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This panel explored Howard Bacal's Specificity Theory and Robert
Galatzer-Levy's discussion of the concept of emergence as they relate to
therapeutic process and therapeutic efficacy. A rich and detailed case
presentation by Leslie Smith offered an opportunity to apply these ideas
to unfolding clinical work.
Ms. Smith described a patient who presented with anxiety and
depression and a tendency to sacrifice herself to meet the needs of
important others. Her history was characterized by incest, emotional
neglect, and blaming and rejection, particularly in response to choices
that differed from those of significant others. As they got to know one
another, Ms. Smith was struck by various and numerous points of
similarity between herself and her patient, as well as by the patient's
exquisite, almost uncanny, attunement to Ms. Smith.
In a series of sessions Ms. Smith and the patient talked about their
recent negotiation of a reduced fee and number of meeting times per
week. As Ms. Smith and her patient explored in detail their separate
and mutual perceptions and experiences of the negotiation exchanges
between them, a new dyadic experience emerged for both the patient and
Ms. Smith, one in which their differences were acknowledged, together
with their connectedness. Ms. Smith's close tracking of the patient's
experience in this process and her willingness to acknowledge moments in
which her assumptions about the patient were inconsistent with the
patient's experience promoted an ambience in which the patient was able
to more fully articulate her own array of feelings, as well as clarify
her own reactions in contradistinction to the assumptions of Ms. Smith.
The patient clearly felt relief and exuberance in connection with this
newfound experience of acknowledgement of difference which was enhancing
rather than destructive of connection. This theme was revisited in a
dream much later in treatment, in which the patient was able to remain
connected to her own emotional experience, even when Ms. Smith was
configuring the situation differently. In addition, the patient, via
the dream, was able to call Ms. Smith's attention to the ways Ms. Smith
was distracted by her own ideas and not understanding the patient's
perspective. Once again, a feeling of shared pleasure arose, as Ms.
Smith and the patient noticed the patient's increasing freedom to assert
her own emotional experience, while remaining in a connection which was
enhanced rather than ruined by the articulation of difference.
Dr. Galatzer-Levy presented a paper focused on the concept of
"emergence." Emergence, according to Dr. Galatzer-Levy, "is the
hallmark of complex dynamical systems, by which novel and unexpected
structure, pattern or process arises spontaneously in self-organizing
systems." Emergence describes a process in which "complexity at a
higher level of description arises from lower levels in a non-linear
fashion out of local interactions." In contrast to more reductionist,
linear models using cause and effect formulations, with emergence, the
outcome cannot be predicted, even with an understanding of the
constituent elements and rules of local interaction.
Dr. Galatzer-Levy proposed that holding in mind the idea of emergence
can reshape the way we listen and understand in our psychoanalytic
endeavors. He identified a traditional tendency within psychoanalysis
when confronted with novelty to look for underlying continuity. He
suggested that this bias toward expectation of continuity can interfere
with the recognition of emergent new phenomena and he illustrated his
ideas with several case examples. Dr. Galatzer-Levy put forward the
idea that emergent phenomena, which are by nature surprising and
unpredictable, are not likely to appear in a system which focuses on
linear, goal-directed steps toward change, but rather are likely to
arise from the novel organizations and configurations that occur within
the dyadic system, formed by the "satisfactory coupling" of analyst and
analysand. Unfortunately, Dr. Galatzer-Levy did not apply his ideas to
the case presented by Ms. Smith. This is regrettable, since the process
description presented by Ms. Smith certainly illustrated the concept of
emergence in the dyad.
Dr. Bacal's paper described his Specificity Theory and applied it in
a discussion of Ms. Smith's case presentation. His summation of
Specificity Theory is as follows: "Psychotherapeutic efficacy is a
function of the specific capacities for reciprocal responsiveness that
emerges within the relational process of its particular participants.
Consistent with a systems sensibility, Specificity Theory regards
therapeutic possibility as an unpredictable spectrum specific to each
particular dyad .... That is, therapeutic possibility is specific to the
capacities and limitations of any given dyad, and not a function of the
expert application of any traditional psychoanalytic theory, (including
self psychology) by the analyst."
In addressing Ms. Smith's case Dr. Bacal stated that "within
Specificity Theory, we are interested in how and why these two people
are working together effectively, or not, in their particular
therapeutic process." He brought his focus to the complex dynamic in
their relationship which concerned the matter of sameness and difference
and called attention to the paradoxical nature of this issue. He
identified ways the patient's experience of thinking independently was
connected with feelings of badness and shame and with not trusting her
own mind. He added that this sense of something being wrong with her
mind was understandable, since there had been something wrong
with her having an independent mind and that experience had led to the
loss of connection with centrally important others. He pointed out that
only in the experience of sameness with Ms. Smith was the patient able
to safely begin to find her own mind and begin to safely experience
herself as different. He illustrated the ways the specificity of their
process was unique, in that the more traditional idea about giving the
patient room to explore in this case was disruptive, rather than
helpful. Additionally, he noted that Ms. Smith's disclosure of her own
feelings and reactions made significant contributions to the deepening
of the work, rather than foreclosing it, as might be expected from a
more traditional view. He also proposed that the issues around sameness
and difference might have been addressed from the perspective of the
twinship selfobject transference as elaborated by self psychology. He
pointed out, however, that had Ms. Smith's work been centrally guided by
this theoretical structure, she would have been constrained to interpret
the patient's need for this selfobject function or the patient's need to
defend against it, rather than attending to the unique and complex ways
issues of sameness and difference emerged between her and her patient.
In summary, Specificity Theory and the concept of emergence offered
fresh and stimulating perspectives on therapeutic process and efficacy,
and Ms. Smith's case provided an excellent platform for discussion of
these ideas.
Carol Mayhew, Ph.D., Psy.D., is a training and
supervising analyst at the Institute of Contemporary Psychoanalysis in
Los Angeles. She was also a former president of that institute. Her
practice is in the Brentwood area of Los Angeles.
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