Musings to Regulate Myself

Amy Eldridge

How can you do this to me? You are disrespectful, self centered, you don't understand my life. You don't understand me . . .. The message goes on to list, with great indignation, injury after injury. I am portrayed as harmful and useless. By needing to change an appointment time to accommodate my travel schedule, I feel as though I am brutalizing my patient. Worse, I feel that the very essence of my being is under attack. We all know this type of call.

I construct many return messages in the wireless phone system in my head. I fight the feeling of being attacked with angry, retaliatory messages. I protect myself with defensive, self righteous messages. I restore my sense of power by threatening abandonment, which I could justify as a reasonable response to my patient's portrayal of my chronic uselessness and hurtfulness. Ultimately, I calm down, my self restored, and begin to think about the meaning of the message, the process that had provoked it, and struggle to find a therapeutic response to it. This is a familiar pattern with this patient; a woman who had suffered extreme abuse at the hands of a psychotic mother.

How do I respond? Do I take an empathic point of view; try to enter my patient's experience and respond from that perspective? I replay the message in my head, trying to hear the background tones that depict a deeply painful state as well as the foreground words angrily depicting injury. I could imagine my return message: "You are worn down from too many demands on you. By asking you to change times, I am making yet another of you. Expecting you to make the change makes you feel that I am not taking your distress into account, and worse, that I do not understand you. I seem to be simply responding to my own needs and unconcerned with you. I did not realize that this would upset you so deeply, and I am sorry." I could throw in an interpretation, about how this was experienced so repetitively in the patient's childhood, but this is best done in the context of our next session.

All of this seems true and useful. If I respond this way, I would likely, one more time, repair the rupture between us. But, this understanding does not seem complex enough to explain my range of reactions, let alone my patient's. She is regurgitating many of the injuries that she has experienced in the course of her very long and intense treatment - as if all of the past injuries are packed into this one devastating blow. Can this be best understood as a result of fragmentation? If so, then the content reflects a breakdown of a self collapsing. I wonder, though, if the angry content of her message has any symbolic meaning? I also wonder, as I have so many times before, about my experience of being surprised and momentarily destroyed by the content and the intensity of her reactions. I shift to an intersubjective position in my conversation with myself.

I recently heard Jessica Benjamin present a paper, illuminating her version of the concept of the third. The experience of listening to her perspective is one of turning familiar concepts upside down and examining them anew. In this paper, she made reference to the process of containment, suggesting that it maintains the one person doing unto another dynamic. In her terms, this is an enactment which destroys the recognition of the separate subjectivities of analyst and patient. By containing, the therapist/analyst re-establishes herself as "good" by not reacting in harmful ways to the patient's affect. By fighting off the painful projection, the analyst leaves the patient with it. She maintains, however, that splitting the relational dynamics into subject and object does not leave room for the analytic process. In her view, harm is part of the process. I begin to think about how this idea applies to empathy.

In self psychology, we believe that maintaining an empathic perspective opens up the patient's subjectivity and allows a developmental process to be activated. We, too, believe that harm is part of the process in that we recognize the inherent injuries involved in the therapeutic process and the cycle of rupture and repair. By entering the patient's subjectivity, the therapist is able to offer a response to the injury which helps restore the patient's self and dissipate fragmentation. The therapist's sense of injury is not addressed; the therapist's subjectivity is often put aside in order to understand the patient. Theoretically, this emphasis on understanding the patient's perspective would ameliorate the injury felt by the therapist. When it does not, and the therapist responds in this fashion anyway, we suspect that a pathological accommodation to the patient is at play.

By maintaining a focus on the patient's subjectivity, we are intentionally excluding the subjectivity of the analyst from the process. This has led many self psychologists to move to an intersubjective perspective. Returning to Benjamin, I wonder if the subjectivity of either party can be excluded without creating an enactment of object subjugated to subject. In self psychology, the enactment is believed to be necessary to analyze the patient. And, we have vast experience with the restorative and curative power of this perspective. But, does subjugation of the analyst's subjectivity limit the analytic process in unanticipated ways? Does it limit my power, specifically, to address the destructive process at play with my patient's negation of my "analytic goodness" (Benjamin, 1999, p. 202)?

How, then, do I understand and respond to my patient? I firmly believe that I must address the injury before I can address the rest. When fragmented after feeling so injured, she can only resort to protecting herself; albeit with an angry attack. To respond directly to it would only prolong and solidify the state of affairs in which she feels deeply injured and misunderstood. So, I, at this point can only protect my self from feeling destroyed by talking with myself about it. I leave a version of the message that I imagined. In our next session, I encourage my patient to tell me about her experience of the request to change appointments. She reluctantly reveals that she felt left alone to die. She hates feeling that she needs me to live. Now we are in her experience together and I have to bear the feelings of being this awful, of being the subject of her hatred. But, with both our selves momentarily restored, we can talk about it instead of enacting it.

Empathy provides an opening and a process that optimally allows both subjectivities in the room. Unless the patient has achieved a state in which her subjectivity is upheld and understood, the therapist cannot be experienced as anything but an object. The perspective of self psychology, which encourages the sequestering of the analyst's subjectivity in order to be experienced as a self object, provides the opportunity for the eventual recognition of both subjectivities. But, without recognizing the enactment, full understanding of the patient is not possible. I think about the enactment, its meaning, and about restoring each of us in order to resume the reflective process. I feel that this complicated process of empathic emersion and my analysis of the enactment eventually brings me into my patient's subjectivity without losing my own.

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