The Self Too Seen

Comparing the clinical practice of contemporary Freudian analysts with that of Interpersonal/Relational analysts, I focus on the difference between primary reliance on continuous participation in, and reflection on, mutually constructed, unconscious clinical process (the Interpersonal/Relational view) and primary reliance on the interpretation of unconscious fantasy (the contemporary Freudian view). I demonstrate the Interpersonal/Relational view by presenting a detailed clinical illustration.     

The role of the therapeutic relationship in the association between interpersonal behaviors and outcome: Comparison of two competing models

Objective: The patient–therapist relationship may be the mechanism behind the effect of pretreatment interpersonal patient behaviors on the outcome of psychotherapy for depression, or the factor determining for whom interpersonal behaviors affect outcome. We seek to establish which of these two alternatives receives empirical support. Method: We conducted a secondary analysis of the findings from the Treatment for Depression Collaborative Research Program to examine two alternative models. First, a deterministic model, in which clients’ ability to create satisfactory interpersonal relationships affects their ability to build a strong therapeutic relationship, which in turn affects outcome; and second, a compensation model, in which patients in a treatment focusing on interpersonal mechanisms of change and not in placebo, who compensate for their maladaptive pretreatment interpersonal behaviors by building a strong therapeutic relationship, benefit from treatment more than do patients who cannot build such relationship. Results: The compensation, rather than the deterministic model, was supported, suggesting that the interpersonal behavior–outcome association is significantly moderated by the therapeutic relationship in interpersonal psychotherapy and not in placebo. Conclusions: Findings support an optimistic view whereby patients seeking treatment for maladaptive interpersonal behaviors can achieve good outcomes if work on interpersonal relationships is conducted in the presence of a strong therapeutic relationship.

Clinical or methodological significance of this article: This study highlights an important optimistic view in which patients with maladaptive interpersonal style who can form a strong therapeutic relationship can benefit from treatment focusing on interpersonal relationships.     

Pilot test of a measure to assess therapeutic distance and its association with client attachment and corrective experience in therapy

Abstract

Objectives: The Therapeutic Distance Scale (TDS) was developed in this project to assesse clients' experiences of distance versus engagement with their therapist. Method: In a survey study of 47 university clients at the “mid-stage” and 34 of these clients at termination, four TDS subscales were identified: Too Close, Too Distant, Growing Autonomy, and Growing Engagement. Results: TDS subscales were correlated as expected with working alliance and Client Attachment to Therapist. As hypothesized, (i) pre-therapy attachment Avoidance was significantly correlated with perceptions of therapists as Too Close (but not Too Distant), (ii) pre-therapy Anxiety was significantly correlated with Too Distant (but not Too Close); furthermore, among clients who developed a secure attachment to their therapist, (iii) pretherapy Avoidance was significantly correlated with Growing Engagement; however, (iv) contrary to expectations, pre-therapy anxiety was not significantly associated with Growing Autonomy. Conclusions: The TDS is a promising measure for assessing the in-therapy corrective emotional experiences of clients with hyperactivating attachment (i.e. increasing autonomy) and deactivating attachment (i.e. increasing engagement).     

Sex in Psychotherapy: The Myth of Sandor Ferenczi

This paper examines the challenges encountered by the analyst when working with patients with disordered attachment relationships, particularly disorganized-disoriented. The author proposes that early in development these patients retreat from authentic contact with their attachment figures into a world of fictive relationships, as a defense against punishing and malignant maternal environments. Consequently, the conscious internal working models that develop are based on the self with the fictive object, leading to an overall lack of coherence in the attachment narratives of these patients. The author contends that the fictive object becomes part of implicit relational knowing and is identified by the highly discrepant semantic-episodic memories in explicit memory. The fictive object incorporates aspects of Fairbairn's “moral defense,” Bowlby's idealized internal working model, Sullivan's “illusory me-you patterns,” Riesenberg-Malcolm and Roth's falsely idealized object, and Bion's reverse of proper alpha function. A detailed case illustration is presented that demonstrates how the analyst's recognition and understanding of the phenomenon of the fictive object facilitates the patient's capacity for authentic relatedness within the analytic dyad.     

Psychoanalytic Reflections on Women's Liberation

In this article I explore some of the implications of the Buddhist perspective on nonduality and acceptance for psychoanalytic practice. Nonduality is a mode of experiencing that breaks down the distinction between categories that are conventionally regarded as opposites (e.g., good versus bad, pure versus impure, sacred versus profane, heaven and hell). The Buddhist perspective on nonduality is that the natural human tendency to think about things in dualistic terms is at the heart of the problem and that wisdom is the ability to experience things nondualistically. As long as we distinguish between things as they should be in some idealized state versus things as they are, we are unable to be fully open to, and appreciate the present situation for what it has to offer. I attempt to convey a sense of the way in which the cultivation of a nondual perspective can lead to a radical and paradoxical perspective on the role of acceptance in the analytic process.     

From Out of Nowhere - The Paradox of Unconscious Experience

Abstract

Using material from physics, linguistics, philosophy, and other disciplines, I hope to introduce a view of unconscious experience that can expand our view of the unconscious and its clinical utility beyond our present psychoanalytic orientations and metapsychological perspectives. Central to this presentation is the examination of the at once nebulous and possibly direct relationship between unconscious experience and the apprehension of reality, a relationship that challenges, as I see it, the current psychoanalytic emphasis on subjective experience (as in the view, for example, of perception as interpretation), and of our use of the concept of psychic reality.     

The Practice of Multiple Analyses in Analytical Psychology

Even those who reject drive theory have had their thinking shaped by its conception of walled-off content. This inevitably generates a one-person psychology, despite the belief that working from a two-person psychology is a matter of choice. Drive logic, with its conception of fixed layers, is so intuitively compelling that it has obscured the way the (misnamed) structural theory conclusively invalidated it by conceiving of defense and defended-against as reversible, even as “in motion.” The revision requires a continuing differential diagnosis to determine what is defense and what is defended-against at any given time, one that rests on the patient's response and therefore is, of necessity, a two-person psychology.

My argument proceeds from early vignettes, followed by two contemporary case reports that can demonstrate the unrecognized continuing influence of layering logic in the understanding of dynamics and in inviting unyielding reliance on an interpretation, despite a patient's protests, the sine qua non of one-person analysis.     

A tripartite model of the therapeutic relationship: Theory,research, and practice

Abstract

The development and empirical examination of a tripartite model of the therapeutic relationship over nearly three decades are described. The model asserts that all therapeutic relationships, to varying degrees, consist of a real relationship, a working alliance, and a transference-countertransference configuration. Research testing propositions about how each of these components is related to treatment process and outcome, and to each other, is presented. Many propositions have been supported, but some have been disconfirmed. Although the tripartite, or perhaps a quadripartite, model appears to be empirically and theoretically viable, continued research and theoretical development will serve to refine the model further. The development and testing of additional models that unpack the global concept of the therapeutic relationship would also be useful.     

Stress-induced synaptic changes in the rat anterior cingulate cortex are dependent on endocrine developmental time windows

Fetal and neonatal brain development is characterized by developmental time windows during which brain regions or neuron types are specifically sensitive to environmental influences. Previous studies on cortical development have revealed evidence for the hypothesis that the extent and the direction of experience-induced neuronal and synaptic changes correlate with time windows of endocrine development. To further test this hypothesis we exposed rats to neonatal separation stress during different phases of endocrine maturation, i.e. prior, during and after the stress hyporesponsive period (SHRP) of the hypothalamic-pituitary-adrenal (HPA) axis. We show here that only stress during the SHRP resulted in significantly decreased (-29%) spines densities on the basal dendrites of pyramidal cells in layer V of the anterior cingulate cortex (ACd), whereas stress during the other two tested time windows had no effect on these parameters. Dendritic length remained unaffected by stress exposure at any of the tested time windows. These results reveal specific developmental time window for synaptic wiring within the deeper layers of the anterior cingulate cortex, which seem not to be mediated by hormonally induced mechanisms.     

How I Work with Unconscious Process: A Case Example

Abstract

I begin with a brief theoretical presentation, to orient the reader for the longer clinical case example that follows. The theory, my conceptualization of unconscious process, is the variety of field theory that I have been developing for some years. The theory grows from the idea of unformulated experience, according to which the unconscious is composed of various, shifting potentials, only some of which will be actualized in conscious experience. Which of these potentials is formulated and thereby emerges in consciousness is determined by the nature of the interpersonal field. Constriction in the field reduces the freedom of thought and feeling of the field’s participants. Freeing the field, then, and not understanding via interpretation, becomes the clinical aim.     

Emotional experience of music by psychiatric patients compared with normal subjects

Psychiatric patients (n= 107) and normal subjects (n= 100) were exposed to seven newly composed pieces of music orchestrated for a small symphony orchestra. The patients were divided into seven subgroups: schizophrenic, depressive and manic psychosis; obsessive, depressive, anxiety and hysterical neurosis. All subjects rated the music on semantic differential scales describing three factors of emotional experience: tension-relaxation, gaiety-gloom and attraction-repulsion. The ratings by patients in the different groups were compared with those by the normal subjects. Expressiveness in music was found to be communicated to patients in the same relative way as to normals. However, in the various diagnostic groups, several marked differences in experience were demonstrated. The main findings were that schizophrenic psychotics experienced the music as more attractive, while depressive and anxiety neurotics experienced it as less attractive, than normals. Depressive and manic psychotics experienced the music as less gay. Obsessive neurotics seem to be more sensitive to tension in music than normals.     

Testosterone reduces unconscious fear but not consciously experienced anxiety: implications for the disorders of fear and anxiety.

BACKGROUND: The fear-reducing properties of testosterone have been firmly established in animals but not in humans. However, human data on the relation between testosterone, fear, and anxiety have predominantly involved questionnaires that index cortically executed conscious appraisal of anxious mood. Animal studies, on the other hand, indicate that the effects of testosterone on motivation and emotion are of subcortical origin and of unconscious nature. Presently, it was hypothesized that a single testosterone administration to humans would reduce unconscious fear but not consciously experienced anxiety. METHODS: In a placebo-controlled, double-blind crossover design, a single dose of testosterone (.5 mg) or placebo was administered to 16 healthy female volunteers. Afterward, a masked emotional Stroop task measured unconscious emotional responses to fearful faces, while multiple self-reports of mood indexed consciously experienced anxiety. RESULTS: As hypothesized, the habitual vigilant emotional response to the masked fearful face observed in the placebo condition was significantly reduced after testosterone was administered, while the self-reported measures of anxiety remained unaffected. CONCLUSIONS: These data provide the first direct evidence for fear-reducing properties of testosterone in humans. Furthermore, by dissociating specific aspects of fear and anxiety in humans, this outcome highlights that testosterone's effects on motivation and emotion concern the subcortical affective pathways of the brain.     

Growth curves of clients’ emotional experience and their association with emotion regulation and symptoms

Objective: Emotional experience during psychotherapy is considered a core mechanism of change. Yet the sheer experience itself may not necessarily be beneficial; instead, the trajectories of emotional experience need to be explored as possible predictors of treatment outcomes. This study investigated whether clients’ pre-treatment levels of emotion regulation and symptoms predicted patterns of session-to-session change in emotional experience. We also explored which patterns better predict clients’ improvement in emotion regulation and symptoms from pre- to post treatment. Method: One-hundred and seven clients undergoing psychodynamic psychotherapy completed questionnaires on their symptoms and emotion regulation at pre- and post- treatment. They also reported their level of emotional experience at the end of each session. Results: Pre-treatment symptoms and difficulties in emotion regulation predicted greater instability in emotional experience. Higher mean levels of emotional experience during treatment were associated with an improvement in emotion regulation, and greater stability during treatment was associated with improvement in emotion regulation and symptoms. Conclusions: These findings lend weight to the idea that experiencing emotion in the therapeutic environment has significant implications for clients’ ability to manage their emotions outside the session. However, emotions experienced in an unstable manner within therapy are associated with poorer outcomes.

Clinical and methodological significance of this article: Therapists can benefit from observing the patterns and not only the level of their clients’ emotional experiences. The identification of clients’ difficulties early in treatment may help therapists guide clients through the delicate process of carefully attending to their emotions.     

The management of resistance in the application of object relations concepts in children's and adolescents' group psychotherapy

Object relations concepts are applicable to child and adolescent group therapy. The author attempts to delineate areas in which developmental conflicts in object relations, emotional deprivations, traumas, and family pathologies are recapitulated in the group. To better understand the dynamics of the group and the interaction of its members, symbolic representations of the group are identified. The manifestation of pathologies is ameliorated during the process of the specific phase, and stages of the symbolic representation of the group. The role of the therapist as a new object in the management of individual and group resistances is illustrated.Private practice, Tenafly, New Jersey.     

Narcissistic Personality Disorder and Pathological Mourning

This paper describes an approach to psychoanalysis conducted as a “talking cure” whereby the analyst privileges the patient's maturational capacity for speaking about experience. An optimal analytic process becomes a method of exploration and investigation through inquiry rather than interpretation. Interpretations facilitate talking, particularly those thoughts and feelings that are unwanted and unbidden. Accordingly, the analyst's chief concern is the resolution of resistances to speaking in contrast to an effort that aims to resolve resistances to insight or understanding. Insight, when it occurs, is a result of the change process and one's burgeoning capacity for talking with another who is interested in understanding. In this way making the unconscious conscious is worked through progressive speech and the enrichment of experience that results. Complementary to this effort is the analyst's subjective reflection on and use of countertransference states. Several features of the analytic process are described and elaborated: the centrality of the patient's voice, the value and function of inquiry, the analyst's crucial function as the sentient other for the patient's unconscious processes, and the leverage provided by the analyst's living into the transference experientially accompanied by personal acts of emotional freedom. A case example is provided to illustrate this approach.     

Emotional experience with dyslexia and self-esteem: the protective role of perceived family support in late adulthood

Objectives: Despite the growing body of evidence that suggests dyslexia persists through the life span, there is a dearth of research that explores the complicating factor of dyslexia in late adulthood. Based upon stress and coping theory, this study examined whether perceived family support protects the impact of negative emotional experience with dyslexia on self-esteem.

Methods: Adults aged 21 years and older with diagnosed or self-reported dyslexia were participants in a web-based survey. A total of 224 individuals completed the survey. These findings are from the 50 participants who reported to be 60 years or older. Completed measures include their perception of family support, emotional experience with dyslexia, self-esteem, and demographic variables.

Results: Preliminary analysis revealed that negative emotional experience with dyslexia negatively impacts self-esteem. Hierarchical moderated regression analysis demonstrated that positive perceived family support significantly buffers, mitigates, and protects the effects of negative emotional experiences with dyslexia on self-esteem in individuals with dyslexia in late adulthood.

Conclusion: In this study, family support promoted self-esteem because as a protective dynamic, it helped older adults cope with the emotional distress associated with dyslexia. Implications of these findings are discussed.     

Brief report: How adolescent personality moderates the effect of love history on the young adulthood romantic relationship quality?

This study examined the effect of previous romantic relationship involvement on later romantic relationship quality and tested whether adolescents' personality type (i.e., overcontrollers, undercontrollers, resilients) moderated this link. We answered our research questions in a sample of 320 Dutch participants (213 girls) who had a romantic relationship when they were 21 years old. At 12 years of age, their personality types were identified. At 21 years of age, participants reported their current romantic relationship quality (i.e., commitment, exploration, and reconsideration) and indicated the number of romantic relationships they had before. No main effects of the number of romantic relationships on current romantic relationship quality were found. There were significant interaction effects between personality types and the number of romantic relationships on romantic relationship quality. With more romantic relationship experiences, undercontrollers committed less to and explored less in their current romantic relationship. No such link was found for resilients and overcontrollers.