The Analyst's Vulnerability
More important for our ongoing work as clinicians is that we, just like our patients, carry these early experiences and motivations with us for a lifetime. The goal for us, and for them, is not to rewrite history but rather bring it into awareness in the interests of greater conscious control and less internal conflict. As we treat other people, we are necessarily working through our own issues and attempting to overcome our guilt and become the best people we can be.
We become analysts to prove, in part, that we are not destructive—that the pain in our families was not our fault.
As children, we did not have any real power over our parents. Once identified as empathic and sensitive, then enrolled as the family's therapist, we essentially felt enormous responsibility with little or no power over events or the behaviors of others. All we could do was respond to situations we were presented with, then make our best attempts to be soothing, empathic, or even entertaining. But we could not change the scenarios that were unfolding before our eyes. One could argue that any attempt to point out a suffering parent's maladaptive behavior would no doubt have resulted in rejection or further distress—something a child could not possibly bear.
"Knowing" has become a synonym for arrogance and reductionism; "not knowing" presumes a more enlightened willingness to discover, an idea central to Buddhism. But this presumes that somehow what needs to surface will do so by virtue of this ongoing empathetic stance. I have no found this to be true in my practice. Witnessing is valuable, but it is not enough. I find that although certain patients need very little direction and may even prefer to be left alone, many need ongoing gentle probing, interpretation, and confrontation.
It sometimes feels as though a duel to the death is taking place, with each member of the analytic dyad determined to change the other. The best therapist for someone is the therapist who can most freely experience the patient's reality, as well as their own. That is why treating people we cannot emotionally engage with is both hopeless and unethical.
Given that some success is necessary, some degree of transformation, much of what is therapeutic for both patient and analyst is the mutual grieving of what cannot be. This can include the limits on individual change, the limits of the therapeutic relationship, and the limits of the analyst. There is always much to grieve.
Psychoanalytic theory and practice have been forged over the past century by the individuals and the culture from which they came. More critical to understanding theory and practice and to their creative evolvement is the acceptance of the ongoing basis for them both in the individual and collective psyches of the people who create them. Our personal motivations for being analysts and theorists naturally arise from our own childhood experiences. Our explanations of the world are also explanations of ourselves. And only the fullest possible self-awareness of these experiences and our resulting needs can facilitate the evolution of analytic theory and technique.
I think we often settle for gratitude, seeking it or complaining about not getting it only when our deeper needs for affirmation are not met. Focusing on gratitude is what you do in an interpersonal relationship when you feel someone owes you something. Implicitly, it means that the relationship is tilted out of mutuality. When both people's needs are being met, gratitude, while present, is not at the forefront.
The therapeutic relationship cannot transcend the limitations of all human relationships, which necessarily include periods of insensitivity, neglect, power-seeking, and even some degree of exploitation. The point is not to create an unattainable ideal, but rather to point out that a certain amount of therapist gratification, both superficial and deep, necessarily occurs in tandem with the patient's improvement.
Colloquial definitions of narcissism are all too familiar. Centered on grandiosity, defensiveness, and a lack of empathy and introspection, I do not believe most therapists fit this description. Nor do simplistic judgments do justice to the complexity of character that allows for the existence of kindness and empathy, while also allowing for bouts of defensive envy, power-seeking, and the need to be special. […]
I have always preferred the concept of narcissistic vulnerability and narcissistic injury, whether in reference to my patients or to myself and my colleagues. I find these terms incisively descriptive and applicable to virtually everyone. We are vulnerable and we all suffer assaults on our self-esteem.
Early career therapists, in particular, often believe that their vulnerabilities are a sign of weakness, deficiency or failure, which inhibits their open discussion of these inevitable treatment events, as well as their ability to handle them internally. […] Ignoring the issue of our vulnerability increases our defensiveness as we expect more than is possible.
I have said before that even if you are "right" […] this should not be confused with doing what is therapeutic.
Enactment is conflict personified, but it is heavily weighted toward the interpersonal rather than the intrapsychic.
Freudian analysis revolved around the assumption of internal conflict as the problem to be addressed. Innate drives potentially at odds with the environment, as well as internal values (e.g., sex and aggression), generated these conflicts. It was the analyst's job to interpret conflicts and identify how they were expressed in the patient's life. The patient's tendency to "forget" the basis for his or her conflict even after it had been identified in the treatment setting inspired Freud to coin the term "resistance." He said that resistance was not the act of an uncooperative patient, but rather a natural tendency to re-forget that which we were pushing out of awareness to begin with. Resistance was commonly due to unbearable guilt and shame over ambivalent ties to loved ones, as well as sexual desires. The analyst understood that repetition was inevitable and that interpretations must be made again and again.
I often find that patients feel burdened by personal information unless it is absolutely needed to explain the analyst's emotional state. […] If you accept that enactment is essentially an affective event, it makes sense that personal information potentially muddies the waters rather than providing clarity.
Michael did not seek to know what motivated my behavior, but he was relieved that I took responsibility for my role in creating what happened between us. He did not need, or want, personal information about me. What he needed was my emotional honesty, about being stuck in an unhelpful pattern, some willingness to self-disclose and, of course, to take responsibility for my behavior.
To summarize, the tasks involved in what is commonly referred to as "empathy" in psychoanalysis are comprised of three different but related activities: first, the communication of affect from one person to another; second, the subsequent emotional and cognitive responding to that affect; and third, by subsequent behavioral responses. The assumption in treatment is that these responses will be sympathetic and helpful (prosocial).
As I have said in my writing many times, when a patient keeps repeating an emotional scenario, without any dilution in its intensity, I know the patient is coming back because she still needs some kind of response that I have failed to deliver.
I think as analysts we are more inclined to constrain our patients' pain-related expressions as we rush to be a soothing presence, including quickly apologizing for any role we might have in their pain. Doing so, of course, succeeds in truncating the patient's pain, but also forecloses the deeper exploration and meaning of that pain.
From the very first session, I actively look for the patient's strengths, make sure I include them whenever I am giving feedback, and try to imagine what a good outcome would look like. I then think about what actions on my part would best facilitate that outcomes. All of this occurs in the context of what the patient is seeking, of course, and includes conversations about the agreed upon goals that are the mark of a successful treatment.
As Kantrowitz said, my role in the beginning of treatment, though still based on a strong relationship with Beth, necessarily shifts from soothing presence to facilitator of interpsychic and interpersonal conflict. Different phases of treatment evolve within the context of a strong analyst/patient bond, challenging the analyst to rise to the occasion. And I would add that acting as a facilitator of strong emotion, particularly grief, represents a critical aspect of the analyst's role in therapeutic action.
I have found that people always know when they are being placated, and while they may experience some triumph in the moment, they ultimately feel disappointed and disrespected. To my mind, authenticity is a critical variable in therapeutic action.
I believe the essence of therapeutic action resides in the constructive and deliberate truth-telling within the analytic relationship. Factors that need to be recognized include the desire to influence, the desire to change each other, the range of feelings we experience with each other, and the inevitable periods of withdrawal that occur. In short, it is the gradual awakening of who we are in relation to each other that is therapeutic, with the ongoing prominent focus on the patient. Grieving losses, missed opportunities, failures, and the fact of his limitations are all therapeutic if done at the proper time. This includes the harsh realities of abuse and not experiencing love.