Twenty-eighth Annual Conference: Developing Clinical Momentum

PANEL II
A Focus on Relationship/Enactment

Carla Leone, Ph.D.

The mood in the room was alive and eager as we gathered for the second panel of the 2005 conference, "Developing Clinical Momentum with a Focus on Relationship/Enactment." Based on our past experiences with chair Rod Bodansky of Germany, case presenter Gianni Nebbiosi of Italy and discussants Hazel Ipp of Toronto and Jackie Gotthold of New York, we anticipated a stimulating and enjoyable afternoon - and were not disappointed.

Case presentation: "Diana: Prince of the Moment" was the title of Gianni's presentation, incorporating a phrase his patient Diana had used to describe her son. We were quickly drawn into Diana's compelling and painful story - and into the one she and her analyst were able to write together - as told by a master clinician and master storyteller.

Although both stories had occurred thousands of miles away, in another country, in another language, I soon felt I was there, in Gianni's consulting room, hearing and watching them unfold. From Diana's opening request, "Excuse me, Doctor, but I want clear answers from you," as she understandably debated whether or not to begin a third analysis, Gianni's detailed descriptions brought the story to life. I - and I think everyone present - felt saddened and sickened as we learned that Diana's first analysis, with a male analyst, had included numerous mis-attuned responses to her loving feelings for him and had ultimately led to a two year sexual relationship with the (married) analyst after the treatment ended. We cringed internally in a different way as we heard of Diana's second analysis with a female analyst, whose outrage at the first one's behavior and extreme imposition of her own agenda resulted in Diana gradually losing touch with her own experience - a process which Diana felt ultimately led her to marry a man she did not love.

With this analytic history, as well as her painful and troubled childhood history, Diana came to her analysis with Gianni. We heard of Diana's love of poetry and her poetic-ness, qualities she shares with her analyst. Their analytic connection was forged in several moving moments of meeting when Gianni was able to use this shared ability to convey his deep understanding of his patient's experience. We learned also of Diana's serious and composed demeanor, her suspiciousness of playfulness in anyone other than her son, and her frequent request from the beginning of treatment that Gianni "not move his face so much". Gianni described his varying reactions to this request and his eventual feeling of frustration and constriction, as he felt required to have a "politically correct attitude."

With this dynamic in the background, we reach the climax of the story. There is a month-long vacation break in the treatment, during which Gianni loses weight and grows a beard. Diana eventually confronts him in the smug tone of someone who has uncovered a bluff, "you may look young, but I know the truth - you are old!" And then comes the "prince" of a moment. In response, Gianni breaks into a big smile and collapses on his desk, saying, "You got me! But please deliver the coup de grace, I am still alive," as he lies there smiling up at her.

Feeling that the English language he had been speaking in did not adequately capture this moment, Gianni dramatically reenacted it for us in Italian, to our delight. He then described his patient's initial response ("Are you nuts? You are an analyst, not a clown!") and explained how their mutual processing of the incident led to new childhood memories that helped them both understand why Diana's playfulness had been so waylaid. Gianni then concluded with the words of a poem by Pasolini which had resonated deeply for Diana when he quoted them to her at one point: "Death is not/ in not being able to communicate/ but in no longer being able to be understood."

First discussion: Being the first discussant to follow this moving and entertaining presentation was no easy task, but Hazel Ipp was up to it. She began by using the Italian word "sprezzaturra" to describe Gianni. Roughly translated as "easy lightness", the term refers to a noble courtier's ability to do a variety of arduous tasks with apparent ease. It was a new term to me, one I was delighted to learn and which certainly did seem to fit Gianni.

Hazel's discussion, "Changing Faces and the Faces of Change," began by conceptualizing Diana as a survivor of multiple relational traumas. She saw trauma as having disrupted Diana's attachment system and having interfered with the development of her capacity for mutual relatedness, recognition of multiple subjectivities, capacity to experience emotion freely and ability to play. For Diana, as with many trauma survivors, Hazel suggested, relationships involve either exploitation or control, doer or done-to. This led Diana to conscript her therapist to act in the very ways that she most needed him not to act: constrained and inhibited, like her.

Invoking Stern's concepts of the inherent "sloppiness" of relating, "Winnicott's squiggling interplay of two subjectivities", and Paul Russell's concept of relating as the "negotiation of affect", Hazel conceptualized Diana's relational difficulties and therapeutic needs for a different way of relating. She saw the dramatic "You're old - you got me" interaction between Diana and Gianni as the beginning of this new mode of relating, the dramatic beginning of their more mutual "shared feeling voyage."

She then moved to discussing the incident as a dramatic enactment: an example of Ogden's "interpretive action" or cognitive psychology's "representation in the enactive mode." Enactment, Hazel reminded us, is the most basic level of representing experience, the mode closest to the body, the attachment system, and procedural memory. She introduced the concept of "poetic action" - a form of analytic enactment that carries a "creative performative message that artfully condenses the momentarily formulated and the . . . unformulated." Citing the Pizers, she suggested that poetic action links primary and secondary process, and notes that analyst and patient can return to poetic action, as we do with a poem, for "further refinement and mining of meaning." Like sprezzaturra, poetic action was another new term I was pleased to learn and which, again, certainly seemed to apply to Gianni's work with Diana.

Second discussion: Next came Jackie Gotthold's discussion, which focused on the question of whether the term enactment adds anything to our understanding of the clinical situation. After thanking Gianni for sharing his work and noting that he makes "just the right amount of faces" for her taste, Jackie began with the words to the song "I'm a believer." Emphasizing that "theory matters", especially when we examine terms like enactment, she started by detailing what she believes in: the theoretical positions of Stolorow and his colleagues, as well as the developments in nonlinear systems theory, infant research, and work of the Boston Process of Change Study Group. She believes, in particular, that the latter group's contribution of terms like implicit relational knowing, now moments, and moments of meeting has added a specificity and clarity to our ability to articulate the "something more" in clinical process.

She turned next to the implications of these beliefs for the question of the usefulness of the term enactment. She described the clinical process as having a co-created rhythmic quality of peaks and valleys, crescendos and diminuendos, with the peaks or heightened affective or more dramatic moments embedded in and inevitably emerging from the less intense moments. She repeatedly questioned the benefit of isolating particular heightened moments by describing them as enactments rather than viewing them as more embedded in the ongoing flow of what came before and after them. All components of the treatment - perturbations large and small - move the treatment along, she reminded us.

Jackie then examined Gianni's clinical material in light of this view. Beginning with the first session, and moving through other important moments of the treatment, she highlighted the many ways Gianni had conveyed to Diana his deep understanding of her experience: through his movement, gaze, playful use of Diana's own words, silence, timing, and so on. Drawing on her work with children, Jackie reminded us that communicating understanding can occur through play, action, verbalization or silence, and questioned why we refer to some moments of conveyed understanding as interpretations and others as enactments. To her, Gianni's playful collapse and response to Diana was an interpretation that occurred through both action and words.

Gianni had left us with the words of the poet Pasolini; Jackie closed with the lyrics of the song she began with, by Neil Diamond: "Then I saw her face/ Now I'm a believer/ Not a trace/ Of doubt in my mind." A brief but lively discussion followed, which included Marion Tolpin's comment that Freud was more playful than later writers have chosen to convey.

As for me - I'm a believer in panels like this one.

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