non-verbal enactments need to be symbolized for clinical change to occur. ..... allowed or needed someone else to decide whether or not her analyst was.
Is verbal symbolization a necessary requirement of analytic change?
1
This
paper
considers
the
potential
of
bi-directional,
non-verbal
(procedural) enactments for effecting therapeutic change and whether such non-verbal enactments need to be symbolized for clinical change to occur.
2
The tendency of psychoanalysis to privilege verbal communication has shifted in the past decade and we have come to recognize, not so much that we can learn
a
lot
from
non-verbal
communication,
but
rather,
that
focused
attention on non-verbal communication can, at times, be a primary factor in effecting therapeutic change. Such a shift recognizes that change, either psychoanalytic affective
or
developmental,
experience,
cognitive
“may
be
set
in
motion
by
changes
understanding
or
interactive
in
encounter
without necessarily assigning privileged status to a particular dimension, such as interpretation” (Lyons Ruth, p.600).
For psychoanalysis, interest in non-verbal communication and its relevance to therapeutic action comes as a result of the explosion of interest in research conducted in the fields of neuroscience, cognitive science and nonlinear
dynamic
systems
interaction
has
had
therapeutic
process.
a
theory.
In
powerful
impact
Beebee,
addition,
Knoblach,
on
research
how
Rustin
we and
on
view
mother-infant
change
Sorter
in
(2003)
the have
written an extensive review of the literature and extended it with their own viewpoint on how non-verbal procedures of communication can be applied to adult psychoanalysis. Of central interest, and a now well established tenet in the field of cognitive neuroscience is the finding that while information can be shown to be processed and stored in memory by an individual it may not be semantically formulated and therefore may not be available for verbal expression (Palley, 1997). and
stored
in
implicit
Rather, some types of information are processed memory.
Unlike
the
information
we
hold
in
declarative memory, that is, information that can be consciously recalled and recounted, information that is stored in implicit or procedural memory underlies capabilities like driving a car, or hitting a tennis ball and then adjusting ourselves for the return of the ball.
This type of information
processing can also take place in interpersonal interactions.
Supporting
3
this view, studies of mother-infant interaction have shown how mother and baby develop expectancies about how one another will behave (Stern, 1998). Such expectancies develop out of complex, bi-directional processes in which each person is simultaneously influencing the other in an ongoing, rapid and complex
feedback
loop.
Information
is
expressed
and
received
via
the
senses, voice volume, rhythm and tone as well as through facial expressions and gestures. These non-verbal, sub-symbolic features of communication hold the interaction together and give it its shape (Bucci 1997).
Over time
patterns of expectancies occur, or in Stern’s (1998) language, there is implicit relational knowing, which allows each member of the dyad to know, without ever thinking about it, how to be with and what to expect from the other.
Bucci (1997, p.159) argues that within this non-verbal domain the
image of the caregiver acts as an enduring prototypic symbol around which sub-symbolic experience, that is experience processed in sensory, visceral or motoric modalities, can become organized.
Of particular relevance to psychoanalysis is the suggestion that traumatic experience, because it is affectively overwhelming and cannot be processed cognitively, may also be encoded in the non-verbal, procedural domain.
In
traumatic early environments the expectancies or patterns of interaction teach the child that it can be dangerous to be, or feel, with another. Without the presence of a benign caretaker to function as a symbol around which the highly charged affective, motoric sensory and visceral aspects of experience
can
unsymbolized experience
coalesce,
form.
remain
It
Bucci
becomes
inaccessible
argues
that,
dissociated and
the
or
dissociated
experience
disconnected. from
other
is
left
in
Parts
of
parts.
The
meaning of such dissociated experience, because it does not seem to refer to a context or to an image is lost to the individual who experiences it.
Such
individuals can be flooded with affect, triggered by cues from any number of
4
sources (e.g. physiological, imagistic, interpersonal), however, they have no clear idea as to what or whom their feelings relate.
In my view, one of the ways in which the effects of traumatic experience can be made available for integration into an individual’s sense of self is by addressing the presence of this dissociated experience.
Obviously it cannot
be addressed directly given that it is represented in visceral, motoric and sensory
modalities.
Attention
to
non-verbal
communication
however,
via
one’s attunement to one’s own subjectivity, allows such communication to be registered and engaged by the analyst and then in turn by the analytic couple.
Within this more benign context the opportunity exists for the
analytic pair to co-create new relational procedures, about how the self can relate with an-other, that stand in marked contrast to the old.
Actually
experiencing and living through the contrasting relationship creates the context in which the implicit (or explicit) meaning of old expectancies must be challenged. expectancy
in
Defenses formed and erected as part of the patterns of earlier
relationships
are
either
not
erected
or
can
be
softened or disassembled in the new implicitly known relationship. This allows potential space for old, and new, affects, thoughts and feelings to emerge.
Consistent with this view, Stern at al (1998, p.917) argue that
changes to the individual’s implicit relational knowing does not correct empathic failures nor does it replace a past deficit, rather something new is
created
which
alters
the
intersubjective
environment
in
which
“past
experience is recontextualized in the present such that a person operates from within a different mental landscape”, resulting in new behaviours and experiences in the present and the future.
A number of authors (Keirsky and Beebee 1994, Bucci 1997, Knoblach 1997, Stern et al 1998, Beebee and Lachmann 1998, Lyons-Ruth 1999, Gotthold, 2002,
5
Black 2003, Beebee, Knoblach, Rustin and Sorter 2003, Beebee, Knoblach, Rustin and Sorter 2004, Fosshage 2005) have engaged the issue of the impact of non-verbal communication on therapeutic action.
And within this context
there has been some debate about whether what is represented in the nonverbal domain must be verbally symbolized in order to effect therapeutic change. Certainly many authors (Davies and Frawley 1994, Bromberg 2003, Jacobs 2003), who employ the notion of enactment in their understanding of therapeutic action, seem fairly consistent in the view that what is enacted (articulated
non-verbally)
is
a
communication
between
the
analytic
dyad
whose meaning should be verbally explored in order to effect change.
In contrast, Stern (1998) and his colleagues in the Boston Change Process Study Group (2002) argue that the “moment of meeting”, a particular example of enactment between the analytic dyad, is pivotal in effecting therapeutic change and that this change does not occur in the symbolic domain, rather it occurs in the domain of the procedural which they regard as non-symbolically encoded information.
From within the perspective of child psychoanalysis, although recognizing that a “moment of meeting” and its verbal articulation is an important component
of
what
effects
analytic
change,
Gotthold
(2002)
argues
that
insufficient attention is given to the power of the long period of time during which the stage is being set for the enactment or “moment of meeting” to take place.
She sees much of the therapeutic action, at least in child
psychoanalysis, as occurring in this primarily non-verbal domain. Lyons Ruth (1999) has also engaged the issue of how enacted structures change.
She
argues that information processed in the non-verbal domain is structured differently
(unsymbolized)
to
information
encoded
in
(symbolized) and is therefore represented differently.
the
verbal
domain
It follows, she
6
explains, that the process of change for information represented in either domain will be different and that experience represented in the non-verbal domain
does
not
need
to
be symbolized
in
order
to
effect
change.
More
recently (2006), the Boston Change Process Study Group (BCPSG) has also emphasized this position.
Fosshage (2005) takes a broader position than the BCPSG and suggests that a broader perspective is required to help explain the variety of non-verbal clinical phenomena we encounter. While he recognizes that some information in
the
non-verbal
domain
is
encoded
and
processed
sub-symbolically,
he
argues that images (and dreams) are clear examples of non-verbal, symbolic processing that are reflective, as well as facilitative of, the process of change. (1997,
Fosshage draws on a model from cognitive science described by Bucci 2000,
2001)
which
offers
an
alternative
view
for
how
non-verbal
experience is encoded and processed. In her multi-code theory of information processing she describes three modes for processing emotional information. The
non-verbal
system
in
which
information
can
be
encoded
either
symbolically (via images) or sub-symbolically and the verbal system in which information
is
referential
process
connection
encoded
between
in
symbolically. which
different
These
images modes
systems
function of
are
connected
by
a
as
pivotal
points
for
processing
(Bucci,
2001).
The
referential process links up the various systems allowing non-verbal subsymbolic processes to be connected to one another which can then connect to non-verbal, symbolic processes (images) and then to language (quoted in Fosshage, 2005 p. 527). The extent to which this can be accomplished is dependent on the role of the environment. Bucci (1997, p.184) sees the mother as the prototypic image around which the baby’s visceral, sensory and motoric experience can come to be symbolized. The infant’s image of mother is formed on the basis of ever-changing appearances of mother which get
7
“chunked
as
functionally
equivalent
units”,
to
represent
an
enduring
prototypic image or symbol around which the baby’s experiences gain meaning and coherence.
These
differences
in
how
the
symbolization
process
is
understood
are
important for how we utilize the concept of enactment in understanding the process
of
usefulness
therapeutic of
the
change.
concept
of
For
the
enactment
most has
part
seen
the
to
be
psychoanalytic in
the
verbal
symbolizing of previously unformulated or unsymbolized experience. In Bass’ (2003) definition, a discreet unit of interaction, often holding affectively charged experience, which engages aspects of both the patient’s and the analyst’s unconscious dynamics, becomes the focus of analytic activity.
In
this view, which Bass describes as Enactment with a capital E, the fluidity of the analytic dialogue is interrupted, albeit often usefully, to determine the underlying meaning of the unconscious dynamics between the analytic couple.
If we consider Gotthold’s view however, that the period of time
which precedes the Enactment, holds important implicit relational learning, and
hence
understand
important the
impact
implicit of
this
change change
in on
relational the
knowing,
ongoing
how
analytic
do
we
dialogue?
Might it just as well be the case that the enactment is an expression not only of the patient’s conflict with the analyst, or visa versa, but also of something more that the patient has learned about the analyst?
Perhaps the
patient is able to enact, in the more discreet (capital E) sense described above, because she feels sufficiently confident that the trauma of the past will not be repeated with the analyst, or will only be repeated in tolerable doses.
It may be that the patient feels (implicitly) that the possibility
exists for conflict to be reworked within the context of the newly created expectancies inherent in their implicit relationship. That is, the patient brings into the analytic space “a new mental landscape” within which the old
8
relational conflict can be negotiated in the implicit domain. While the enactment
might
be
a
culmination
of
something
that
has
been
implicitly
negotiated, at the same time it may also be an invitation by the patient to renegotiate something old in a new way. Might it not be that the enactment of the old conflict provides the analyst and patient with the opportunity to live
with
the
conflict
in
the
present
and
to
create
a
new
pattern
of
expectancy about how it can be lived with differently. Whether its meaning must be explicitly understood and verbally symbolized is perhaps an open question.
Let’s consider, for example, the case described by Black (2003) in which she suggests caution in assuming that verbally symbolizing the enactment is the most
efficacious
course
of
treatment.
Black
raises
the
question
about
whether it is the exploration of the enactment or the enactment itself that drives the therapeutic action. In the case presented, Black and her patient, decide
(implicitly)
that
the
engaged at the verbal level.
meaning
of
their
enactment
should
not
be
The subsequent changes in Black’s patient may
have been a direct result of the enactment not being engaged verbally. They may,
in
fact,
be
a
result
of
how
the
patient
and
analyst
implicitly
negotiated how to be together amidst the powerful affects that had been evoked between them.
In Black’s example the analyst refrains from forcing
the patient into the old relational pattern in which the authority figure has the dominant role of asserting her position over the patient who must either submit or struggle. Perhaps, with exquisite attention to the nonverbal
cues
in
each
other,
and
through
the
process
of
self
and
mutual
regulation, Black and her patient learn a new way of being with the other while holding powerfully held opposing views. It might be the case that this analytic pair implicitly agreed not to rigidly insist on their viewpoints in the face of the other’s opposition because they had the expectation, based
9
on their previously developed implicit expectations of one another, that something else might transpire when they allowed themselves to attend to “something more” (Stern, 1998) than words.
This is not to suggest that at
some later date that a verbal understanding would not occur or would not be useful.
But rather that new ways of being with powerful affects at the
procedural level can have profound effects on the ongoing analytic dialogue that represent significant changes to one’s sense of self and of self in relation to other.
Is it possible that an enactment can be processed in the procedural domain without
a
verbally
encoded
outcome?
In
my
view
the
answer
is
yes.
The
patient’s experience may remain in part undigested, as Black suggests, but the
affect
and
how
to
be
with
that
affect
with
another
person
can
be
regulated (processed) through the complex, bi-directional processes of nonverbal communication which creates more benign implicit relational knowing, allowing the patient to function in more adaptive ways interpersonally. A corollary to such changes in the domain of implicit knowing is a parallel shift in the patient’s self and self with other representations.
I will use my work with my patient Leah to illustrate the process of change in the implicit domain.
I see these changes as fundamental to my patient’s
increasing ability to function more adaptively both in her relationship with me
and
in
her
relationships
with
others.
Although
the
explicit
symbolization of experience does occur in the treatment, the focus of this paper
is
on
procedural.
documenting
the
change
that
occurred
in
the
domain
of
the
As a point of reference a particular question, asked repeatedly
by Leah throughout the course of her five year treatment, is used as an indicator or marker to measure the process of change.
10
The Treatment History It is difficult to assess the impact on Leah of having spent her first 7 months in a Chinese orphanage, mostly in a crib with 5 or 6 other babies, before she was adopted and brought to Canada to live.
This early experience
certainly raises questions about the impact on her attachment patterns, her strategies for self-regulation and the patterns of expectancy she developed with respect to her external environment. Leah’s
parents’
lack
of
attunement
Nonetheless, it is apparent that
and
ongoing
insensitivity
to
her
developing needs was a contributing factor in her becoming the obedient and deferential
child
that
her
parents
desired.
The
development
of
this
compliant self was an adaptive response, utilized in order to cope with the trauma inherent in being subjected to repeated failures of attunement to her emotional needs.
Such adaptation was accomplished, through the process of
dissociation, resulting in affectively overwhelming experiences being split off
from
conscious
awareness,
unprocessed
by
thought
or
language,
and
therefore remaining inaccessible to memory and lying outside the sphere of verbal
self-expression.
Instead,
encoded
in
sub-symbolic
form,
such
experience can be located in the non-verbal domain, that is, in facial expressions, tone of voice, posture and other bodily-based communications, all of which can have a powerful impact interpersonally.
In my first meeting with Leah what stood out, in addition to her seeming inability to articulate why she had come to see me was the powerful impact of her non-verbal communication.
Leah’s demeanor, her tone of voice, the
manner in which she related information to me and the way she drew attention to her body all left me feeling far more intrigued by her than did the content of her stories.
My first encounter with Leah, however, came indirectly.
Vicki, a close
11
friend of Leah’s, left me a message telling me that she wanted to refer a patient to me.
But first, she said, she wanted to talk to me so that she
could “check me out”.
When I returned her call she quickly announced her
agenda. “So, are going to love her?” she said.
Somewhat surprised by her
question I began by trying to address her concern about finding a good therapist for her friend.
Vicki was not to be managed in this way. “No,
that’s not it”, she said, “I want to know if you are going to love her or not. That’s what she really needs, someone to love her”.
Finally, after
what felt like some maneuvering, I said, “Look, I don’t know how I’ll feel about her. I don’t know anything about her; I’ve never even spoken to her. It would be dishonest of me to say I know I’m going to feel a certain way”. Vicki’s response of, “Oh, I like you, you pass, you pass”, was her stamp of approval.
Within minutes of her hanging up the phone Leah called to set up
her first appointment.
I wondered what it meant about Leah that she had
allowed or needed someone else to decide whether or not her analyst was appropriate for her.
As it turned out, Vicki was an excellent diagnostician. the experience of feeling that she was loveable.
Leah indeed needed
It quickly became apparent
that Leah felt that her lovability depended on how well she could meet the needs of others.
She was eager to please and to accommodate to what she
felt where my expectations of being a good patient.
Her desire to do this,
however, created a difficulty for her because my expectation was that she would talk about herself.
Her understanding of relationships was that if
she focused on the other person, took up as little space as possible, and had them focus on themselves, they would respond to her positively.
The gap
between our expectations created a space between us that made Leah quite anxious. When I didn’t respond to Leah’s comments or questions with the typical social responses that she anticipated she found it difficult to know
12
how to proceed with me.
Her body movements, posture and manner of relating
generally indicated that she was struggling with intense anxiety.
We spent
a good many months trying to figure each other out. A typical session would have many interactions that look something like the following vignette.
Leah would come in to my room with a big kind of energy, a bit frenetic. She might start talking about something before she sat down, the rhythm of her speech would be fast paced.
She wouldn’t take off her coat. Her eye
contact was minimal. Sometimes she used her hair to cover her face.
I would
begin to feel a bit uncomfortable feeling that we weren’t settled.
She
would place herself on the edge of the chair holding a cup of coffee chest high in two hands.
(Much later, she told me that she was frightened by how
close our chairs were to each other). “So what shall we talk about”, she’d begin, “… … uhmmm … I’m not sure. playing
a
harmonica
on
the
performers. Do you like them?
You know on my way here I saw this guy
street,
he
was
really
good,
I
love
Oh, you can’t answer that can you?
street
I really
think they’re cool. I used to love rehearsals when I was doing drama at school, I hated actually performing, but the rehearsals were great. to hang out all day together like one big happy family. Do you even like plays? Do you go to the theatre?
You got
Did you ever act?
Your probably can’t
answer that either, you don’t really say much about yourself you know. Silence. Do you think you could say something or tell me what I should talk about … just tell me what to talk about so I know where to go ….” I feel quite anxious and I’m not sure what to focus on.
I am acutely aware of how
she is sitting on the edge of her chair and that she still has her coat on. I want to say to her, “Could you sit back in your chair”, but I don’t. Sometimes, I would wonder to myself if I should ask her to expand on one of the things she’s mentioned, like the feeling of hanging out with a big family.
I wonder about answering her questions or actually coming up with
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something to talk about.
I search my head to come up with a response that
feels relevant to what she’s saying and what I’m experiencing but there’s an intensity that impedes my capacity to think in a calm and reflective way. feel overloaded.
I
Regardless of the response I finally choose, my motivation
is generally to calm my own anxiety and to pass ‘the hot potato’ back to Leah.
As I was able to self-regulate, however, I developed more helpful
responses. Focusing less on her words and more on what she seemed to be saying non-verbally, I might say some version of … “well, I’m not sure that I know exactly what to say or what we should talk about.
I guess I could
come up with something but I’m not sure it would fit with where we seem to be with each other. is
the
point.
I’m not sure that just finding something to talk about
Maybe
what
we
need
to
talk
about
is
uncomfortable for you to be here, talking or not talking.
why
it
seems
so
I can see that
you haven’t taken your coat off and that you seem so very tense.
I guess I
wonder if there is something I could do or say that would make you feel like it was safer to be here with me.”
She might proceed by saying something
like she feels ridiculous coming in and just starting to talk about herself, “People just don’t do that”.
And so we would go on in this fashion.
During
these sessions, of which there were many, I tried to talk enough so that Leah didn’t feel overwhelmed by the space between us, but not so much as to fill it all up.
At times I found them excruciating, they felt cumbersome
and awkward. Leah seemed so frightened, I felt inept and inadequate.
But
despite this I felt very tender towards her and was deeply moved by the intense anxiety she seemed to feel in my presence. Overtime, with repeated instances in which my self-regulation helped Leah to down regulate (Beebee and Lachmann, 1998), a process of self and mutual regulation developed in which Leah and I began to relax in each other’s presence.
She sat back in
the chair, she tucked her legs under her body, after a while she tried sitting on the floor, and finally settled for the chair.
14
As treatment continued it became increasingly obvious that Leah was keenly aware of, and vigilantly tracked, my responsiveness to her.
For example,
seemingly amused, she pointed out that in our early sessions she noticed that I always shifted my posture in response to her shifts in posture.
And
frequently throughout the course of treatment Leah would surprise me by asking, “What are you thinking?” a question I initially understood to be her way of tracking where I was in relation to her. research
conducted
in
proposed
by
Ruth
Lyon’s
the
field
(1999,
of
Using a model adapted from
cognitive-developmental
p.595)
to
explicate
changes
theory in
and
implicit
relational knowing, it is this question, and our interactions immediately surrounding it, that I will use as a tool to illustrate changes in the quality of implicit relational knowing over the course of the treatment.
I
regard
Leah’s
question,
“What
are
you
thinking”,
and
the
responses
immediately surrounding it, as enactments occurring throughout the duration of her treatment.
Embedded within each of these enactments, as I define
them, are the old patterns of organizing experience for both patient and analyst, the newly acquired implicit relational knowing that has developed between them, which runs counter to the old patterns, and a tension between these two positions that holds and presses for the possibility of change. Some
of
the
enactments
described
are
not
the
highly
charged
affective
interactions that Bass describes. Instead, they seem like fairly ordinary interactions. To my mind, these interactions still warrant the designation of capital E. meaning
for
They stand out as discreet interactions that hold important
where
the
treatment
is,
and
where
it
is
going.
They
are
reflective of the previously learned implicit relational knowing which has created the context that allows the patient to re-living old relational patterns with the analyst in a new way.
15
As noted earlier, Lyons Ruth (1999, p.578) argues this type of “enactive knowing”, which she sees as the central feature of implicit learning, is represented in affective-perceptual and spatio-temporal contingencies, and “develops and changes by processes that are intrinsic to this system of representation
and
that
do
not
rely
reflective (symbolized) knowledge.”
on
translation
of
procedures
into
She does not argue that translating
procedural encoding to symbolic encoding is not a useful agent of change, but rather that development or change does not proceed only or primarily by moving from the procedural to verbal forms of thought.
From the perspective of modern cognitive-developmental theory Fisher, Case and Fisher and Granott (1980, 1991, 1995 respectively, cited in Lyons Ruth 1999) propose a model for how enactive meaning systems (including their associated
adaptive
development.
Lyons
skills Ruth
for
(1999,
doing
things
p.595)
in
the
extrapolates
world) this
change
model
with
to
the
interpersonal domain. In this model, development or change occurs, when single enactive procedures are assembled, like component parts, to create increasingly complex systems of meaning for being together. The outcome of each single procedure must be reliably repeated over a variety of instances before it is assembled, or coordinated with another procedure. Lyons Ruth (p.595)
illustrates
an
example
of
this
process,
using
the
interaction
between a mother and her two year old child. I will reiterate her example as it
elegantly
describes
the
complex
model.
The
two
year
old
has
an
established implicit procedure of soothing herself into a calm state, after experiencing distress with her mother, by relying on a number of resources, i.e. thumb sucking, getting a hug from her mother, snuggling her blanket. At some point in development this enacted procedure or meaning system might be assembled with another interactional procedure with the mother, like that of
16
engaging the mother in joint play.
This more complex assemblage, of knowing
how to move from distress with the parent, to a calm state, then to engaging the parent in positive play, may represent an enactive procedure or meaning system for “making up with mom”. then
be
assembled
with
In turn, this more complex system might
interactive
structures
such
as
engaging
with
playmates, so that in increasingly complexity, a coordinated meaning system, or enactive procedure, for dealing with conflict with playmates is encoded. None
of
these
skills
or
capabilities
of
being
with
the
other
are
symbolically encoded, but nonetheless, they can develop in complexity.
The
constraints to what can be assembled are defined not only by the child’s developing cognitive abilities, but also to a significant degree by the quality and extent of participation of the relational partner.
In extrapolating from development to the treatment situation, Lyon’s Ruth (p.601)
argues
developmental
that
the
essential
common
change
and
psychoanalytic
structuring
change
is
element
the
intrinsic to the process of getting to know another’s mind.
task
in
both
structure
The trauma that
is part of Leah’s mind, and that the analyst must come to know is an intrinsic piece of this task. As Leah’s treatment began I saw her traumatic experience as being dissociatively held outside the analytic dialogue but making
its
presence
felt
in
non-verbal
ways.
As
implicit
relational
procedures developed in complexity and Leah felt that more of these aspects of her self could be known by me and lived within our relationship, we engaged this non-verbal experience in increasingly complex ways.
If we assume that the structure of Leah’s implicit thinking is held in the action
of
her
language,
looking
at
our
verbal
interaction
perspectives will allow us to see changes in its structure.
from
various
To this end, I
will explore the timing and affective dimensions of our communication around
17
Leah’s question and suggest how shifts in our interaction reflect shifts in the
structure
subjectivity
of
as
a
Leah’s tool,
thinking. I
will
also
motivation for asking the question. process
of
creating
adequate
In
addition,
look
at
my
and
using
perception
my
of
own
Leah’s
Lyons Ruth (p.582) explains, “that the
intersubjective
recognition
in
development
requires close attention to the child’s initiatives in interaction.
It is
through these initiatives that the child communicates his or her local or general goals (motives) and their associated meaning structures.
Without
recognition of one person’s initiatives by another, no intersubjectivity or dyadic regulation is possible”.
The
initiatives
(motivations)
that
Leah
and
I
express
in
the
following
vignettes are presented with words; but each sentence was filled with its own affect, its own rhythm and tone of voice and presented with a wide range of body postures and facial movements to create its implicit message. ironic that the words carry these non-verbal communications.
It is
Most of the
processes I will illustrate were to my best recollection, not negotiated through
my
reflecting
on
“what
is
happening
here
and
what
can
I
do
differently”. Rather, they seemed to take place on the level of trying to regulate the affect between us and in finding ways of being with one another that allowed us to use the analytic space in a way that felt relatively comfortable. Enactments 1 and 2 We take as a starting point the very early weeks of treatment in which a lull in the conversation or in Leah’s rapid telling of an event might prompt Leah to ask, “What are you thinking?”
When I enquire as to what prompted
her question she looks down and says, “I don’t know, I was just wondering”. What can we understand about this brief interaction, the timing of Leah’s question,
my
response
to
it,
and
Leah’s
reply?
I
refer
to
my
18
own
subjectivity to inform my answer.
Initially, I found Leah’s question
anxiety provoking. Our initial sessions seemed so fast paced and filled with so much information I often felt overwhelmed.
Usually I was just trying to
keep track of the information she was giving me. Leah’s question annoyed me; it didn’t seem to fit with what was going on. that question!
I didn’t want her asking me
Although my response to Leah looks innocuous and “analytic”,
the motivation behind my asking it is to manage my own affect, not Leah’s. Leah’s
deflecting
reply,
“I
was
just
wondering”,
tells
me
that
she
understood my motivations.
What can Leah infer about being with me?
When Leah took the initiative, and
tentatively reached out to me, my questioning reply made her retreat.
She
knows she can expect little from me.
As I empathically began to understand
that
question
the
motivation
underlying
her
was
the
management
of
the
anxiety she felt at having to fill up so much analytic space, and that her question was her best initiative at inviting me to help her to do that, it was relatively easy to share with her what I was thinking. And I did so, without
question,
whenever
she
asked.
In
regard
to
such
empathic
responsiveness it seems important to note that empathy, which is most often thought of as a consciously directed attempt to appreciate the patient’s experience, also holds a dimension of procedural knowledge communicated by the registration of, and responses to, body shifts, facial expression, voice rhythm etc (Lachmann, 2002).
Somewhat further along in the treatment Leah again poses her question.
At
this point I do not, as has become customary, respond by just telling her what I am thinking.
Instead, I wonder out loud, what prompts her question?
Leah retorts, “You look like you’re thinking”.
My shift, in not behaving as
had come to be expected, was represented in my not immediately answering her
19
question. Leah’s retort represents her reciprocal shift.
Leah’s retort is a
much more engaged response than her previous, “I was just wondering”, and suggests that she too knows that we can be together in a different way.
Her
cheeky delivery makes me smile. Unlike earlier, Leah is now willing to tell me that she senses I have left the analytic space.
She no longer feels the
need to manage the “too big” analytic space by retreating. Her affect, a little
teasing,
implies
a
warmth
between
us
as
well
as
a
belief
(an
attribution about me) that I will respond to her perception of me in a way that is not dismissive.
I implicitly understand that her motivation is to
locate where I am in relation to her and to have me come back to the analytic space.
The change from Leah’s retreat to her retort is not merely
descriptive, rather it represents a qualitative shift in what we know about each other and in our ways of being with one another.
We feel and perceive
qualitatively different things about one another as a result of the implicit learning that has occurred.
In a way she is saying, “You’re doing what I
know you do”.
In
contrast
to
the
view
proposed
by
Lyons-Ruth
in
which
these
changes
reflect the assemblage of increasingly complex procedures in how to be with one
another,
Fosshage
(2005)
would
see
aspects
of
Leah’s
experience
as
becoming organized around an image of me, that is a symbolic representation of me, drawn not just from the me she perceives in the immediate moment but rather
a
prototypic
image
formed
on
the
basis
of
the
ever-changing
interactions with me that get “chunked as functionally equivalent units”. He would see this image of me as facilitating the integration of affective, motoric
and
visceral
information
into
a
coherent
representation
of
our
experience together. Enactment 3 As we explore the meaning behind Leah’s question about what I am thinking,
20
in a later part of the treatment, it is clear that our ways of proceeding with
one
another
have
gained
further
complexity.
Now,
when
I
ask
what
prompts her question, Leah replies, “If I know what you think, then I’ll know what I think”. some
how
Leah is becoming increasingly aware that our minds are
related.
My
earlier
responsiveness
to
her
unarticulated
communications has let her know that she can influence my behavior.
To my
understanding, this knowledge, lived in the domain of the procedural, has made possible, at least in part, her growing sense that she can find herself located in my mind.
Leah’s sense that she will know her own mind if she can know my mind is presented to me in the context of her talking about her current relationship with her parents.
No longer presenting their relationship as positively as
previously, she expresses some distress.
In essence, her distress centers
on how unhappy they seem to be (with her) and on her inability to change that fact regardless of her interactions with them. She seemed to “ignore” my explicit constructions (interpretations) about their relationship. Within the
context
of
this
ongoing
conversation,
when
asked,
“What
are
you
thinking”, I understood Leah’s motivation to be her need for another mind to define her(self) within.
And indeed Leah used my mind for this purpose.
When I reflect on our discussions during this period I am aware that often the expression of my thoughts or my questions were influenced by angry and indignant parents.
feelings Her
evoked
lack
of
in
me
agency
by in
the
stories
managing,
or
Leah in
related
about
recognizing,
her
abusive
interactions with them fuelled my feelings of resentment at their treatment of
her.
Without
going
into
the
obviously
complex
transference-
countertransference dynamics that fuelled this dynamic, but looking at it from the framework of this paper, it seems to me that as I explored with Leah her understanding of what was going on between her and her parents, my
21
inquiries
often
carried
(through
my
tone
of
voice,
facial
expressions,
gesticulations, etc) an underlying message that she was being treated quite badly.
In this way Leah and I were implicitly engaging the hateful feelings
that she experienced in relation to her parents, and to my mind, we were beginning to develop procedures for being with those feelings.
The negative
affect that is associated with dissociated aspects of their relationships was making its way into our relationship.
In the vignette that follows
(perhaps a year later in treatment) we see how this early engagement has shifted allowing a more explicitly articulated view of what Leah expects can happen between us regarding the management of negative affect in relation to her parents. Enactment 4 Around the beginning of the third year of her treatment Leah related a conversation that she’d had with her mother. Leah was to attend a conference at which mother’s colleagues would be present.
As they were parting her
mother said, “Have a good time at the conference, don’t do anything to shame me”.
Rather
than
her
usual
defensive
response
of
finding
her
mother’s
insensitivity amusing, or wondering about her own behavior, Leah was deeply hurt and confused.
She felt she had done nothing about which her parents
could feel ashamed. Her increasing capacity to tolerate painful feelings, as well
as
an
increased
capacity
(or
potential)
to
attribute
motivation
(beliefs, intentions) to her mother’s behavior, is evident in her poignantly asked question, “Why would she say something like that.”
In the middle of
discussing this incident, Leah bluntly blurted out a different version of her “What are you thinking?” question.
“So what don’t you like about me?
she asked. Taken aback by her question I groped around wondering how I would respond.
When,
anxiously
buying
time,
I
asked
what
was
prompting
the
question, she responded with, “If I know what you don’t like about me, maybe I’ll understand what it is that my parents don’t like”.
The room was filled
22
with affect, hers and mine.
I was mindful of the importance of responding
with authenticity. Uncomfortably, I began to think about what I didn’t like about her. I stumbled around and said something about feeling frustrated with
her
when
I
felt
she
was
recognizing anything positive.
being
self-critical,
to
the
exclusion
of
She rolled her eyes at me and made some
comment about my answer being lame. I felt somewhat lame as I told her that I didn’t really have negative feelings about her.
Considering this somewhat
“startled” subjective response from the present vantage point, it seems that Leah was inviting me to engage the negative feelings that she believed I had about her but of which I had not let myself be aware.
Significantly, and
clearly a response to her invitation, when I opened the door to greet her the next day and was met with her typical vivacious “Hello” I felt a wave of dislike that stayed with me for much of the session. through
why
I
felt
detachment from me.
so
irritated
with
her
I
was
As I tried to sort
aware
of
feeling
her
In that session I became aware that sometimes the
manner in which she spoke left me feeling shut out and powerless to impact her, and that I found this quite frustrating.
Later, when I tried to convey some of this experience to Leah, she seemed surprised.
She felt hurt and criticized.
In a sense she behaved as if she
had no idea what I was talking about. Her reaction to my revelations was to wonder if I hated her. I felt quite confused about what had happened and about how to understand what had transpired between us. Over a period of time, during which Leah insisted that I hated her, I, privately, struggled to
understand
Increasingly,
what I
had
became
occurred aware
that
and I
what had
was
not
occurring
allowed
between
myself
to
us. fully
experience or reflect on negative feelings about her, which in retrospect I knew crept around the edges of our relationship.
When I allowed myself to
elaborate on these feelings, I was aware that sometimes I felt that there
23
was a provocation in her interaction with me.
And although I did not share
it with her I became aware that sometimes I felt that she was intentionally (though perhaps not consciously) sadistically tantalizing and teasing me, enjoying my struggle, and failure, to locate her. verbalize engaged
these
at
a
thoughts
later
to
time.
Leah, From
rather the
I
I did not re-attempt to
assumed
vantage
that
point
of
they this
would
be
particular
discussion, however, and given the course of the treatment subsequent to this interaction, I think Leah’s question could be seen as her taking the initiative
to
engage,
at
a
procedural
level,
the
negative
beliefs
and
attitudes I held about her (until now, dissociatively out of consciousness). Her invitation (or motivation in asking what I thought) was to begin to expand our procedures, or patterns of expectancy, for being with parts of her-self that others had found problematic.
But before I discuss the shift
to the engagement of negative affect I want to illustrate Leah’s increasing capacity to think about (know) the motivations/minds of others.
In the
vignette that follows we can see her struggling to hold onto her own beliefs about herself in the face of differing beliefs in the minds of her parents. Fonagy et al (1996) would call this the capacity for mentalization.
During a trip home she went to see one of the families for whom she had babysat as a teenager and with whom she had remained friendly over the years.
It struck her quite powerfully that this family really liked her,
enjoyed her company and felt attached to her.
In the past she had sometimes
felt confused about their behavior towards her, as it seemed in such sharp contrast to how her parents behaved towards her.
That a shift in her
experience of her self, and of her self in relation to others, had occurred is evident in the comments she made to herself. these people really do like me too”.
“If Mary likes me, maybe
And on yet another occasion, when she
and her father got into a volatile argument, rather than accommodating to
24
his view of her as bad she tried to address what had happened between them. Although unsuccessful in influencing her father’s perspective, I saw it as forward movement that she was able to hold onto her feelings of confusion and hurt at his accusation rather than just accepting his view that she was an “ingrate”.
Struggling to hold onto her own self-experience, she asked
with poignant sincerity if I thought she was ungrateful.
I said that I
didn’t think so. “I don’t just mean with my parents, I mean with you, in therapy. Do you think I’m ungrateful with you?
I want you to tell me if
that’s what you really think.” I answered simply, “I don’t think that”. said, “I don’t feel that way, I love my therapy”.
She
During this session I
felt deeply moved by Leah’s struggle to find a place in her heart for her parents that didn’t compromise her sense of self.
Leah sensed my mood.
Towards the end of the session she said to me quietly, “You were so quiet today,
are
you
O.K.?”
Deeply
connected
to
my
own
feelings
about
her
struggle I said, “I think I was feeling how really sad it is for you, how hard it is for you to deal with your parents, to find a way to see their point of view as well as to hold onto your own”.
Later that night Leah
called and left a message on my answering machine.
Clearly experiencing a
tremendous amount of anxiety indicative of the risk she felt she was taking, she said, “Mary, I just wanted to go back to our conversation today when I said I loved therapy.
Well, that’s not exactly right.
Actually what I love
is the person I’m in therapy with, and I guess that would be you”. When we discussed this message the following week she said she wanted to be really honest about what she was feeling, she didn’t want to hide behind words that diminished her feelings.
I see Leah’s phone call as representing a shift,
regulated by the distance of the telephone, in implicit relation knowing. Loving feelings can now be (more) safely felt and then shared. She can take the initiative to ‘live in’ the “different mental landscape” created by the increasingly complex affective processes that can now be contained in the
25
space between us. Enactment 5 In year three of treatment Leah and I were struggling with one another.
A
retrospective analysis of my subjective experience reveals that I no longer hear the motivation in Leah’s statement “If I know what you’re thinking, then I’ll know what I’m thinking” as her need for another mind in which to find herself. Rather, I felt frustrated by the implicit structure of meaning inherent in her view that to know her mind she needed to know mine first. didn’t
feel
unwilling
to
share
my
viewpoint
with
her,
constrained by the implication that I should go first. and resistant.
but
I
did
I
feel
I felt pushed around
Implicitly, I sensed that the structure of her thinking was
different. I felt that her motivation for knowing what was in my mind had shifted.
Implicitly, I understood Leah to be saying, “If I know what you’re
thinking (and feeling) then I can avoid feelings about what I’m thinking”. Consciously, contact.
I
was
aware
of
my
desire
for
more
affectively
connected
At the same time it was clear to me that Leah experienced me as
being motivated by wanting less contact.
Something new was happening between Leah and me. began
to
experience
unresponsive
and
real
conflict
withholding.
I
in had
our
For the first time we
relationship.
similar
feelings
She about
found her.
expectations about how Leah and I could be together had shifted.
me My
I felt
less willing to see myself only as someone who provided Leah with what she felt she needed.
I felt she was more able to let me know what was in her
mind than she allowed.
During these months we seemed to be in a power
struggle and our conversations often descended into a confusing mess. often
emerged
from
our
sessions
feeling
inadequate,
misunderstood
incapable of thinking reflectively about the process between us.
I and
Although I
realized that I was probably experiencing aspects of Leah’s own experience
26
with her parents, I felt bullied by her. Consciously, I tried to consider what I might be contributing to the stranglehold on our relationship but I repeatedly found myself finding fault with Leah.
It was a significant
internal struggle to find my way to simultaneously being able to hold my own viewpoint and to think about what Leah might be experiencing.
When I was
finally able to empathize with what it must be like for Leah to be with me, in the way that I was feeling about her, I was able to soften my responses to her.
This is a further example of the change process as Bucci and
Fosshage describe it, whereby my shift became possible through my imagining (non-verbal symbolizing) what Leah must be feeling. But what I want to convey here is not the importance of the fact that I was able to think and feel differently about our interaction, but rather that in thinking and feeling differently my way of being with Leah (communicated in my tone of voice, my body posture, my facial expressions and my own felt experience of who Leah was to me) was qualitatively different and that this qualitative difference, in my affective presence, was of paramount significance to the process of change.
To
my
mind
these
powerful
transference-countertransference
interactions
could be seen as a more articulated version of learning how to be with, within the domain of the procedural, the negative feelings that attend our relationship and that are fuelled by the complex histories that we both bring
to
the
interactions
analytic
represent
encounter.
and
hold
the
Negative assemblage
though of
they
multiple
be,
these
systems
of
implicit meaning (procedures) that have been put together, like component parts, to help Leah manage how to be with, rather than how to understand, the
abusive
and
neglectful
significant others.
aspects
of
her
relationships
with
important
Although our goal was to move beyond the conflict in
which we were engaged I think the conflict served a useful and necessary
27
purpose by allowing us to learn how to be with and emerge from it. The final enactment is taken from a relatively recent session. The change in implicit relational knowing is evident. We handle feelings of rupture with more ease. Our repertoire for engaging Leah’s interest in what I am thinking and how we are able to share and fill up the analytic space has expanded. Also evident is the verbal symbolization of some of the implicit procedures in which we have engaged over the course of the treatment.
The evocation of
significant images (e.g. Schopenhauer’s porcupines) functions to integrate, aspects of Leah’s experience moving the process of meaning making along. It is a lovely example of the bi-directional process of the mutual influence of the different modes of representation and processing in the procedural and symbolic domain. Enactment 6 This last vignette is taken from a session that was the last in a series of three sessions that carried a central theme. first two.
I’ll briefly comment on the
In the first, Leah complained of being tired and of having
nothing to say.
Some tension seemed to occur between us around my raising
the issue of whether her tiredness held more meaning than her simply being tired.
We both left the session feeling frustrated.
session
with
interaction.
an
in-depth
She
showed
analysis
of
considerable
how
she
Leah began the next
understood
reflective
our
function
previous
and
self-
awareness, commenting both on how she saw her own behavior in the session and on how she understood mine.
Essentially, I responded with “wow” and
shared my perceptions of the discrepancy between her impressive ability to use her mind to understand our interaction in this instance and how she used her mind in other interactions.
I wondered with her what motivated the
difference. I also wondered out loud if she sometimes relied on my mind for fear that she would lose me if she relied on her own.
28
Leah begins the third session in the series as follows. P: I wondered if you had more to say in our last session? A:
Was there something that you were left with that gave you that feeling?
P: I just felt you had more to say. A: Well, right this minute I’m not sure if I had more to say.
I guess I
don’t feel quite oriented to the session and feel a little caught off guard. I’m more than happy to talk about the session and see if I had more to talk about but I think I need you to orient me more. P: Well, when you said, “I seemed to be saying your mind rather than saying my own”, do you think that’s a problem. A: Actually, I think what I said was that I think that sometimes you use my mind rather than using your own.
And I guess by that I was saying two
things. First, that I think that is what good therapy allows people to do. And second, I was wondering if there was a way in which you use my mind as a way of staying connected.
Like if you use your mind I will abandon you
somehow, like I won’t get involved in your mind.
I wonder if you get
anxious about saying what’s in your mind because you don’t know what I’ll do with it.
You’d rather know what’s in my mind and then you can say yes, I
think that, or no I don’t think that. P: (Silence, a deep breath).
I do do that … (pause)… a lot. (Pause) I don’t
respond to a situation with full presence.
I make a full assessment before
I show myself. She goes on and makes a comment indicating that she’ll do better at this. A: I wouldn’t be in such a rush to fix it. it.
Let’s see if we can understand
How is it that that’s what you do?
P: It’s safe.
Then another comment about noticing next time she does it.
A: You’re in such a rush to fix it.
I guess I’m curious about how it’s
safer and what needs to be protected. A protracted silence. A: Where did you go? P:
I knew you’d ask me that?
I guess I’m changing the subject. You’ll
think it’s not relevant, but have you heard of Schopenhauer’s Porcupine? A: (engaged) No. P: Well it’s about Schopenhauer who spent all this time watching porcupines in winter.
They wanted to huddle together so that they could stay warm but
when they connected they got all spiked.
They had to readjust their way of
living to meet their needs for warmth and not get spiked. A: How perfectly relevant to what we were talking about!
29
P: I think it’s relevant. A:
So how do you think it’s relevant?
P:
Well how do you think it’s relevant?
A:
(teasing, a little) Leah, I have no problem telling you why I think it’s
relevant, I’m more than happy to do that.
I’ll even tell you before you
tell me. But I would do that feeling uncomfortable that I stood in a place that seemed to belong to you at this moment.
There was something really
beautiful about your association that holds both your understanding and the creativity in how you can express that understanding. P:
Well …ahm, er.
Long silence
A:
(a statement) You’re feeling very shy.
P:
Yes!
A:
Can you say more about that?
The session continues with Leah and I being immersed in and discussing the idea that she can express her thoughts without losing me.
The process of
mutual influence is evident as are the different modes of processing in the procedural and symbolic domain.
Conclusion The changes that are evident in Leah’s interactions with me across the course of her treatment are due in significant part to shifts in the ways that we felt we could be with one another.
I see much of this change as
occurring in the domain of the procedural through our implicit sensing that the other was receptive to engaging aspects of self that had previously been dissociatively held out of consciousness. As illustrated in the described enactments, function
of
these
shifts
them
being
in
our
verbally
ways
of
engaged
feeling and
and
their
being meaning
were
not
a
understood.
Rather, they turned and developed in relation to the processes themselves expanding the possibilities for what could then be engaged verbally.
30
Each enactment is reflective of a point in the treatment that marks, in a more defined way, our understanding, often implicit, of how we can be with one another. Much of what happened between enactments was communicated and processed implicitly.
As such, the enactments
themselves were an announcement of, as well as an elaboration and consolidation of, what had already happened between us, and therefore did not require a verbal focus for them to be understood or appreciated.
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the
Facilitating
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