I was munching a delicious sandwich of Italian sausage and peppers on a sunny, clear Saturday in November at the Farmers' Market in Santa Monica. I was chatting with my best friend. I had that euphoric feeling that there was nowhere I would rather be nor anyone I'd rather be with. In our chat, I found my thoughts turning to the therapeutic action of psychoanalysis, not surprisingly, given my expansive state of mind. By that I mean that I found parallel feelings I have had with patients with whom I experienced a seemingly effortless flow of relatedness, as though we were just "right" together without having to "try". I noticed that the sense of "rightness" did not just apply to the ones that I found relatively "easy" to relate to; there were others with whom the effortful, somewhat stressful relatedness called upon and challenged the best that I had in me.

I began to think about what factors account for psychoanalytic success; what is foundational. The Boston Process of Change Study Group [1] has been attempting to capture the "something more" (beyond interpretation) that seems at the center of psychotherapeutic change. They have coined the term implicit relational knowing [2] to denote a systems approach to understand relatedness that is non- or un-conscious as well as implicit and non-verbal. However, I am reaching for another dimension that is related to implicit relational knowing, but grasps the dimension of being rather than knowing. I believe that it is partly related to the analyst's character or personal presence and how it affects the "moving along" dyadic system. By bringing up "character" I refer to traits that are specifically and uniquely important to each individual analytic pair. For example, I think of patients who are extremely shame-prone. It's not a stretch to see that they thrive and grow in interaction with an analyst who enjoys their quintessential presence. Is there a kind of analytic "chemistry"? If so, what do we mean by "chemistry"? Beebe and Lachmann have studied reciprocal influence patterns between mothers and infants, then have established parallels in the conversational patterns of adults, considering rhythms of listening and timing [3]. We all note that we find some people "easy to get along with or easy to talk to". I'm searching for something more than we can explain by mutual or reciprocal empathic attunement - something in the intrinsic personhood or being of the people involved.

In the contemporary psychoanalytic community we speak of various relational experiences that we consider essential to the successful process of therapy. These include corrective emotional experience, empathic attunement, mutual reciprocal influence, secure attachment base, intersubjectivity (Stern, 1985)[4] optimal responsiveness, and many more. These terms all reflect an attempt to understand the essentials of psychotherapeutic interplay. When we speak of "something more than interpretation" we may tend to imply that interpretation is foundational (which certainly coincides with traditional psychoanalytic theory of cure). I've grown weary of debates over whether insight and interpretation are basic or whether experiential factors are curative and we might agree that both factors are derived from and reflect the relational matrix from which both phenomena arise. It strikes me today (I don't know how I shall feel six months from now) that what is really foundational is implicit relational being [5], the deep affective engagement of two beings interacting with each other honestly and that the rest (interpretation, etc) is secondary, flowing from that matrix. I believe that "moments of meeting" and "now moments" are emergent events in that process.

While I'm at it, I'd like to retrieve "corrective emotional experience" (Alexander, French, 1946) from the classical psychoanalytic scrap heap. Our older, classically oriented colleagues snubbed the concept, claiming that those who were informed by it were advocating the "manipulation of the transference", a big no-no based on the idea that transference needed to be allowed to emerge spontaneously, purely as a projection of the analysand's intrapsychic dynamics, unaffected by the analyst's therapeutic intentionality. (As if that were possible or even desirable!)

Several years ago, at a scientific meeting, I presented a case of a male patient who suffered from severe, life threatening gastro-intestinal symptoms for about twenty years whom I treated face-to-face with once weekly psychotherapy over a period of eighteen months. Fortunately, he showed great improvement and a recent twenty-year follow up revealed that he has remained asymptomatic. One of the facts of the case had to do with the discovery of the all pervasive sense of shame this man suffered since his early childhood and I described my efforts to tailor my interventions so as to minimize the likelihood of recreating the shaming environment shaped by his interactions with his mother. I must say that I was especially proud of that case, since I had been his family doctor twenty years before he started psychotherapy with me and that I had examined him at that earlier time for the same complaints. He came to see me twenty years later when he had heard that I had become a psychiatrist, at which time he was "ready" to tell me his story. What I remember particularly about the discussion period that followed the presentation was a comment made by an old colleague with whom I shared a mutual uneasiness. With a triumphant sparkle in his eye he asked with a tinge of sarcasm, "How is what you did different from a corrective emotional experience?" I am convinced to this day that he believed he was exposing the fraudulence of the positive outcome of that case by linking my work with that reprehensible concept. (I don't remember exactly how I answered him, but I do remember that I was not ashamed of myself afterwards).

While we are talking about factors that contribute to the therapeutic action of analysis, have you noticed how gingerly we analysts tiptoe around speaking of (our non-erotic) love for our patients? Our colleagues pick it up easily as it flows implicitly in our case presentations to one another. It seems that we engage in all sorts of evasions and subterfuges to avoid that term. We speak of "unconditional positive regard", "caring", almost anything rather than love! There seems to be a taboo about using that word, as if no self-respecting analyst would risk his/her reputation in either his/her discourse with patients or in case write ups. This caution surely is a legacy of traditional drive theory which held us all to observe the eleventh commandment "THOU SHALT NOT GRATIFY" at the same time that we attempted to remain human in our sessions with our patients, hiding our loving feelings even from ourselves. Perhaps, we hid them to avoid shame and self-accusations of being insufficiently analyzed and/or "overinvolved" with our analysands. In our case write ups we left out not only loving feelings, but other affects, e.g., shame, guilt, erotic feelings, hate, etc., thus creating a shared myth that those feelings had no place in a well conducted analysis. Have we changed enough since the old days to dare allow that "L" word to creep into our contemporary vocabulary?

I thought about all this after talking it over with a colleague[6] during which I came to see the associational links in my thinking about the analyst's being, presence, corrective emotional experience, and love[7]. I hope this doesn't sound like some romantic notion about "love cure". I do think, however, that all of those factors constitute a vitally necessary medium in which successful analytic activity (including understanding, interpretation) flows.

Endnotes

1. Contributions that Effect Change in Psychotherapy: A Model Based on Infant Research. (1998) Infant Mental Health Journal, Vol. 19(3) pp. 277-353. [Return to text]

2. Lyons-Ruth, same article. [Return to text]

3. Beebe, B and Lachmann, F. (2002) Infant Research and Adult Treatment, The Analytic Press. [Return to text]

4. I use this term to denote intersubjective relatedness. [Return to text]

5. I wish to thank Maxa Ott, MFT for pointing out the redundancy of this term, as there is no "being" that is not relational. [Return to text]

6. My thanks for Lynne Jacobs' input to this conversation. [Return to text]

7. Doryann Lebe has enlarged this notion by adding the phenomenon of creativity to it. [Return to text]