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Panel III
Evolving Perspectives on Interpretation
Joan Rankin, Psy.D., M.S.W.
In this interesting panel discussion Anna Ornstein, M.D. outlines her
current thinking on the interpretive mode with her paper entitled "Do
Words Still Matter?" Shelly Doctors, Ph.D. adds a welcome
intersubjective systems focus to the discussion in her paper,
"Interpretation as a Relational Process".
Ornstein begins her discussion of the interpretive mode by focusing
on the clinical challenges with patients who develop defensive
psychological organizations which helped them survive traumatic
childhoods, but which, over time become crystallized into personality
features and patterns of behavior that hinder the development of
sustaining relationships and optimal mental health. She underscores
that the question self psychologists need to ask themselves now is: How
do we include defensive structures into our empathic interpretive
comments when we recognize that they both protect a vulnerable self and
constitute great obstacles to change? Indeed, for those with severe
personality disorders, defenses may become a core part of the sense of
self. Kohut believed that the self psychological analyst must be
concerned with the state of the self, with therapeutic progress
requiring an increased cohesion of the self, rather than focusing on the
more classical notion of "psychological mechanisms" leading to change.
Ornstein adds her belief that we also must assess whether or not self
cohesion is maintained by defensive structures. This challenge becomes
even more complex when one realizes that even the most intractable
features of personality are context dependent, and can become less
automatic and more flexible, or more rigid and intractable, depending
upon the degree of engagement in the therapeutic dyad. In the process
of treatment, the fate of defenses largely depends upon whether or not
the patient's archaic mirroring, idealizing, and other selfobject needs
are being met in the transference. Through an empathic listening
perspective and empathic interpretations, the therapeutic process can
deepen, and the presence of well established selfobject transference may
make the use of defenses unnecessary.
Anna's two clinical examples illustrate how both the need to repeat
and the dread to repeat maladaptive relational patterns co-exist
throughout treatment, and how defensive structures impact the
therapeutic process. Ornstein emphasizes the dread to repeat which she
defines as the fear of repeating old behavioral and relational patterns.
She also utilizes Brandschaft's concept of the need to repeat, which is
illustrated when a patient clings to noxious relational ties and
experiences self-endangerment when these come under stress.
The first patient, Mrs. Tennenholz, a seemingly high functioning 50
year old patient, came to treatment during a personal crisis of
bankruptcy, which brought on bulimic symptoms of her adolescence. After
two years of treatment, Ornstein was unable to engage her in a
meaningful therapeutic process that would allow for a selfobject
transference. This patient repeated her tendency to become radically
self reliant in the face of her life crisis, and, as a result, was
unable to explore the meaning of her symptoms in treatment. She needed
to hold onto her defenses in order to assure her sense of self cohesion.
Ornstein candidly describes her own sense of distance, formality, and
lack of involvement with Mrs. Tennenholz, who frustrated her sense of
usefulness as an analyst. One is left wondering what would have been
needed by this patient to have become engaged.
The second patient, Mrs. Moore, brought a disturbing array of
symptoms to her treatment: a history of hospitalizations due to
self-mutilation, and states of dissociation accompanied by
disorientation to place and time. Despite her announcement of a
previous diagnosis of Borderline Personality Disorder, this analytic
pair established a selfobject bond that held this patient through a
traumatic disruption of the treatment brought about by her witnessing
the unknowing Ornstein as she greeted her son at the airport with a
loving kiss upon his arrival home. Mrs. Moore was able to verbalize her
suicidal despair, rather than remain in a dissociated self state. In
the following session she was relatively undefended as she shared her
realization that what she wanted was love, not analysis, and she wanted
the same love from her analyst that was bestowed upon Ornstein's son.
While it took time for this analytic pair to right itself, Ornstein
suggests that the selfobject transference provided a temporary or
transitional self-cohesion which got them through this crisis, but not
without Mrs. Moore temporarily needing to fall back upon old ways of
preventing self-fragmentation in the form of defensive dissociation.
Mrs. Moore was able to articulate her archaic longings which are seen as
a dread of repeating old relational patterns. This represents a shift
toward increased self-cohesion. The warm, affective engagement with
this patient was markedly different for Ornstein. This engagement
should not be understated in its importance in maintaining the
selfobject bond, as well as expanding what could be explored in the
treatment.
For Ornstein, the pull to repeat old habits and the newly acquired
capacity to tolerate tension, hurts and frustrations appear in the
transference-counter transference interaction. The newly developing
structures need to be validated to become permanent, and validation
requires clearly and explicitly articulated interpretive comments. In
short, yes, words still matter!
Shelly Doctors adds a vibrant dyadic, intersubjective systems
perspective to the discussion as she delineates the ideas of Kohut which
are inextricably woven into the fabric of her work: the empathic
listening stance, the selfobject concept, the experience near
perspective and the pacing of interpretations. Her definition of the
concept of interpretation as a relational process, (in her paper of the
same title), is multi-faceted: By relational she means all
psychological aspects of relatedness between patient and analyst, (with
no specific connection to the relational school of analysis intended).
Doctors illuminates the shift in our contemporary views of
interpretation, which is evolving from a focus on insight and the
content of what the analyst illuminates, to include how the patient and
analyst interact, as well as what emerges from the dyadic interaction.
Doctors underscores that interpretive activity isn't just about
imparting knowledge: any insight achieved is inseparable from the
affective bond from which it emerges. Two related points explicate the
patient-analyst interaction:
Any understanding achieved by patient and analyst emerges from the
co-creation of their shared interaction. Dyadic interactions, operating on many levels, conscious,
unconscious, non-conscious, declarative and procedural, facilitate (or
constrain) what can be thought about and communicated in treatment.
The following clinical vignettes illustrate Doctors' key points.
In the first case, Evelyn's participation in her treatment was
characterized by rapid, non-stop speech which left little room for the
analyst's responses. Indeed, any attempt on Doctors' part to join the
conversation was rebuked. The culmination of this dyadic state of
affairs was illustrated in the helpless exasperation of Doctors' plea,
"Evelyn, I'm trying to participate!" Evelyn held great fears of being
usurped, while Doctors had needs to be recognized and feel useful.
This statement was a declaration produced by the interaction of these
worlds of experience. According to Doctors, the statement qualifies as
an interpretation in that it was a spontaneous attempt to illuminate
unacknowledged meanings. Evelyn's need to be appreciated and her fears
of impingement became foreground when met with Doctors differently
organized need to be recognized and useful. This "collision" of their
experiential worlds perturbed their dyadic system, but opened up new
areas of exploration between them.
For Doctors, the focus on the content of interpretations has
broadened to include an interest in communicative processes and its
intriguing implications. For example, her openness to strong
impressions which "seemingly come from nowhere" is evidenced in her
second case:
Raphaela began treatment for her anorectic symptoms by talking about
her intrusive and disturbing relationship with her mother. Offhandedly,
Doctors learned of a stepmother and indicated that she wasn't aware that
her father had remarried. Raphaela's response, "Oh yes. Zelda . . . she
died", was met with both verbal and non verbal responses from Doctors,
who "felt physically galvanized, and profoundly distressed . . . like an
alarm signaling danger." She ultimately responded with the
interpretation, "Somehow I have a sense that you are starting to let me
know that there was something violent about this." Raphaela nodded and
said, "Yes."
Doctors thinks of this interpretation as:
Communicating her view of the patient's psychological world of
emotional violence. Using both affective "overtones and under tones" of Kohut in
shaping it. Utilizing those undertones and overtones in conveying many
aspects of her own state of receptivity to and interest in the
experience of the patient. This conveys a respect for intense
emotional experience, and a capacity to bear what the patient might
share. She believes in the therapist's capacity to share herself with
her patient, which allows her state of mind about the relationship to be
known. This contributes to a dyadic freedom to be able to think,
experience emotion, and to more comfortably share their experience of
each other.
The third case is Justine. In a dyadic exploration about her
mother's medical choices, choices which hastened her mother to her
death, Justine comes to a sudden realization of the need for her mother
to be in control of the way that she died. This realization was
facilitated by a multi-layered and complex interpretive process. The
patient's perception of the receptivity of the analyst facilitated the
patient putting her experience into language. Doctors and Ornstein seem
to be in agreement about the importance of language as an emergent
property of dyadic systems and language as crucial in the interpretive
process.
Dr. Rankin is an analyst and former Board member of the Institute
of Contemporary Psychoanalysis in Los Angeles. She is the incoming
Chair of the Southern California Area Committee on Psychoanalysis in
Clinical Social Work. She is in private practice in West Los
Angeles.
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