62, 64, 67, 339 Farchione, T. J., 38, 359
Ellard, K. K., 38, 359 Faulkner, W., 75, 340
Ellenberger, H. F., 10, 339 Fel, D., 69, 359
Feldman, M., 120, 354
Emde, R. N., 5354, 96, 339
Feldman, R., 71, 348
empathic, 32, 48, 5354, 67, 75, 87,
Fenichel, O., 29, 49, 94, 166, 340
161, 273, 301
Ferenczi, S., 8, 38, 41, 43, 340
analytic, 54
Fiscalini, J., 52, 54, 340
attunement, 54, 62, 89, 219220
fixate/fixation, 6, 12, 34, 38, 241
availability, 53
Fliegel, Z. O., 3, 340
bond, 95
Fogel, G. I., 87, 340
engagement, 194
Fonagy, P., 2, 5759, 69, 80, 82, 91, 95,
experience, 54, 219
97, 110, 153, 207208, 225, 280,
failures, 48, 82
333, 340
immersion, 195, 200201 forbidden, 5, 17, 22, 47, 59, 79, 189
inquiry, 56, 96 Forrester, J., 10, 332
-introspective, 47, 49, 201 Fraiberg, S., 133, 341
mode of observation, 47 free association, 22, 25, 2731, 35, 37,
resonance, 150, 172 58, 75, 89, 92, 103, 123, 192193,
envy, 59, 85, 89, 112113, 117, 124, 231, 243, 253, 328
166167, 169170, 248 French, T. M., 54, 94, 332
Erikson, E. H., 139, 339 Freud, A., 29, 46, 73, 82, 94, 341
Erle, J. B., 9, 339 Freud, S. (passim) see also:
existence, xiv, 4, 11, 25, 31, 44, 47, 49, psychoanalysis/psychoanalytic
174, 183, 185187, 209, 247, 270, A note on the prehistory of the
272, 277, 281, 285, 287, 291, 294 technique of analysis, 27, 335,
human, 78, 136, 185, 187 342
368 INDEX