toward a view of "positive resistance": one perspective on change in psychoanalytic...

Toward a View of “Positive Resistance”: One Perspective on Change in Psychoanalytic

Psychotherapy

James Tobin, Ph.D.Licensed Psychologist PSY 22074220 Newport Center Drive, Suite 1

Newport Beach, CA 92660949-338-4388

Assistant Professor of Clinical Psychology601 South Lewis Street

Argosy UniversityOrange, CA 92868

714-620-3804

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Case VignetteCase Vignette

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Case VignetteSection A.

When the Therapist Becomes “Real”

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Section A. When the Therapist Becomes “Real”

• My goal in this presentation is to describe an approach toward understanding and working with one form of an unexpected “surprise” experience in clinical practice I am sure we all face.

• The case vignette features an interaction in which the therapist reveals himself to the patient in an unintended, spontaneous way.

• Ghent (1990) describes this type of interaction as a moment of the therapist’s “surrender” to the patient and the clinical process. These moments are contrasted with voluntary self-disclosures of the therapist’s countertransference reactions. 4


• The moment of surrender in the case vignette represents (1) a breaching of a patterned form of relatedness established between patient and therapist and (2) a deviation from the therapist’s “relational” persona (how the therapist modifies or adapts oneself to work with a given patient).

• Moments of surrender arise from “being in the moment” (Ghent, 1990) in which the therapist foregoes a persona anchored in technique (Hoffman, 1983).

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• What occurs is the sudden emergence of what may be characterized as the therapist’s “real” self -- which I am distinguishing from the therapist’s “relational” self.

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• These moments have the effect of imploding an established (status-quo) relational mode of being between patient and therapist, injecting a shared moment neither can deny and that permanently alters how each sees and relates to the other.

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• Moments of regression and integration experienced by patients throughout treatment and even in one particular session have been described (Gilhooley, 2005); the case suggests a moment of surrender that can be viewed as the therapist’s necessary regression.

• These moments are necessary because, as intersubjective theory suggests (Stolorow, Brandchaft, & Atwood, 1987), patient and therapist at some point in treatment arrive at a mode of relatedness that becomes “calcified” – there is an inevitable press to move toward a deeper level of relating (moving from self-object to self-self relatedness); I see the therapist as the agent of this transition.

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Case VignetteSection B. The Therapist’s Use of

Self

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Section B. The Therapist’s Use of Self

• Traditional psychoanalytic theory characterizes the therapist as a “blank screen” who allows the patient’s transference to emerge in pure form in the context of a neutral and non-gratifying position.

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• In the traditional model, the therapist is an “object” of the patient’s drives and drive derivatives; the therapist as object is a subjectivity not relevant.

• Only the patient possesses a “psychic reality” and the analyst is oriented solely toward representing that reality (McLaughlin, 1981).

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• Contemporary psychoanalytic theory views patient and therapist as influencing, and being influenced by, each other (2-person psychology).

• No longer a “blank screen,” the therapist is an object (of the patient’s self) but also a separate subject with a separate subjectivity (Chodorow, 1989) who co-participates in influencing the relational field along with the patient (Stern, 2010).

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• The 2-person psychology model holds several important implications for contemporary therapists:

a) The patient can no longer be viewed as accepting at face value the therapist’s words or behaviors (“the naïve patient fallacy”) (Hoffman, 1983);

b) Patients are accurately and intuitively reading the therapist’s hidden communications and identity (Aron, 1991; Singer, 1977);

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c) A new mode of psychoanalytic listening is suggested: “A consequence of the analyst’s perspective on himself as a participant in a relationship is that he will devote attention not only to the patient’s attitude toward the analyst but also to the patient’s view of the analyst’s attitude toward the patient” (Gill, 1982, p. 112);

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d) The therapist uses his or her subjective experience to attempt to understand the patient better (Aron, 1991; Frankel, 2006).

e) Those drawn to the psychotherapy professions likely have strong conflicts regarding voyeuristic and exhibitionistic wishes: there are longings to be known by patients as well as hidden from them (Aron, 1991).

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Case VignetteSection C.

How the Therapist Selects a “Way of Being”

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Section C. How the Therapist Selects a “Way of Being”

• Presumably all therapists accommodate to their patients and at some level select a relational mode of being in which the therapist’s true character is altered or suppressed, to a greater or lesser degree.

• My gazing away from Jessica is one example of this.

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• This choice or “way of being” with the patient is usually conceptualized as an issue of technique, i.e., it is based on the therapist’s assessment of the patient’s level of ego functioning, identity development, and capacity to take in and use alternative views and challenges.

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• This assessment yields a stylistic way of being that resides at some point along a continuum from empathy (therapist as self-object) to interpretation/confrontation/use of self/ transparency (therapist as a separate subject).

• In my work I seem to drift toward a point on this continuum and linger there, despite modest attempts to move in one direction or another that gradually become more infrequent.

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Case Vignette

Section D. The Patient’s Accommodation

to the Therapist

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Section D. The Patient’s Accommodation to the Therapist

• The case vignette, however, suggests that the therapist’s subjectivity is revealed or suppressed not only for conscious technical reasons oriented toward the patient, but for reasons related to the therapist’s own psychology and unconscious conflicts around being revealed in the clinical situation.

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• What I realized in working with Jessica is that the differences in our innate tendencies and predispositions were unconsciously utilized by me: I had not wanted to acknowledge Jessica’s familiarity to me as my own transference object AND ALSO as a person whose core emotional experience was quite similar to my own (I had not wanted to see myself in her).

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• Consequently, I had established an interpersonal decorum or relational culture with Jessica in which my apparent ease and spontaneity was set against her stiffness and hesitancy (a form of polarized role induction).

• Jessica’s stiffness and lack of spontaneity positioned me in relation to her singularly (and rigidly) as the agent of loosening her up, which had the paradoxical effect of rigidifying how I saw and interacted with her (who I was in relation to her).

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• Wolstein (1983) observed that the patient’s resistances often are interpersonal efforts to cope with the analyst’s personality, character, and metapsychology.

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• In his seminal paper “The Patient as Interpreter of the Analyst’s Experience,” Hoffman (1983) describes the patient’s capacity to apprehend the therapist’s character and unresolved conflicts; in this paper, Hoffman argues that successful treatment involves the therapist recognizing how the patient has chosen to adapt to the therapist.

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• Similarly, Aron (1991) and Wolstein (1983, 1988, 1994) argue that it is helpful to approach the patient’s resistances as possible reflections of the therapist’s. Aron (1991), in summarizing Wolstein’s work, states that “ … the ultimate outcome of successfully analyzing resistances is that the patients would learn more not only about their own psychologies but also about the psychology of others in their lives, particularly about the psychology of their own analysts” (p. 35).

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• In response to therapists’ (counter-)resistances, what many patients do is communicate observations about the therapist’s character/relational mode of being through displaced material or descriptions of these characteristics as aspects of themselves in the form of “identifications” (Aron, 1991).

• This became apparent in my work with Jessica as her “stiffness” became and was my own (metaphorically/physically), was in each of us, and was by “osmosis” moving back and forth between us.

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Case VignetteSection E.

Application of Intersubjectivity to the Case

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Section E. Application of Intersubjectivity to the Case

• Intersubjectivity (Stolorow, Brandchaft, & Atwood, 1987) is a theory of relatedness in which self and other are independent beings who engage with each other in a way that promotes “subjective expression” as well as “shared experience.”

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• The other is an object of the self’s subjectivity (“self-object” relatedness) but is also a separate subjectivity (“self-self” relatedness).

• Advanced intersubjectivity represent a developmental progression in which both domains of relatedness can be simultaneously engaged and amplified.

• When the intersubjective model is applied to the therapeutic situation, there exists a paradox: the clinical process between patient and therapist is simultaneously an experience of separateness and relatedness, subjectivity and objectivity (Pizer, 1992, 2003).

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• Therapist and patient are simultaneously a subject and an object to each other (Wolstein, 1983).

• How each character’s subjectivity is concealed and revealed in the course of treatment, what these patterns may mean, and how they are analyzed, is a central feature of treatment.

• Using the intersubjective model, my crying can be seen as a release from self-object relatedness and entry into self-self relatedness (in many ways, each of us had served as a self-object for the other).

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• I believe that moments of countertransference surrender emanate from the mutual need for advanced intersubjective relating – unlocking both patient and therapist from a more primitive (status-quo) form of relatedness revolving around distortion, concealment, and accommodation.

• The therapist “reads” the signal for this advancement in the clinical process and responds to it, often unwittingly.

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Case VignetteSection F.

“Positive Resistance”

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Section F. “Positive Resistance”

• The emergence of the therapist’s subjectivity often has the effect of advancing the patient’s subjectivity (each character is pulled toward an advanced form of self-self intersubjective relatedness).

• In this phase of treatment, Jessica introduced aspects of her self that had been denied, censored or defended against (due in part to my own resistances).

• She became more visible, both to me and to herself, and no longer abided by intervention strategies I had previously relied on.

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• The patient began to act in a way that resisted what my persona had been before I cried – that is, she jettisoned a former way of being with me that had been devised to conform to how I had accommodated to her (which had a lot to do with what I could/could not tolerate in relating to her).

• There is not really a term for this phenomenon in the psychoanalytic literature – I am calling it “positive resistance.”

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• The patient was freed to unveil a new persona in relation to the therapist (and to herself) who was more “real” or subjective because the therapist had become more real.

• Ghent (1990), in discussing Winnicott’s theorizing about the impact of impingement on identity formation, describes “the individual then (who) exists by not being found” (p. 120). For me, treatment can be seen as a process of finding the patient in the context of the therapist’s impingements.

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• If the patient’s positive resistance can be effectively analyzed, her ability to access denied internal self-states and multiple conceptions of self can be advanced (she becomes more visible to her own self – which is important to this case given Jessica’s fear and suspicion that she inevitably became invisible to her partners).

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• It is interesting to note that a patient’s positive resistance often leads to her becoming increasingly less known and understood by the therapist; new clinical data is generated that cannot be successfully assimilated by the therapist’s previous construction of the patient.

• Frosh (2009) characterizes this phenomenon as the “incorrigibility of otherness” (p. 187).

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• As positive resistance unfolds, the patient’s coalescing self-experience becomes the focal topic of dialogue.

• Over time, the patient’s self-experience may still overlap the therapist’s metapsychology but no longer does entirely (the patient begins to exist outside of the therapist’s construction/comprehension).

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• With this perspective, treatment may be viewed as the launching of the patient toward the inception of her own metapsychology – which has a lot to do with the therapist’s capacity to tolerate not knowing/not understanding (humility). This is another important component of the “impossible profession.”

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• Wolstein (1994) describes this well: “The mutative center of therapy moves away from the therapist's constructive narration about the patient as such, over to both their experiential psychologies of the self. Breaking through the set parameters of interpretive schematics to the live experience of interpersonal exploration, as it happens, indefinitely enlarges the range of therapeutic action: it opens out to the unique selfic sources of both their individual psychologies. The growing awareness of two uniquely individual selves in interpersonal relationship, with two uniquely individual philosophies of life, signifies a sea change of psychoanalytic approach” (p. 488).

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Case VignetteSection G.

Summary and Implications for Technique

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Section G. Summary and Implications for Technique

• Both patient and therapist create a relational mode of being that restricts the emergence of unconscious, denied or unformulated observations of the identity of each other and of oneself (Hoffman, 1983; Levenson, 1972; Racker, 1968).

• In the course of psychoanalytic psychotherapy, there is an ongoing stream of interpersonal sequences in which each character’s subjectivity is alternatively concealed and revealed.

• Intersubjective theory provides a framework for understanding the mutually-determined and reciprocal processes of relatedness in the therapeutic situation.

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• Moments occur in treatment when the therapist’s “real” self is revealed as co-existing with a “relational” self: how each is seen or exists by not being seen (is found or “exists by not being found”) is the central clinical phenomenon I hope the presentation has illustrated.

• I conceive of a successful therapy as the meaningful amplification of each character’s unique subjectivity in the context of the therapeutic relationship.

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• The case suggests that moments of the therapist’s surrendering of his relational persona are inevitable and implode a collusive status-quo relational culture established by patient and therapist.

• The emerging subjectivity of the therapist alters how he is seen by the patient and renders his prior relational persona as distinct from his real self.

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• If the therapist is able to organize the patient around a careful non-defensive inquiry about aspects of the therapist’s subjectivity newly recognized, an advanced state of intersubjectivity in the relational field will be promoted.

• This fosters the patient’s capacity to find herself (or more of herself), and to be found by the therapist, through a phase of treatment I call “positive resistance.”

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• The therapist is always finding a way to be with the patient (sometimes defensively, sometimes not), but perhaps even more importantly the patient is finding a way to be with the therapist.

• What can be very alarming for any therapist is the moment when he discovers, with the help of the patient, that despite his intentions he brings something to the table the patient needs to accommodate to and perhaps has been stifled by.

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• Implications for technique include the therapist’s need to expand his mode of listening to achieve a greater sensitivity to the patient’s displaced commentary about her adaptation to the therapist’s character, resistances, and intersubjective limitations.

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• The therapist must be mindful of ways to intuitively and/or systematically gain insight into the relational culture he has engendered in the clinical situation –and aspects of that culture that deter from the patient’s expression of her own subjectivity and progression toward advanced levels of intersubjectivity.

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• The patient’s observations of the therapist must be actively explored by the therapist “with the genuine belief that I (the therapist) may find out something about myself (himself) that I (he) did not previously recognize” (Aron, 1991, p. 37).

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• Aron (1991) suggests that the patient can be asked to speculate about what she thinks is going on for the therapist around a particular issue but also warns that exploring the patient’s perceptions of the therapist may be used defensively, by the patient and/or therapist.

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• Several writers (Bollas, 1989; Renik, 1996, 1999) have argued for the importance of the therapist to establish himself as a separate subjectivity actively, and make available to the patient aspects of the therapist’s inner life for the patient to use.

• Yet transparency must be used cautiously and supported with a rationale such as the one presented today.

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• The therapist must always strive to achieve a dynamic balance between technical decision-making and spontaneity in the clinical situation, and must remain mindful of how and when his own defenses/resistances exist embedded within and condoned by technique.

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• Training typically does not focus on moments of the therapists’ unconscious self-disclosures and corresponding states of regression in which the therapist no longer knows who he is in relation to his own self and to his patient.

• Though the patient is typically viewed as being vulnerable to the therapist, my view is that the therapist is just as or even more vulnerable to the patient – especially in light of my argument that it is the therapist (not the patient) who is the agent of intersubjective progression.

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• Many therapists struggle with this reality and tend to rely on defensive maneuverings.

• The therapist must be prepared for the emergence of his own vulnerability in the clinical situation, and eager to learn something new about himself (Gill, 1983) even if it is disheartening or painful.

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References

• Aron, L. (1991). The patient’s experience of the analyst’s subjectivity. Psychoanalytic Dialogues, 1, 29-51.

• Bollas, C. (1989). Forces of Destiny: Psychoanalysis and human idiom. London: Free Association Books.

• Chodorow, N. (1989). Feminism and psychoanalytic theory. New Haven, CT: Yale University Press.

• Frankel, S. A. (2006). The clinical use of therapeutic disjunctions. Psychoanalytic Psychology, 23, 56-71..

• Frosh, S. (2009). What does the other want? In C. Flaskas & D. Pococh (Eds.), Systems and psychoanalysis: Contemporary integrations in family therapy (pp. 185-202). London: Karnac Books.

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References

• Ghent, E. (1990). Masochism, submission, surrender. Contemporary Psychoanalysis, 26, 108-136

• Gilhooley, D. (2005). Aspects of disintegration and integration in patient speech. Modern Psychoanalysis, 30, 20-42.

• Gill, M.M. (1982). Analysis of transference I: Theory and technique. New York: International Universities Press.

• Hoffman, I. Z. (1983). The patient as interpreter of the analyst’s experience. Contemporary Psychoanalysis, 19, 389-422.

• Levenson, E. (1972). The fallacy of understanding. New York: Basic Books.

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References

• McLaughlin, J.T. (1981). Transference, psychic reality, and countertransference.

• Pizer, S. (1992). The negotiation of paradox in the analytic process. Psychoanalytic Dialogues, 2, 215-240.

• Pizer, S. (2003). When the crunch is a (k)not: A crimp in relational dialogue. Psychoanalytic Dialogues, 13, 171-192.

• Renik, O. (1996). The perils of neutrality. Psychoanalytic Quarterly, 65, 495-517.

• Renik, O. (1999). Getting real in analysis. Journal of Analytical Psychology, 44, 167-187.

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References

• Stern, D. B. (2010). Partners in thought. Working with unformulated experience, dissociation, and enactment. New York: Routledge.

• Stolorow, R.D., Brandchaft, B., & Atwood, G.E. (1987). Psychoanalytic treatment: An intersubjective approach. Hillsdale, NJ: The Analytic Press.

• Wolstein, B. (1983). The pluralism of perspectives on countertransference. Contemporary Psychoanalysis, 19, 506-521.

• Wolstein, B. (1988). Introduction. In B. Wolstein (Ed.), Essential papers on countertransference (pp. 1-15). New York: New York University Press.

• Wolstein, B. (1994). The evolving newness of interpersonal psychoanalysis: From the vantage point of immediate experience. Contemporary Psychoanalysis, 30, 473-499. 59

Abstract

A case vignette will be presented that features a unique moment in a psychoanalytic treatment when I unexpectedly revealed to my patient an aspect of my personhood. This moment will be considered from the perspective of intersubjective theory which focuses on the dynamic tension between forms of relatedness centering on the other as object for the self vs. a separate subjectivity. The interaction in the vignette will be conceptualized as a countertransferential “surrendering” in which my emerging subjectivity breached a relational mode of being co-created by the patient and myself and resulted in an alteration of my persona vis-à-vis the patient.

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Abstract

The patient’s response to this moment is characterized as “positive resistance” in that it stimulated a new phase of treatment in which formerly dissociated elements of the patient’s identity – once subverted by the patient’s accommodation to my persona – entered the interpersonal field. Issues of technique including the therapist’s capacity to tolerate personal revelation, self-observe, and recognize how his own character may inhibit the patient’s potential for intersubjective relatedness will be considered.

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Toward a View of “Positive Resistance”: One Perspective on Change in Psychoanalytic

Psychotherapy

James Tobin, Ph.D.Licensed Psychologist PSY 22074220 Newport Center Drive, Suite 1

Newport Beach, CA 92660949-338-4388

Assistant Professor of Clinical Psychology601 South Lewis Street

Argosy UniversityOrange, CA 92868

714-620-3804

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