Panel II
Struggling Out of the Box
D. Bradley Jones, LCSW
The second panel entitled "Struggling out of the Box: The challenge
of Self and Interactive Regulation" highlighted Renee's treatment from
the second to the fourth years. In the first two years, a sense of
safety had developed in the therapy providing a suitable setting for
traumatic memories of harrowing sexual abuse to emerge. Lucyann
Carlton, JD, MA carefully tracked Renee's extreme oscillation of affect
as the patient moved in and out of dissociative states and painful
memories of childhood sexual abuse at the hands of her mother. Lucyann
presented three of Renee's dreams that occurred in the third and fourth
year of treatment. The first dream represented dissociative states
Renee utilized as a defense against feelings prompted by the abuse,
along with a painful "fusing" that led her to experience and better
integrate fragmented aspects of herself. In the second dream, Renee
confronted both her unrelenting fears that experiencing her feelings
would incapacitate or kill her and her sense that of being completely
defective and someone who could not be helped at all. The third dream
symbolized Renee's nascent ability to experience her feelings without
threat of "psychic death," and a new understanding that, at the hands of
the adults in her life, she was up against senseless and random acts of
violence. Therapist and patient began to better understand and validate
what had always been dismissed, rationalized and ignored during Renee's
childhood. This new experience of "making sense" brought great comfort
to the patient as well as an element of organization to Renee's horrific
and chaotic childhood. In the final moments of this portion of the
presentation, we begin to see a path of growth in the patient as Lucyann
presented a dream Renee experienced in color, symbolizing "hope" that
comes from a therapeutic relationship "healing" in part as a result of a
burgeoning sense of love between the two.
Lucyann's presentational style had an evocative and theatrical feel
as she fluidly used her voice to demarcate Renee's affect in oscillating
self-states. This dramatic rendition of the case brought to life
Renee's painful life and turbulent emotional world. It exemplified as
well the analyst's gift for empathic immersion with this particularly
fragile patient. Perhaps because of the amount and intensity of the
clinical material presented, Lucyann's ardent exposition at times felt
to this listener as repetitive and distracting.
The afternoon's discussants Henry Friedman, PhD, and Jim Fosshage,
PhD, had markedly different views of this treatment. Dr. Friedman,
responded to this case with a discerning and somewhat critical edge,
appearing cautious to mention alternate ways to obtain therapeutic
results. Bringing to the table a theoretical orientation he did not
clearly delineate, Friedman introduced an approach he called
"Interactive Self Psychology." Hypothesizing that Renee's character
problems stem from an identification with destructive and abusive
parents, and that her extreme mood vacillations may be caused by a
bi-polar disorder, Friedman wondered about the benefit of the reliving
of the affect associated with her childhood trauma as a suitable
intervention for this highly fragile patient. He suggested that similar
therapeutic results might result from an approach that grew not only out
of empathic understanding, but may also have included "active"
interventions such as medication, alcohol and drug treatment, and in the
face of more dangerous behaviors, possibly brief hospitalizations.
Sharing his doubts about the long-term outcome of this treatment,
Friedman pointed to Renee's proficient ability to turn herself into what
others need her to be. With the possibility that Renee might reenact
this with Lucyann, Friedman wondered whether or not this might result in
Renee's embodiment of a "self" that appears more stable than it is in
actuality. He expressed his concern that her bi-polar tendencies would
re-emerge. Given that the "average expectable" person usually does not
possess the tools to respond to traumatized individual needs in the same
manner as a trained therapist, Friedman wondered how Renee would find a
satisfactory life or relationships outside the treatment environment?
Friedman easily handled being the divergent voice at this conference.
His comments pushed the audience onto one side of the age-old polemic
often encountered in our field around the plus and minuses of more
confrontive and "active" treatments vs. more empathically centered
psychoanalytic approaches.
On the other side of the dialectic, Jim Fosshage PhD, and his paper
entitled "When the Music Changes, It's Possible to Come Out of the Box,"
responded more to the forward edge of Renee's conundrum, citing her
resiliency in the face of horrific childhood trauma. He described
Lucyann's ability to provide Renee with an analytic relationship in
which new relational procedures were learned on both explicit and
implicit levels. To Fosshage, Lucyann's calming influence helped Renee
begin to regulate physiological and hyper emotional arousal, as well as
to enhance a gradual shift from negative to positive relational
expectancies. Dr. Fosshage stressed the importance of the repetitive
aspect of this new relational experience. Over time, he suggested, such
repetitive experiences may gradually become established into long-term
memory. He emphasized the difference between process and content with
regard to transference, believing that Renee's growing ability to share
traumatic experience with Lucyann did not reflect unconscious strivings
in the transference. Rather, it was her ability to feel safe in this
analytic dyad that aided the healing "process." Focusing on dreams,
Fosshage illustrated ways in which Renee continued to process her
traumatic childhood experience in sleep. Suggesting that Renee's dreams
had the following complex organizing functions, he cited: 1)
transformations from self blame to a burgeoning sense of self agency, 2)
re-integration of self and other from dissociative states, and 3) the
process that allowed Renee to have a more compassionate view of herself.
In the fourth year of treatment, we were reminded of the first dream
Renee experienced in "sweeping color" and her new vitalizing excitement
with life. Fosshage concluded his paper by giving examples of Lucyann's
"consistent empathic based spirit of inquiry" that culminated in a deep
sense of safety for traumatic memories to be recalled, for the
illumination of Renee's negative precepts of self to be suspended, and
for newer models of explicit and implicit relational knowing to build in
long term memory systems. The co-construction of analyst and patient in
this transformative therapeutic relationship thus became Fosshage's
poignant metaphor for the changing music that helped Lucyann's
facilitation of Renee's climbing out of her "box" of trauma and despair.
Lucyann responded to the divergent ideas of these two speakers by
asserting her view as more consistent with that of Dr. Fosshage. She
thought, as he did, that Renee's gradual transformation grew out of the
"lived experience" between Renee and her analyst at both the implicit
and explicit levels, and that her patient became "known" through the
analyst's consistent optimal responsiveness. Acknowledging Dr.
Friedman's contribution, Lucyann agreed that with some other analyst, a
different shared reality could emerge that may have proved beneficial
for Renee. She also assured the audience that the success of this
treatment was not based on Renee's ability to be what others needed her
to be as it had been in her relationship with her former husband and
with other analysts. In her previous analysis, Renee had tried to mold
herself into what her therapist needed her to be. This effort resulted
in a fantasy where Renee experienced herself as a nonhuman wooden
marionette with no possibility of emotional connections. In summary,
Lucyann used Renee's own words in describing her current treatment:
"With you the work is inside of me, and it comes from our relationship
and my feelings. I'm not getting a paint job on this house. We have
taken it down to the foundationÉ. I'd say we have started on the
plumbing, the part that can make it so that it can all flow through."
In the face of divergent opinion, Lucyann and Renee have clearly found
their way to a successful therapeutic path.
A lively interchange among the panelists ensued. Friedman stated he
believed an analyst may have a dialogue with a traumatized patient at
the beginning of treatment, that would avoid the "very controlled"
position of a clinician forced to follow the patient's "exaggerated
sensitivity" and experience of "craziness." He believes there are ways
to speak to a patient's sensitivities that both stabilize the
therapeutic interaction, and bring to the fore the chaotic psychic
organization. Fosshage responded by reminding the audience of Renee's
sensitivity to intrusion, stressing once again that any intervention
other than Lucyann's careful listening could be experienced by her
patient as an assault. He added that confronted with extreme behaviors,
therapists may experience their own internal "pull" to "manage" patients
with medication and other active interventions. Fosshage commended
Lucyann's ability to resist such management and to find ways to modulate
her own feelings when Renee was exhibiting more extreme behaviors. He
pointed out that had Lucyann made an attempt to "manage" Renee during
these periods, she may have permanently ruptured and "aborted" the
therapy. Lucyann spoke of her own internal struggle during this
treatment, and how her work with Renee did not represent a "set
condition" for therapeutic action with all patients. Lucyann made it
clear she adheres to the wider frame of treatment specific to each of
her patient's individual needs.
With a weary quality to his voice, Arthur Malin MD requested
respondents keep their question and comments to a minimum. Thus began
protocol of question and comments from the audience. Highlights
included Dr. Susan Lazar's observations about the importance of
"process," "entering into the world of the patient," and concern about
the analyst who privileges "cognition," "exploration," and "talking" in
the beginning of treatment. It is her belief that one can reinforce
compliance and the "brittle identification" that Renee was so apparently
prone to. Dr. Lazar's later comment to Friedman that he did not fully
appreciate "process" and that he should "reconsider" his position
momentarily thrust the conversation to one pole of the dialectic.
Stuart Perlman, PhD brought us back into our dialogue with his belief
that it might be useful to enlist a patient by sharing all the many
therapeutic options there are for dealing with traumatic experiences.
He added that in his opinion reliving traumatic experiences can be both
beneficial and defensive in nature. He highlighted the importance of
Lucyann's focus on self-regulation as well as her creation of a soothing
and calming environment for Renee. Dr. Bruce Herzog believed Renee
might have enacted with any therapist her childhood trauma of getting
"too much" or "too little" (both representing the relational template of
her parents), and that anyone who treating Renee might do so
successfully only by tolerating the inevitable and difficult phase of
treatment described during this panel discussion. Linda Chassler, PhD.
recognized the split in the conference between a "right" and "wrong" way
of implementing treatment as unnecessary, and postulated that
hospitalizations and other active treatments needed to come out of a
therapeutic relationship that extended the "containing" aspect of the
analysis as far as it was possible to do so.
Summation and closing comments by Friedman included his prescription
for Renee's ongoing treatment: 1) ultimately to explicate the
seriousness and degree to which Renee's parents were destructive to her,
and 2) to help her to understand she had been lucky to survive such
"murderous" surroundings. He alluded to a working through of the "envy"
that comes with patients who have not had enough "good stuff." Friedman
also stated that a good analysis is not necessarily an experience of
"re-parenting," but more a situation in which the analyst, "by guiding
himself by decency in the interpersonal," provides a "good experience"
where the patient can go on. Fosshage countered by pointing to
Friedman's use of the other centered listening perspective, stating that
an analyst's "authentic engagement" with a patient has more to do with
the analyst's subjectivity and style of listening. To Fosshage, a
patient who "demands" to be taken care of by an analyst is a patient who
desperately "needs" to be taken care of. He explained one can use the
other centered data by itself and find a way of opening it up with a
patient, or one can reflect on the other centered data, choose to fall
back on the empathic mode, and inquire about the deeper feelings
connected with the patients behavior. Friedman stated that he did not
believe that he and Fosshage were irreparably far away from each other's
perspective. He believed the difference to be found in how and when to
use the other centered perspective, and he leaves this decision up to
the individual analyst using "outcome" of the intervention as a guide.
(It might have been beneficial if he could have given a concrete example
of how he uses this particular listening perspective. One wonders, how
does an analyst accomplish this without eliciting compliance or eroding
an appropriate atmosphere for a transitional space or psychic fantasy to
emerge?) Friedman did pose important questions about the analyst who
consistently utilizes the empathic model: Can the analyst ignore
dangerous behaviors? Do we have to fear making wrong choices? Does an
analyst risk being too active or too passive? Can losing a patient be
better than being too passive? Fosshage concluded this segment of the
debate by speaking about the misnomer of the term "passive," and that
expressing one's subjectivity with a patient is an "interactive" process
that can include many interventions such as inquiry, validation,
affirmation, modulations of affect, and an educational vision of how
analysis cures.
How does analysis cure? Certainly not by division or polarization.
So why do analysts continue to compete with each other? And does this
competitive spirit keep us from really hearing and learning from
analysts with differing views? Because we are thoughtful beings who
have access to our feelings, and because the challenging patient will
evoke both the intuitive and counter intuitive aspects of our
subjectivities, the good analyst will naturally ask himself ALL of the
questions posed at this panel. And although we are all deeply rooted in
our particular ways of working, when we enter into the "either" / "or,"
do we run the risk of missing something important we may need for a
particular patient when we least expect it? We owe a debt of gratitude
to Lucyann, Dr. Friedman, Dr. Fosshage, and especially to Renee for this
fascinating discussion.
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