TRANSFERENCE MEETS DIALOGUE:
A Discussion Between Self-Psychologists and Gestalt Therapists
Ronald Alexander, Bernard Brickman, Lynne Jacobs, Jeffrey Trop, and Gary Yontef
The following is a transcription of a panel presentation that was held at our 13th Annual Conference which met in Manhattan Beach, California The panel was the concluding event and took place on Sunday morning, April 14, 1991. In editing the transcription we have made minimal changes in order to capture as much of the spontaneity as possible.
As you will quickly note, Jacobs presented a case, both orally and in writing, for the panel to discuss. Copies of the case were distributed at the conference, but for reasons of confidentiality it is not included here. You may find this a bit frustrating, but we decided not to remove the references to the case as they stimulate much of the discussion.
In the question-and-answer period, several in the audience refer to one another by their first names and sometimes not. We've simply left the questions/ comments as recorded so it is sometimes difficult to determine what precisely is being responded to by the speaker.
The panel was moderated by Ron Alexander, Ph.D.
RON ALEXANDER: I'd like to start with introductions. To my left, Dr. Bernard Brickman, a training and supervising analyst at the Southern California Psychoanalytic Institute. He's also an assistant clinical professor of psychiatry at the UCLA School of Medicine. He's on the attending staff at Cedar-Sinai Medical Center, and is in private practice of psychiatry and psychoanalysis. Next is Dr. Jeffrey Trop. He's a psychoanalyst and psychiatrist in private practice in Brentwood. He's a supervising and training analyst at the Institute of Contemporary Psychoanalysis and he has written, published and spoken extensively in the field of self-psychology. Gary Yontef is a licensed psychologist, diplomate in clinical psychology, and a licensed clinical social worker. He's in private practice with Gestalt Associates, Santa Monica. He was formerly on the UCLA psychology department faculty and chairman of the Professional Conduct Committee of the L.A. County Psychological Association. He is past president of the Gestalt Institute of L.A., and was long-time chairman of the training faculty. He is a member of the editorial board of The Gestalt Journal and the author of sixteen articles and chapters on Gestalt therapy. I'm Ron Alexander, director of clinical training and chairman of the graduate program of psychology at Ryokan College in Los Angeles, and I've written and published several articles on Gestalt and self-psychology. I'm in private practice in Santa Monica, California. Lynne Jacobs is on the faculty of the Gestalt Therapy Institute of L.A. She teaches and trains internationally. She was recently appointed to the editorial board of The Gestalt Journal. Her two abiding interests are dialogue in Gestalt therapy, and integrating insights from psychoanalysis and Gestalt therapy.
So we'll start first with Lynne Jacobs, who will introduce her case.
JACOBS: I actually would like to do three things in the period of time that I have this morning. One is to introduce...set the tone for the next dialogue. The next would be to introduce the case. And the third would be to discuss the mode of interventions that I made a little bit. I know there's going to be quite a bit of disagreement or discussion about that.
So let me start by saying I think this is an unusual program. I don't think we've ever had a dialogue between ourselves and another school of therapy at one of these conferences, and I'm eager for the discussion. I also must admit I'm quite anxious about the discussion. And I hope we can all keep in mind that vigorous debate is a step along the way in human development. And I would like you all to keep in mind that my case is a step along the way in my own development.
I have for six years been at work in trying to understand self-psychology and more recently intersubjectivity theory and what kinds of contribution it could make to Gestalt therapy. And this case represents, as I said, a step along the way in that understanding.
Given that, let me tell you a little bit about this case. I'm not going to say very much because actually the presenters have no more information than what you have in the transcript.
I did want to say, since there's some question about having seen her for so long -- that is, ten years -- that she is essentially unresponsive to medication. She has gone for medication evaluations and experimented with medication twice in the course of the treatment.
She originally sought treatment with me for depression and made great efforts to be able to see me, in part because she saw me as fundamentally like her: our style of dress was similar, our mannerisms were similar. And that, in her eyes, held hope for her, a hope that she could someday be more functional, as she saw me. And also that has been a real seed-bed of feelings of depletion and envy, as I continue to go on developing my career and she continues to struggle.
There has been a repetitive theme in our relationship of her desiring confluence with me in the form of a connection with me that is unbounded and unlimited. And whenever she's come upon limits, they are a source of anguish for her, where she feels abandoned by me. What she very much wants is for her development to be as important to me as it is to her.
On the other hand, closeness with me, given the limits that are inherent in the relationship, evokes painful longings in her that then stimulate reactions that take the form of behaviors that are -- that symbolize for her the desire to have me take over her life for her -- me or somebody. That if I could very concretely participate in her life that would mean to her that I was offering her the emotional involvement that she knows she needs in order to develop.
And some of what's been emerging recently in part as a response to the crisis that's represented in the transcript that you have, is that if I can do that for her, it would obviate the need for her to grieve over what she didn't get in her childhood, and she's afraid that grief will overwhelm her. I do want to say since it's not clear from the transcript that in the session that wasn't taped, which unfortunately was the emergency session, what came out in that session is that she was ambivalent about being in graduate school, which we knew all along, but felt some relief about having to leave graduate school, that the emotional pressures were just too burdensome for her. And I also want to follow up now by saying that she is working parttime, still unsure of her direction in her life, but is now once again paying for her sessions because she's working. And the third thing I want to do, given that little piece about the case, is just to talk about the emphasis that I'm sure you all have seen now in the transcripts on what may be called an interpretive mode, although I do want to tell you a little bit of a story about that.
I showed this transcript originally to two people who were helping me decide what to do with it at one point. One of these people has a classical understanding of what an interpretation is and he said, "I don't know what you're talking about. I don't see a single interpretation in this case." Then I showed this case to a friend of mine who's in the audience who is very well versed in psychoanalytic and humanistic schools of therapy and he read it and said, "Lynne, this is all full of interpretation." So...I think most Gestalt therapists are going to look at this case and say it's full of interpretation because...so let me do a very broad definition of interpretation that we can all work from as we go, throughout the discussion.
From my point of view, an interpretation is a statement by the therapist that attempts to clarify the structure of a gestalt or to clarify the structure of the patient's experience, or experiencing. So this would include commenting on the figure, as in the emergent affect; the ground, as in developmental history, repetitive themes, self-experience, and self-other experience; and/or commenting on the relationship of the figure to the ground, that is, providing a contextual understanding of the emergence of a particular affect or feeling. That's a definition of interpretation, I think, that would be palatable to Gestalt therapy and it is what I think I did, by and large, in this transcript. That's open for discussion, of course. And what I want to suggest is that although because of the nature of this crisis, my work was almost entirely interpretive by this definition, the work with her generally is not entirely interpretive, but it is predominantly interpretive. So it's still, to me, worth discussing, because obviously that's not classical Gestalt therapy.
And what I want to make a case for is that the interpretive approach that I took represents a systematic attempt to understand my clients' or patients' experience from their vantage point, because I see the interpretation as serving the function of "inclusion" -- Buber's concept of inclusion -- or empathy. And that, I think, will be discussed more later. I think Gary wants to talk somewhat about that. But I see that while at times patients may need the chance to articulate their own experience, obviously the experience of mastery, of articulating their own experience, at many other times they may need the confidence that the therapist's understanding establishes for them. It establishes a tie that demonstrates the therapist's capacity for inclusion or empathic immersion which I see as the ground for dialogical contacting.
So that's a case I'm going to try to make as we go today, as it comes up.
And that's all I have for now.
ALEXANDER: OK, thank you. The way that we're going to structure this is each of us will have about ten or fifteen minutes to make some kind of commentary reflections on the case. And then it will go back to Lynne and there will be some rebuttal from her. And then it will float back around with us. Then back to Lynne. And then we'll open it up to the audience so that we can truly, in the spirit of contact, meet each other, so that it's not simply a mono-dialogue.
In the spirit of the dead and the living, I thought we'd just start with a couple of quotes about contact. I was wondering, if Jim Simkin were alive today and if he were here, what his responses would be. This is at least what he had to say about contact. "To make good contact with one's world, it's necessary to risk reaching out and discovering through the experience of what is me and what is not me."
And Erv and Miriam Polster, in their writings on contact, speak about "the life blood of growth, the means of changing oneself and one's experience of the world. Change is inescapable, the product of contact between appropriating the assimilable or rejecting the unassimilable. Novelty will inevitably lead to change or contact may be thought of as the awareness of and behavior toward the assimilable novelty. What is pervasive, always the same, or indifferent is not an object of contact."
I wanted to start, before I get into the case commentary at raising some questions that both Lynne and I formulated and also to let the audience know that this group has met before and worked at integrating and creating some contact between ourselves on some of the formulations and ideas that we want to raise.
Some of the questions that I think are timely and relevant for us as Gestalt therapists and self-psychologists to be pursuing, particularly at the level of integration and that I think the first series of questions may be helpful for you, the audience, to track and follow the case.
Number One: What's therapeutic about tracking contact boundary disturbances when working from the point of view of developmental arrest in needs and are these views in conflict with each other?
Two: Where does therapeutic listening exist and what is it for the therapist and what is for the patient?
Three: Are these similarities and differences between transference and countertransference in contact and presence when working within the I-Thou dialogic approach or the intersubjective field approach? What are their similarities? What are the differences? What's the place of focusing in both self-psychology and Gestalt therapy and how is patient self-experience being tracked in this case example?
Then if there's time I have some questions that I'll pose at the end of this forum since it's being taped, as a way of stimulating our thought and our ideas about furthering all of this work.
My commentary on Lynne's case was to follow and pay attention to the issues of separation and abandonment as well as the notion of articulation as a self-object function. Overall, I really liked the case and I thought Lynne did an excellent job with it. I think she was particularly helpful and useful at allowing the patient to have an opportunity repeatedly to regulate and focus deeply on the specific affect -- states of pain and anger and rage. And the central issue that I thought was accompanying those feelings was the patient's fears of separation and abandonment. I liked how Lynne repeatedly used reflection and articulation as a self-object function within the transference, and I think it allowed the patient to open up to a central emotion which was rage.
I liked how Lynne helped her to bear the experience of what she repeatedly called "the unbearable feelings" and I think that by Lynne functioning in the role of the self-object to repeatedly articulate, over and over, for the patient, when the patient had confusion in understanding what she was experiencing, particularly around the notion of that the patient kept always saying that she felt flooded.
One area where I took issue with how Lynne responded to the patient was at the point where, on page 4, Lynne's comment was, "You seem defensive." (Page 4, line 189). And the patient says, "Yes, as if you won't believe me." I saw at that point this response from Lynne was directing the patient more inside than I myself would have liked to see the interaction go. I think I would have at that point stayed a little bit more in the present and asked for more of a response of "What is it that you're experiencing now? Are you curious about what is happening?" -- to allow for the exchange to come more deeply into the interactional dialogue as well as to allow for reflexivity and curiosity, so that the patient could have started to access those systems.
On page 6, Lynne was very useful with articulating for the patient her experience of the central emotion of shame which I thought was primary to a lot of the rage and the anger and the frustration -- where she talks about the glass jail. And I thought Lynne did an excellent job at helping her to move from an understanding of shame also into rage and frustration. And again the perspective that I'm following from is how Lynne would function as a self-object meaning that she would articulate and help to organize and clarify for the patient the emotions, some of the powerful and flooding emotions that the patient was having trouble with.
On page 10, line 481, Lynne did an excellent job of the use of observational skills leading to awareness. So in that part of the case I thought she was functioning more in a Gestalt therapy model. She says, "You look sad, like someone who's been hit." The patient says, "I have a fear of being harmed for expressing my vulnerability and my mother would abuse me when I expressed myself." Lynne's response was most useful at articulating the patient's experience of the unbearable feelings of loss, grief, and horror, and the terror at being alone. Once again, I think Lynne was repeatedly really allowing this patient to feel understood and to have an overriding, confirming sense of being mirrored for how much terror, pain, and aloneness the patient experienced around separating herself.
Lynne keeps following the centralized theme of the patient's deep and profound need for support, and comfort, and connectedness. There are several places where Lynne stayed more reflective. I would have liked to have seen a little bit more direct "I" statements around support and connectedness, but overall I think the emotional exchange of how supportive Lynne was was accomplished quite successfully.
The patient's feelings of being connected to being cut off from the phone machine I thought brought up the emotions of hurt and anger, the sense of woundedness and deep, bitter shame for her needs and her neediness which I thought was the essential theme of all three sessions. And then Lynne, at that point in the case as I saw it, really got her to look at what she experiences inside of herself when she is feeling cut off and how there was an emotional train from anger to frustration to shame and then to hurt and then to the feelings of abandonment and separation which could be key and pivotal for this patient in how she activates herself or doesn't activate herself in relationships.
And Lynne, I thought, was very helpful at containing, regulating and connecting this patient to herself through her reflections and eventually helped her get to the much more core and pervasive feeling, I think of grief, which was central in the session. And that was underneath the self-attack, the frustration, the disappointment, and once again Lynne was most helpful at helping her to get to the underlying fear of abandonment.
I think Lynne did a good job at both alternating in and out of utilizing some awareness oriented skills and reflective, interpretive statements and really essentially helped the patient who was having a very difficult time accepting the depth and degree of how difficult it is for her to activate and articulate her emotions in a close relationship and face her fears of limitations and abandonment.
TROP: I'd just like to put in a word here -- we're sort of at an historic event today. I've never been at a workshop where in fact somebody has passed out their clinical material to be scrutinized in this way, and I think we all should appreciate what great courage it takes to put yourself out there in this way. It is truly easy to take apart somebody's clinical material and we all know that and it's harder really to take a central overview and step above it but, again, It think it's unique. It's not easy to present your clinical material. I presented a case that I thought was just great -- wonderful case, last October at the Self-Psychology meeting. He'd been in analysis for ten years. He started out basically as somebody who was predominantly homosexual...very fearful, scared of women, humiliating mother...who was just a very, very scared guy and gradually over time his homosexuality receded and it was seen predominantly as defensive and eventually he has this woman, got married, doing great. I was totally ripped apart for this. Mainly because they said, "Ten years." Somebody said, "I could have done this in a year and a half."
So you know you can always do that with somebody's clinical material. It's really easy to second guess, so I would like to thank Lynne for presenting us with this rich clinical material. It is crystal clear to me that this interaction between patient and therapist provides a stirring example of sensitive attunement to the fluctuating affect states of the patient.
I would heartily say that this case material represents an integration of self-psychology and Gestalt therapy and I can absolutely embrace the process, as I find this material an example of sensitive attunement in empathic immersion in the experience of another person.
So what else can one say about this work? Probably I would have given the same discussion no matter what case I read. So you're hearing my thoughts about...an attempt to delineate certain clinical issues in self-psychology which for me occupy my own thinking at the moment. I'm fully aware that in so doing, that Lynne could get up afterward and tell me that the comments I'm making have been addressed sequentially in the therapy, as in fact what we're seeing here are the several sessions and not an overview of the work. And that when Lynne says, "Well, at the emergency Thursday session, that the patient actually felt relief," it would probably color my discussion differently. But again, we're seeing a few sessions. We don't get an overview of the sequence. So I'll preface that by saying much of what I'm going to say is my own speculation.
Nevertheless, it is my hope or belief that some of my comments will have general applicability and address what I see as some potential problems in self-psychology.
Back to the patient, in overview of her situation. She's a forty-year-old woman, been in a longterm psychotherapy. How have the goals of therapy been met in this case? She has a horrendous background of abuse. She has suicidal feelings. And Lynne has helped her to stay alive, thinking and growing. In addition, the therapy has been very successful in several important areas, namely affect identification, affect articulation, and affect tolerance.
So the patient is able to identify her feelings better, to know what she feels and also able to tolerate them. So it's obvious from the clinical material that this patient has had enhanced experience of her own feelings. She is verbal, communicative and it is implied but it seems to me that she has enhanced capacity to deal with these feelings. Lynne deals with her patients in very sensitive ways, very concerned about this patient should she have to terminate -- with a lot of compassion and a capacity for empathic immersion with this patient. So from this vantage point, the patient's therapy has been extremely successful. That, to me, needs to be acknowledged. It's been very successful.
Where has the therapy still left the patient in a state of need? A goal of psychotherapy is the transformation of self-experience. What we are told is that one year ago she was expelled from school for not turning papers in on time but was readmitted. The sessions we now see occur after a similar episode that occurred where she was again expelled for going to school without being registered. So essentially one year later she repeats a similar episode. Lynne states this occurred for a variety of administrative errors but also because of the patient's "avoidant inattentiveness." So the patient essentially repeated two interactions at school where she failed to comply with external requirements and was dismissed from school. This seems an area of personal exploration where the transformation of self-experience awaits further interpretive work between patient and therapist.
So then, how can one look at this therapeutic interaction and address what is to me a critical question? What, in the therapeutic interaction between therapist and patient, enhances this goal and what may interfere with it? The broad question remains about the transformation of her self-experience and the underlying motivations that have led to her being dismissed from school.
Now, I think there are several ways to think about this question. From the selfpsychological vantage point, the question is what is occurring in the intersubjective field which gives us information regarding this? The nature of the therapeutic work again and again recapitulates how awful and depriving the parents were to her. The patient articulates many episodes of the mother's harassment, undermining, and invalidation. The patient says, "I hate them all. I hate them all. And I want them to know I hate them. I want them to know. I want them to feel fucking guilty. I want them to know they did bad." The therapist replies, "To know they've hurt you." Then the patient goes on to talk about a terrible dream where she is not seen at all or recognized, and she's raging in frustration. The therapist replies, "It is so annihilating. They won't see you, take in what you want to convey." And my thought here is this is true. These parents will not take in what she wants to convey.
I guess my question here is, I would feel it would be important to ask, why does she need them to feel bad at this point? What is still...why is that a necessity? Where is she stuck on needing them to feel bad about this? Why isn't it enough that she and the therapist can both acknowledge that these are awful people? What more is needed here?
For me the critical question is how does one help the patient make the subtle and fundamental and necessary shift? She has a longing for her mother to know what she's done and acknowledge it. The patient needs an awareness that in some ways the actions she took in regard to the university embodied a missing longing to be treated in a special way. The patient does not yet understand what the impact on her of her abusive mistreatment has contributed to her own organization of experience in the world. Thus the focus of the therapy emphasizes the patient's recapturing of her sense of being abused by her parents, but it does not focus on looking at what may motivate her in relationship to the university to do things which leave her without a self-nurturing and self-caring capacity. A goal in the therapy would be to help her so she does not need this special treatment in the world but is able to have a special feeling inside of herself so that she does not need the university to provide this feeling of specialness.
I think this patient does articulate this longing in the transference as well. She says, "I know I can make a difference to you, but not enough of a difference to make a difference in my life. This is where I get caught in what's real in what I want and they are never, never, ever going to mesh." The therapist replies, "You need a mom. Me." Again, in my opinion, this interaction needs to be examined carefully. The patient needs to understand what she needs to get from the therapist is to acquire a sense of completeness inside of herself. If the patient's feeling of validity depends on making a difference to the therapist, the patient is quite right. She will never get what she needs. She will never be as special to this therapist as she would like to be. None of our patients ever will.
My concern, again, is that the reply, the patient needs a mom, may reinforce the archaic longing that her experience can alter only if she is important to the therapist. The patient does need a protective, kindly, and loving mom inside of herself. She needs to acquire from the therapist a capacity to nurture herself over time so she can be free of needing to feel special -- to the therapist. This would be something to become free of. Again, it's my concern that this stance may contribute to the more archaic longing and may interfere with the patient understanding that she needs -- that she feels special by getting responses from others -- needs to gradually be internalized as a self-nurturing capacity.
I hope what I'm saying it clear and let me be more specific in what I -- in terms of my own stance and self-psychology in general.
Self-psychology has performed an extremely important correcting function in terms of psychotherapy by acknowledging the primacy of self-experience, and validating the concept of real trauma, real failure of parents to supply really needed self-object functions to their children. This patient is truly a victim of real abuse and real disappointment. A danger in self-psychology is that by validating the patient's subjective experience, the therapist may stay in the self-object dimension of interaction with the patient and avoid attempting to analyze the patient's organizing activity which is left as a residual impact from it. This activity is always -- this analytic activity always provokes a resistive element in the transference. As it applies specifically to this patient, the first episode with the university the patient would need to see that her longings for being treated special were embedded in her relationship with the university. It was an enactment of an archaic longing. It's a legitimate longing. I mean, she should have been treated in a special way. She wasn't. This wouldn't be to blame or accuse the patient, but to have her understand that the legitimate longings, when they're enacted, can end up being absolutely internally disappointing and that the therapist needs to absorb them.
The atmosphere of psychotherapy is to provide an environment where the patient understands their own unconscious organizing activity, that what they think is real in the outside world is shaped by their organizing unconsciously the experience. It's what they make of it and how they shape it. It is my concern that self-psychology can lead to persistent therapeutic patterns of focusing on external trauma and shape the interaction away from confronting organizing activities in the patient.
My discussion is over and I look forward to Lynne's responses to this and I wouldn't, again...this is my organizing activity right here -- the paper -- which is to say that I wouldn't want anything that I've said to detract from my overall assessment that this patient was handled in an extremely sensitive and empathic manner and that this therapy is very successful from many vantage points.
BRICKMAN: First of all, I'm very appreciative of the comments that have been made by Ron and by Jeff thus far, particularly with regard to the courage that Lynne has demonstrated in providing this clinical material for us to give us an opportunity to so richly discuss it and also my unqualified agreement about the very evident attunement, affective attunement that is evident in this work, the -- particularly the shifting in her ability to pick up changes in the patient's central affect states which I believe are absolutely essential in our work with people. And in particular the comments that Jeff has made about the progress that she has made.
Now the comments that I would like to raise go to the -- you might say -- the interpretive dimension of the work in the sense that if some of you in the audience feel that Lynne has been too interpretive in that she's explained too much about the patient's experience, I would probably go to the extent of being concerned that maybe there was some work that really needed further interpretation that was, I think, not picked out of the material. Specifically, what I want to call to your attention is a dimension of the transference that Jeff referred to as the repetitive or conflictual part of the transference. Now just a comment, a digression, very briefly about transference. Here transference is seen self-psychologically as the patient's way of organizing his or her self-experience vis-a-vis the therapist. And there are two basic dimensions of transference and these, according to the work of Stolorow, Atwood, and Brandchaft which I strongly agree with and I believe Lynne does too, there is the selfobject pole of the transference in which the patient's longings to unfold her self-experience and have her self-experience maintained and transformed takes place within the context of the self/selfobject bond with the therapist and I would characterize these longings as the longings to be very special, to be very central, very precious to the therapist as she did not experience herself to be special to her mother and how she felt that the only way that she could be special to her father, who apparently was very responsive to her in this way, was to open herself up to exploitation and abuse. Then the repetitive part of the transference is the dread of repeating certain kinds of traumatic experiences that she had as a child, experiences such as being undermined, abused, disregarded, discounted, in a traumatagenic way.
I believe that some of the material that is brought out here shows that from my vantage point what would have been necessary would have been to lift out some of the elements of the repetitive poll or the negative poll, conflictual poll of the transference that I believe was not done. And I would like to say something about that aspect in terms of the intersubjective context in which the therapy unfolds.
In order for the patient to unfold and to express, experience negative, particularly negative affect states toward the therapist there must be some sense that the patient has that these feelings would be completely welcome by the therapist. Especially given her circumstances of having an unusually low fee with a big bill that she still owes, it would tend to predispose the patient to feeling that maybe she's not entitled to have these feelings and if she were to have these feelings perhaps she would be in danger of abandonment or rejection.
To go to the material, I'd like to show how on repeated occasions the patient expressed some very negative affect states which were correctly tuned into and picked up by the therapist. However, I don't feel as though the therapist responded to the patient's need to have the therapist recognize that some of these very intense affects were really connected to the therapist rather than to the genetic situation, that is, with the mother and the father.
On page 2, lines 6067, the patient tells how awful it was to tell Katy about her having to leave and she identifies with Katy, because of the time the therapist told her that she wasn't comfortable hugging her at the end of each session.
She says that this was the worst pain she had felt in years.
On page 2, lines 65, 66, she says: "That's the worst feeling I remember having in years and years and years. That was really awful. So in this sense she is talking about how she identifies with Katy but she's really talking basically about her own experience, of having felt a horrendous sense of loss at the time that the therapist told her that she didn't feel comfortable hugging her at the end of each session. She later goes on with associations which reminded her of the time her father left her -- where the father left -- which is taking away her main caretaking functions and leaving her with her less empathic and tuned in and more cerebral mother.
So this situation that the patient expresses seems to signal -- would signal to me, an opportunity to give the patient an opportunity to once again review a certain dramatic experience that she has had with the therapist.
On line 86, the therapist responds to this material by interrupting as the patient seemed about to change the subject by saying, "He brutalized you." Now, again, it seems to me that the patient might experience this as the therapist's lack of receptivity, lack of welcoming the very painful, hurtful experience that she had had, I think several years ago, with the cessation of the hugging. So this was one exchange which might give the patient the sense that the therapist is not receptive to hearing the really negative, powerful negative feelings toward the therapist.
Later on...so again, just to reiterate, it seems that the attention and the flow was then diverted by the genetic comment toward the patient's genetic traumatagenic past away from the terrible pain and loss that she felt in the transference bond.
Now going to page 3, line 90, the patient moves to protect her father by saying something -- let's see. Patient says, "But I want to stop and say, yeah but he was drunk. It wasn't conscious." And there is the -- now, on line 94 the therapist said, "Maybe he was so upset that he needed your sympathy and needed to see his upset reflected in your eyes, something like that." Now this again would...might represent to the patient another detour away from the patient's hurt and rejection toward a speculation about the father's feeling or, again, away from that also the patient's experience with the therapist.
Line 104 the patient goes back to the transference bond and alludes to how tenuous it has felt for years and again expresses a fear of a repetition of the loss and the feeling of rejection through her expression of fearing that the therapist might get married. Again it seemed to me that she was providing the therapist with yet another opportunity to refocus on the work that needed to be done between the therapist and the patient.
Now, going to page 4, line 165, the patient is expressing her anger toward her mother, whom she saw as undermining, harassing, invalidating, and crazymaking. This goes on to line 188. Then down to the bottom of the page where the patient says...looks up to the therapist at a time that she says, "I'm not thick. I understand things faster than almost anybody." She looks up quickly. There's a bit of fear in her eyes, as described by the therapist. She says, "This is just true. I am very quick in class in grad. school," and she looks up again, apologetically. "And I have to do this, blow my own horn." And the therapist says, "You seem defensive." And the patient says, "Yes, as if you're not going to believe me."
Now here, again, the therapist is tuned in to the patient's experience and says, "As if you're ready for an attack." Now, to leave it that way, to say, "As if you're ready for an attack," without including the phrase, "from me." As though you're expecting me to attack you, would suggest, once again, that the patient would not feel comfortable bringing into central focus the feelings of endangerment the patient felt with the therapist at that time.
This might seem to be obvious to anybody, that you wouldn't really need to say, "from me," but it seems to me that the omission of that term, "from me," might tend to give the patient the feeling that you're not totally receptive to having the patient experience these things with you.
And I think it might have been...the patient might have feared, at that point, being undermined by the therapist in a revival of the negative maternal transference, that is the undermining mother who needed in some ways to attack her daughter and perhaps to elevate her own self-esteem at the expense of her daughter.
Again now, on page 5, line 192 -- this follows the attack and the patient says, "Yeah, right here, though with them I am wrong." Now, "right here" -- I wasn't there, so I don't know exactly what that meant -- but I would see that as once again another opportunity that the patient is giving the therapist to recognize that there is a set of feelings that are taking place "right here" in the context of the intersubjective experience with the therapist. This might have provided another opportunity for exploration of the repetitive form of the transference which tended to get bypassed and might have made it hard for the patient to express her anger directly at the therapist.
So, going back down the page also when she says, "I hate them all." This is line 224 on page 5. "I hate them all. I hate them all. I want them to know I hate them." This is what Jeff quoted. "I want them to know. I want them to feel fucking guilty." And obviously she's in intense rage. "I want them to know they have been bad." Now, once again, she says, "I hate them all." The therapist could hear that as related only to the family, the mother, the father, the genetic family, but I think any time the patient says "all," "I hate them all!" it's another opportunity to pick out, from the figure/ground configuration that particular piece that has to do with the angry feelings and disappointment with the therapist, but the therapist response by saying to know that her cue -- and of course she's quite accurate and attuned -- to the patient's longing to have everybody know how badly they've hurt her, but I suspect that the statement, "to know they've hurt you" would once again tend to preclude bringing to the patient's full awareness the angry and disappointed feelings with the therapist.
The issue that I would like to then sort of summarize here is that I believe that there is a central, repetitive, conflictual transference configuration that has been overlooked at this point, the importance of which to my thinking is that not attending to it carefully and systematically bypasses a very important area of anger and disappointment and frustration toward the therapist that would need to be brought into focus for further exploration of what the patient's conflictual and negative subjective experience of the therapist is and was.
Now, from this point, I would like to engage in just a little bit of speculation. The reason why I think it was important to integrate this material is that there is a chance -- and that would have to be explored only in the context of the patient's subjective experience once the negative affect states were elucidated -- a chance that what was being repeated in the transference was the patient's feeling that the only way that I can maintain a close, caring tie with my selfobjects is to let myself be exploited, to keep myself a fuckup, to give the other person a chance to feel like they are superior to me and I just have...I think there are just a few little comments here and there which I can't lift out at this moment, that might suggest that the patient's feeling is that the only way that that tie can be maintained is to allow herself to be used or exploited in certain ways. Not that the therapist is doing this, but that the patient's experience is that this is the only way that this tie can be maintained and that this might have something to do with the repetitive failures in her life and having to always fuck up. She says that "the longer I'm in therapy, the more I seem to fuck up," which may lend itself a bit to this kind of conjecture, but it's something that I think would have to be explored further.
YONTEF: I think this is a wonderful opportunity for a dialogue between self-psychologists and Gestalt therapists. In a way, I think the dialogue has not yet started. I think it's quite courageous of Lynne to present this material, and I also appreciate the courage of Jeffrey and Bernie to come into a place where we speak a foreign language. It also gives Lynne and me an opportunity to continue a debate we've been having for the last year, around Lynne experimenting with limiting interventions to empathic interpretations.
I think that viewpoint is not a good methodology and I think it is also not representative of what I would call Gestalt therapy. Jeffrey said, "If this is Gestalt therapy, I can embrace it." I'm sorry. I can't. I love Lynne, but not what's going on in this...with this case.
I think this methodology reduces the liveliness and the reality of the hereandnow engagement of the person of the therapist and the person of the patient. It reduces the methodology to one technique, namely interpretation.
I also think that approaching it the way Lynne has...reduces the emphasis on the patients taking responsibility for their own awareness work, for their own lives.
Besides my thinking that it's generally not a good methodology, I also think it's not a good methodology with this patient because there are so many strivings by this particular patient, not just to be understood, but to be taken care of. If the patient's fantasy of confluence, an unhealthy confluence, with unboundedness, is subtly reinforced or not confronted or dealt with it leaves alive, in this case for ten years, a belief and way of framing the world that's going to make it very likely that she will never respond to the limits in the outer world, and indeed that's what happened.
I think there has been a convergence between self-psychology and Gestalt therapy in that the direction that self-psychology has moved from classical psychoanalysis and some of the recent trends in Gestalt therapy, namely the emphasis upon the relationship are very similar. And also in moving from an emphasis on abstinence in the psychoanalytic framework and confrontation in the Gestalt therapy framework to one that does have more respect for the patient's experience.
But I think there still are also some significant differences. For me the emphasis on the patient's experience, the increase in the emphasis has partially come from an influence of self-psychology, some through Lynne, but more than that it's come from rereading our primary sources. From looking at, from reanalyzing Perls, Hefferline, and Goodman, looking at material on dialogue and phenomenonology and looked at in this matrix, I think, emphasizing the patient's experience takes on a different cast.
One difference is the emphasis on the presence of the therapist. How active a part does the sharing of the therapist's experience play in the therapy? That is one of the unique contributions of Gestalt therapy and I think it is irreducible. You can't eliminate that. I think we have no coherent methodology if we eliminate the active presence of the therapist, and the therapist's phenomenology, as a part of a twoperson encounter -- the full engagement of two persons with genuine and unreserved communication in the present. Most of these incidences that have been talked about in these sessions could be dealt with by more personal engagement by the therapist in the session. In a funny kind of a way, that's also what Bernie was saying about the therapist's receptivity to the negative feelings toward the therapist and making it a shared experience.
I'm going to read a quote from Lynne's Dialogue Paper.
JACOBS: You fink. Go ahead, Gary.
YONTEF: "Presence involves bringing the fullness of oneself to the interaction. The therapist must be willing to allow themselves to be touched and moved by the patient. The Gestalt therapist also tends to use the full range of emotions and behaviors, eye contact, physical touching, and movement. Thus we speak of one's presence. With presence and with genuine and unreserved communication, the therapist's role becomes wide ranging, limited only by creativity and personal style and the therapeutic task itself. Gestalt therapists do not confine themselves to a limited range of responses so that a transference can develop as in the more traditional type of analytic therapy. They're free to laugh and cry, to dance, yell, or sit quietly. They are free to be fully present with the patient in ways that suit their style, serve the dialogic relation, reflect the temper of the moment, and further the therapeutic task."
That's what I think they needed more of in this case.
I think that includes struggling with the patient, not just being empathetic or sympathetic. Presenting the demands of the world in the therapy session. We have to start with inclusion...with a real respect for and identification of and identification with the patient's experience, and then the therapist's experience. And out of that interaction something emerges, something novel emerges. We're sometimes confused that therapists being more present means somehow having the patient adopt the therapist's point of view, but the contrary is that the two different points of view come into juxtaposition and out of that emerges something new and noncontrolled by either the therapist or the patient.
I see Lynne's new position as changing from the interpersonal perspective to a "within subjects" -- and that's her term -- "within subjects" framework.
And it's not just an issue of what kind of relationship, but also about the therapeutic methodology. I think inclusion, and I prefer that term because it doesn't have some of the ambiguities of the word empathy, is absolutely necessary to good therapy, but not sufficient.
I want to separate, for a minute, the term empathy from the term interpretation. I think empathy is essential. I think there is always an interpretive element in our work. I think the word interpretation refers to inferences by the person making the interpretation. We're talking not about the obvious or the given, in phenomenological terms, but about an inference about the meaning.
The difference is not whether there are these inferences but how do we use those inferences? I believe in Gestalt therapy we use our inferences as part of the...both the dialogue and the phenomenological exploration. Having this idea of what's going on is essential, but "making an interpretation" is not. Making an interpretation is telling the patient what they experience. In general that tends to become more intellectualized. It puts the therapist in the position of guessing the patient's experience. If the therapist is sensitive and checks with the patient, then that may not do so much harm, but it doesn't create the framework for the patient to assume that they will do this awareness work themselves. So that later on in the therapy those supports by the patients able to set their own boundaries and take the responsibility, clarify their needs, haven't been strengthened.
I think our phenomenological focus is somewhat different from the self-psychological focus in that we not only emphasize the subjective experience of the patient, but we also work with phenomenological focusing and bracketing and of epoch, in effect training the patients how to be aware and how to separate their own inferences from their own primary experience, and what they observe and what they infer. How to stay in touch with, how to express, how to sharpen the expression, how to let go, how to build some soothing responses in your own repertoire, etc.
I think this phenomenological framework in Gestalt therapy focuses us to a wide range of interventions, in which the therapist and the patient, moving to a quick change or a behavioral focus, can still be very active and more intense.
In terms of this particular case, I find it a little hard to comment because it seems to me that in some ways the relationship is very good. By this I mean the patient feels understood. Its been maintained for a long time and a very difficult...a patient who has difficulty in maintaining herself has maintained herself for ten years. It's difficult to know exactly how the sessions would go if the whole therapy had taken a different course.
My reaction to this patient is that I'm very touched by the pain she's going through. I would want to tell her that. When she talks about wanting a place of oneness and peaceful retreat, that unbounded confluence Lynne referred to, I would also like to tell her that she could have that and also cope with the world, because I don't believe that this patient knows that you can do both.
One of the things I would emphasize with this patient, I think, is what I call the "and function." Bringing together both parts of polarities that I think she splits. For example: caring and limits; oceanic peace and coping with the world. This patient has trouble putting those into "I want this and that." I think she confuses being cared for, being cared about, and being taken care of. That kind of a split, a "but" instead of an "and" function is very important in its consequences. She would get what she wants and therefore feels love, which is endless. You can't feel satisfied. Or she faces the other pole and doesn't feel cared about.
I think I would have a more active presence as a therapist with her and deal more with limits and responsibilities within the session. There would be a more active chance of dealing with the issue of this patient taking more responsibility for herself. If the therapist is being so confluent -- you need to call it a new, "good word," like selfobject -- I don't think it stresses enough the boundaries and taking self-responsibility.
I often knew in these sessions what Lynne thinks the patient feels. There's almost no point where I know what Lynne feels.
I think I'm just going to repeat what I've been saying. I would have liked to have done by this point with this patient a lot of work around selfsupport functions and boundary skills. Being able to separate you and I, for example. I don't know if this was done. I don't see evidence of it having been done. If it was, I would still want to do it more.
The last point I want to mention is that I believe that for this patient her rage and revenge and needing the parents to change is an absolute trap. She can't be liberated and still be having her figure formed by rage and revenge. She can't really get revenge, and rage is still a holding on. And I think the patient needs to be...this needs to be dealt with rather directly, overtly, and firmly. And probably quite repetitively.
ALEXANDER: Now we're going to start the dialogue with Lynne Jacobs.
JACOBS: I'm not going to say a great deal at this...can you hear me? No. Now can you hear me. OK. I have very little that I disagree with in what anybody said, actually, and just one point that Gary raised that I want to raise in my own defense is that this patient knows very well what I feel most of the time. It's not reflected in the written transcript but we have had, over the course of our relationship, enough interactions that she is generally fairly in touch with what I feel whether I want her to be or not, actually.
What I wanted to do was comment on what I've gotten the most of so far which is that I got some supervision here and hopefully a resolution to a difficulty I've been having that actually takes into account points raised by all three people. What I have been struggling with with this patient for a long time is the apparent contradiction between the depth of our work in therapy and the fact that her life is falling apart. And I have had the experience in the first five years of the work with her that confrontations with her about her lack of responsibility and her avoidance of identification with her own experience led nowhere. They led to severe protracted disruptions in the therapeutic relationship and that's about it. So over the years I've been struggling with how to deal with those same issues without using a confrontive approach, and today I think I have a better understanding of it. For one thing, I think Bernie...what Bernie picked up on about this patient's...my contribution to this patient's inhibition of dealing with her anger and her disappointment in me is apt. As he spoke I could recognize some of my own "countertransference," if you will, reluctance to make room for her to do that with me. And I think it's that, that derails the development of self-delineation that this patient needs to do what Jeffrey is talking about; that for this woman to develop more of a capacity for self-validation -- I know by experience with her -- that confronting her about seeking something from me that she must provide for herself goes nowhere. But if she has the chance to work through her anger and her disappointment with me, she will find herself. She will come to herself in her capacity to validate herself. So I'm excited about putting those two things together.
Actually, that's all I have to say at this point.
YONTEF: I'd like to clarify the word "confrontation." It can mean too many different things. If it doesn't include an inclusion or empathic kind of understanding of the patient's experience, that the patient can hear, then it's not the kind of meeting that I'm talking about. We would also have to obviously include, to be a real struggle, the anger of both people or at least the patient's anger or Lynne's limits, etc. And I don't know the quality of the confrontation. I certainly don't mean by confrontation what we meant in the sixties. I mean it as an existential meeting between separate people.
ALEXANDER: Let's begin taking questions from the audience.
A WOMAN: I think this is a wonderful example of the opportunity that comes in longterm therapy. And I think right in the first few pages what the patient said shows that she is benefiting from a kind of buildup. But what I guess is happening is that Lynne doesn't even fully realize, at this point, the solid base that forms so that kind of thing can happen. With regard to the responsibility, it seems that she, the patient, invites you to look at that again with her in this new context of this experience with Katy. And part of what's wonderful about long term therapy is this cycling effect, where you come around to the same issues again, but it's not good to approach that reductionistically, just bringing it back to the early trauma, but to keep using those new perspectives to help the patient mature, connecting it with the early trauma, and you've got three connections that can be made here: She's a therapist too, a child, she's putting her parents in a role to a child, and she has failed a child, partly 'cause she doesn't have her life in order, so she has done to another what has been done to her. She also has issues with the therapist how has the therapist done that to her or not done that to her. She has got to talk to you as being in the same place she is, so as to help understand the choices you have had to make with regard to her. So it's just so rich with that opportunity. And in the beginning she connects what's happening with Katy with her history with you. And with the history of her parents. She's laid the base of trust. She's laid the base of vocabulary, identifying feelings, and I just think you don't have to go back to the basics again. You can build on that. I think also you could deal with guilt as a feeling, not just the feelings of loss, but I think dealing with the guilt helps deal with the rage and the loss from a more mature level. And I don't believe any of these opportunities are lost; were talking about something that's not such a fragile moment, it's something you build up to, even if it's not this issue, her life will provide an issue to kind of do that...
TROP: I would like to just take a moment to respond to that comment with which I strongly agree. I think it's one of the wonderful things about the therapeutic encounter is that the patient will offer us a variety of repetitive opportunities to understand something that has not yet been understood. In the second or third session, I don't recall which, the patient said something about her third ear. They were talking about the exchange, you know, like there were four people in the room and she said something about her third ear. I thought that that was a beautiful opportunity, again, to bring up the whole issue of how attuned she, the patient, is to the therapist's level of comfort or discomfort as to what can be comfortably brought into the therapeutic encounter. And she said...the patient actually articulated quite spontaneously that, "My ear, all my life I've been very tuned in. I have this third ear about what the other person is comfy about." And these comments could...could give the therapist the opportunity again to wonder what was she tuned into here and what might I have needed to see that I didn't see.
ALEXANDER: OK, if you're going to ask a question there's a mike here, if you would come up to the mike or speak loudly.
A WOMAN: I don't want ask a question, I want to make a comment on what you said, Dave, about the patient in this longterm therapy -- in the meanwhile her life is falling apart. While you were going on about the rage and the anger and the revenge that that patient still has a need to do that, my thought shifted to what is it that that patient is still holding onto the child by refusing taking responsibility but from the positive point of view, not the rage, not the anger, because not taking responsibility means she wants to remain a child. That's where my thought went to, so I thought maybe you could take something from this and just look into this...
JACOBS: Well, I thought I spoke to that. See, this is...it's not so much based on the transcripts but this particular patient feels poisoned by interventions aimed at elucidating what she is holding onto or aimed at asking her to explore that she might be holding onto something. They simply do not work for this patient. I have to find another way, and I don't also agree with the assessment that she wants to remain a child. She wants, I think, some of the advantages that she thought that she had in her...or that she ascribes to childhood, but she very much wants to be pursuing her ambitions and feels incapable of doing that, is incapable of setting a goal and pursuing it. And what...one of the things that's interesting is this issue about how seriously badly treated she was by her parents has only...she's only really gotten a grip on it in the past year and in this past year she's reassessing her views about what it means to be a child. She's now beginning to see that in her childhood she was pretty powerless and at the mercy of both parents' abusive behaviors, so she doesn't have any desire to hold onto that. It's trying to capture things that she thinks are available to children that she's afraid as an adult she couldn't have; and she's discovering that she actually has more of a chance of getting them, like the freedom of choice, as an adult than she ever had as a child.
ALEXANDER: I agree with Lynne. I don't think it's a question of the patient choosing to remain like a child or childlike. I think the very intense emotions of shame and of rage flood her as she said in the transcript, and then at times she herself becomes uncohesive and fragmented and then it's very difficult, or this patient has a very difficult time at articulating her self-experience.
A WOMAN: There are lots of things that I could focus on, but I want to focus on one particular thing, which is a point made in the context of Gestalt theory, which is that context determines meaning. And specifically with reference to mother and father. For me what is happening the second half of page 2 is that as in childhood the patient is shifting, is escaping from a potential encounter with Lynne to father and that looks like the context. And I would be wary about looking at the relationship with mother in isolation either historically or in terms of projection of transference. There's a whole gestalt which is that mother pushed the patient toward father who both cared and abused. And it's that whole pattern of motherfather interaction which is being -- as far as I can see -- repeated in this therapy, so that the whole issue about confrontation is almost a matter of going back to basics and looking at the therapeutic contract. What is available? What is possible? Without going to the pole of the maternal abuse and without going to the pole of the paternal loving abuse. So that by focusing on what is happening, and I think, Lynne, you did that by saying he brutalized you, and I'm surprised that after ten years that the patient said, "I never thought about that." Now probably she did think about that before and wasn't aware of it.
JACOBS: It doesn't matter. To me I was actually out of touch with where she was at that moment. That was a misattunement. She's actually talked about it many times, but it wasn't important at that moment. I was out of touch with her.
A MAN (CONTINUED): My sense is that it's so much a oneness, the gestalt between mother and father about what happened between them that it's almost never going to be a good idea to talk about mother without the context of how that relates to father. So that's my comment.
A MAN: This is a comment directed mostly toward you, Gary. My fantasy about this patient, as many, is that she has the introject that she ought to be responsible, that she ought to take responsibility for her life. What I wonder about is how to "get her to be more responsible," which is a piece of what I heard you saying, without impugning her and making her feel more guilty for her failure already to do something that she's unable to do and that is why she's seeking treatment.
YONTEF: You stick with the present. You focus on what the patient is doing, can do, in the present. And the question of responsibility will come up. You don't do the patient's work and you don't back off, and you get in touch with how the coping with moment to moment, the lots of moments of...in which the patient either will or won't act as the agent of his/her own awareness process and his/her own contacting process. So I would focus on it in that context, in the relationship, in the present, in the room, in terms of their awareness work.
A MAN: Your construct, then, would not be shared with the patient but is guiding your work more...
YONTEF: I would share it, but I would not use a word like responsible because it's a shaming, fighting word. But talk about what she can do, what she chose to do, what she could do, what she can't do, and the emphasis usually comes in. This is what you can do...I'm getting stuck in which pronoun to use...the difference between what a person can do and therefore can either have the courage to do, or the person can't do and needs to acknowledge and to be able to differentiate between that. So, we talk about responsibility, but I would probably not use that particular word with the patient.
BRICKMAN: I would like to just comment on that briefly. I don't see the problem so much as the patient's inability to take responsibility. She seems to try to take responsibility again and again and again, and repeatedly fails. I would see that the major issue is the inability to establish and to maintain and prolong a sense of functional competence in the world. And in order to understand that I would want to try to do everything that I can to understand in what way the transference experience can engage this. In what way because any psychopathology, in my opinion, no matter what it is, needs to be engaged and recognized in terms of how it exists and functions within the transferential experience between patient and therapist. And for that, that is why I stress the need to explore the dark side of the transference, the part that's been in the background that needs to be lifted out of the background, brought into the foreground, and explored further, in what way the patient feels, perhaps, that her competent functioning may in some way endanger the therapist or endanger the tie with the therapist. That is the area that I think would need to be carefully explored and understood.
YONTEF: I agree with most of what Bernie said, except to add that one of the ways of exploring that is by exploring in detail the taking on a responsibility or a task or a motivation and then it gets interrupted somehow. And at the moment of interruption would come lots of opportunities to explore just what Bernie was talking about.
BRICKMAN: I would agree.
ALEXANDER: Next question, please.
A WOMAN: I have a comment. I think the relationship is wonderful and can be used very fruitfully. I think if you think about this situation in developmental terms there's certain tasks that she hasn't completed. Because she hasn't learned how to soothe herself, she needs it from others. She hasn't learned how to operate in the world with...she hasn't had enough support, apparently in her life, to explore how to do things. She hasn't learned competence. And given the therapeutic relationship you, as the good mother, the good parent, can give her that kind of support and as a kind of collaboration, if you begin to look at...when she says, "My life is falling apart," and you take a phenomenological approach and look with fascination with her at how in particular these things, where she falls down, happen, and how she makes her choices at certain points that enable or contributed to the falling apart or the lack of success. Then, as she begins to look at this, she begins to get some sense of how she might behave in different ways. So as she begins to have...looking with fascination. You don't have to confront. You simply look with her, help her explore phenomenologically, well what did happen. And I think that the result of looking in that way and her beginning to try new things, given the support she has with you, she will feel the sense of empowerment. I think that's the way you break down the victim's outlook.
ALEXANDER: OK, next question, please. Or comment.
A MAN: Jim Simkin used to say that all psychopathologies are disturbance of the contact boundary, no matter where you are on the continuum of psychopathology, and the interpretation is a derivative of the therapist's experience. Just as the selfobject is a derivative, and I think the risk that you run here is the risk of both of you talking to yourselves in front of each other, and at best coming up with the derivative which best suits the patient's needs in the moment to organize her experience, but begs the issue of the disturbance at the contact boundary in the moment. And until you address that you can go on for ten years and at best stabilize her or keep her going, but she never gets to experience the novel or to grasp where the real disturbance exists.
TROP: I just want to say briefly something about that. Are we all so different? Gary says, "Well I wouldn't use the word responsibility because that would be experienced with the patient as shaming." And I think what everybody is struggling with is you cannot give somebody a painful truth if you don't have an intact bond. And the question is where is the intact bond. Your kid falls in the playground. You just said, "Don't play over there. You could skin your knee." Your kid falls down. Comes to you in tears. If you say, "Why didn't you listen to me?" you're going to have a more upset kid. You calm, soothe, put together. The next day you sit down and say, "You know sometimes you don't listen to me and you hurt your knee," when the kid is repaired. That's the issue. You can't confront a patient with a painful truth unless you have an intact bond. Now you're taking the chance all the time. You know, maybe the bond is intact and you can do it. I think everybody seems to be struggling with that. I wonder, are we saying, "Are self-psychology and Gestalt so different, you know? I mean aren't we all sort of saying the same thing?"
YONTEF: Well, in that respect, not so different, but in terms of how you use the present moment and what you do with the therapist's phenomenology I think there are some significant differences in what we're saying. But there is some...we're saying some of the same things and some different things.
MAN: I think you have to ask, for instance, "What is the patient doing now, in the moment?" So that if the patient, for instance, is expressing tremendous affect and rage about having been abandoned, but in the process is abandoning the contact with the therapist, it might be important to point that out so that the patient can satisfy her need in the present and in doing that learn a new behavior.
A MAN: I would again totally agree with what you're saying. I'm having trouble seeing the divergences here but...
JACOBS: I want to bring up something which I think is very important about what Bernie said. The way you've got it framed, it's the patient who is abandoning the contact with the therapist.
MAN (CONTINUED): Or both.
JACOBS: Well, but you see, you made an assumption here about that if...you know, in this process she's going to be abandoning contact with me. That may be a reaction that she's having to my having abandoned contact with her, which may be a reaction to...I mean this is a field.
MAN (CONTINUED): I'm not making a statement about the patient. It's really hypothetical to point out the difference between focusing on the process in the moment, what's happening now versus the trading of interpretations which can produce an important -- I'm not trying to diminish the importance of the stability that can be produced by the type of derivative or interpretation that satisfies and supports me in the moment but begs the issue of the contacting function.
JACOBS: I don't think interpretation has to do that. It may have been missing in my transcript, but I don't think interpretation, by definition, bypasses work at the contact boundary.
YONTEF: When you interpret about the tape machine, you could have done other things that would have focused on the present moment in which you are there, and I would bet showing yourself nonverbally as very present -- my guess. And the patient was not responding to that and then you took her away back to the symbolic interpretation about the tape machine, so...
JACOBS: Right, that's where I missed.
YONTEF: Making the interpretation was part of how that happened, rather than...
A MAN: I did not read the paper but my impression from the discussion is that the depth of transference issues in this case are greater than I'm used to seeing in traditional Gestalt therapy, fostered, I imagine, by what I think has been called the intersubjective approach. I think Gary used that term. What I'm intrigued about...what I'm wondering about is if the therapist, as Gary had suggested, has maintained more of a...more genuine contact where the therapist was more present as a person rather than going into the experience of the patient, would all of this, all of these deep strivings be played out as much? Would they be felt? That's my question. You think so?
YONTEF: I think so. It's my experience.
JACOBS: Well, I can tell you from my own experience something about that. There's certain interventions I can make based on my own presence that can be impinging; sometimes making an "I" statement mistimed, for instance, can be quite an impingement. On the other hand, in my own experience, as a patient, if I can't feel my therapist's deeply engaged presence, I ain't coming out of hiding.
MAN (CONTINUED): No, I understand...deeply engaged presence, I have no argument with. It's a necessity. But if I see my therapist very much as a person with his own needs and what not, some of my deeper, more aggressive kinds of material, I might be reluctant to even share or be in contact with, because this seems inappropriate to my conscious...
YONTEF: It's how much you show, what you show, timing and dealing with the patient's reaction and realizing when something like that is going on and the therapist having the observation or intuition to be able to make that explicit so that becomes part of what's worked with. If the therapist doesn't have that sensitivity then nothing's going to work.
ALEXANDER: I would say the importance of the therapist elucidating that situation for you -- that would be your work. That would be the therapy, to go on in advance of anything else.
A MAN: I like the statement that you made at the very end that as long as the patient was motivated by a rage and need to get back at parents that of course their life was misdirected. I know some of the traditional Gestalt ways of working with those kinds of issues but I also wanted to hear anything that you might say in terms of what you would do or if there's anything else that's...that you would add about that, doing that work.
YONTEF: Yes, I'd add the difference between rage and straightforward anger, and with rage there are lot of...always something besides the angry component that needs to be made explicit or the rage never completes itself. Longings, shame, impotence, feelings of impotence that need to be made explicit. I also don't find it very useful with certain kinds of patients to go through a lot of expressive work even on the angry component. For example, with a borderline, this as an example, that just sort of automatically, going into expressing the angry function with rage in general, and certain kinds of patients in particular is not very useful.
MAN (CONTINUED): But exploring these things is.
A WOMAN: The case seems to me to be an example of how incredibly attuned the patient is to you and I think that she is expressing by discussing that hugging comment, the hugging situation in the beginning, that...how attuned she feels and there are a number of examples that I think Dr. Brickman brought up of little ways she's feeling a bit held off by you. And my guess about that is that there's that difficulty that comes up in being empathically attuned and being a self object to a patient that one feels quite close to that it gets mixed up with wanting to be completely there for her. And that that's not possible. And that there are those minute limitations and all kinds of little limitations where she isn't experiencing being completely hugged by you. And she couldn't. And that that is causing a great deal of rage again. And that that's so difficult. I think that this is coming because of the intimacy that you two have together and the fact that she has felt so completely hugged by you or whatever at a number of moments. But...and years. But that there are all these little ways where it's not happening and that I think when you said that there's an issue of countertransference, it seems to me that probably that's...that there's something there of not wanting to address each one of those little ways where you have to feel that you want to hold her off. And that maybe there's more rage...I'm not sure about this, but engendered by the fact that there are the extra sessions, there are the phone calls. So that...well, I guess it's always very difficult to understand where the boundaries are. Not just boundaries, but where the actual boundaries are between the two of you and what she can have and what she can't have. And probably...maybe this is just crass, but also when there's low fee and no fee and lots of phone calls, there has to be some ambivalence towards that on the part of the therapist. A little bit, you know, of that holding off feeling that does get expressed because it is an invasion. And I think that the patient also talks about that in a sense she's expressing that she feels let down by you as she is letting Katy down, but to me that is not a negative thing. I mean, that is something that does occur, that there are ways that she does get let down. And that it's just one of those turning points which I'm certain you've encountered a million times with her where then you have to address again all these little ways that you can't be there.
JACOBS: Point is well taken.
TROP: You know, I think those are really good points. Empathy is not...empathy is an investigatory stance. It's a stance of understanding it. It doesn't say that you have to be a perfect selfobject. I mean, it doesn't say anything about that. It just says that you investigate the patient's experience from their own vantage point. I don't know whether Lynne would feel comfortable talking about it, but do you...how do you feel about the phone calls, the no fee, low fee, because they're...you know, what you just said is that there has to be some ambivalence. I don't know that that's a truth. I mean, Lynne might not...I mean, for you, there would be. For me, phone calls are tantamount to, you know torture. But I don't know. I was going to ask Lynne. How do you feel? What is your experience of that and what role do you think it plays in your work with her?
JACOBS: My attitude about phone calls has changed over the years, which reflects in part some, what I consider healthy, changes I've made over the years, from defensively guarding my boundaries to a more...to more capacity to give and care about and for people in my life, which includes my patients. So, when this woman started with me, my attitude toward phone calls was, "what's wrong with you that you can't make it until the next session?". You know, obviously a defensive, "leave me alone" attitude. And now my feelings about the phone calls depend on what time of day or night they come, how lazy I am and what state of mind I, myself, am in. With her and with one other patient whom I see, the phone calls have become an integral part of the developmental process of the therapy and although at times I'm bothered by them, in the overall sense I feel...at one point I said to her when she picked up that I was...as Susan was saying, this patient is very attuned to my state of mind...when she picked up that I was tired and bothered by one of her phone calls, after we explored it for a while, what I came down to was saying, "That's true sometimes and it would be much better for you if I could be on top of myself enough to say that to you, that `let's only spend a few minutes, I'm worn out, I'm tired.' But I've got to say, the bother is worth it in the overall scheme of what we're doing in our treatment." So it isn't, I mean it is...my reactions are multifaceted to the phone calls. And a lower fee is only a problem in that she wants to come more often, she should come more often and I don't want her to come more often at that fee.
BRICKMAN: I would like to just, if I may, add something about that. I tend...I quite agree. My attitude toward phone calls is similar to the one that was just expressed by Lynne. I think if you're going to take phone calls though you have to have the freedom to express, to admit to yourself when you're not really in the mood for a phone call, when you can't really be there for the patient, and I think you have to be able to say that to the patient or else it can be disaster. And so I can recall many times where I've felt called upon to say to the patient, "I'm really not in a good place right now. I don't think this is a good time. Maybe it can wait until suchandsuch a time." I recall another time where a patient paged me while I was at a party and she was in a really terrible state and I had had too much to drink and I said to her, "You know, this is not a good time for me to talk to you because I've had too much to drink." And that opened up a whole other...like, you have a life? You drink?
YONTEF: You didn't keep the transference pure, huh?
BRICKMAN: So I really think you have to reserve that option, to say, I'm not here right now and I really can't talk to you.
A MAN: I'd like to thank you all. I appreciate what you're all doing, but I would like in the remaining time to hear the balance shift, the foreground and background shift away from the particular case and I would be more interested in you and us discussing the similarities and differences, where we can enrich each other and where we are validly different. To me we can enrich each other, certainly we as Gestalt therapists can be enriched by self-psychology and other psychoanalytic systems by informing our developmental theory, which is relatively sparse. And the discussion about developmental theory, the discussion about personality functioning, I think is very useful for us. I think on the other side, as a method of treatment, as a treatment methodology, we have some very big differences that have emerged in the panel. One of the big differences is that we're dialogically based therapy and when you only have the phenomenology of one of the participants a dialogue can't happen, that my interpretations cannot be a statement of my resence. They're a very narrow range of communication, important as they may be. They don't allow for my presence. And without my presence, in addition to your inclusion, there can't be any dialogue. We also have some real important emphasis on the difference between dealing with the whole field, for instance, dealing with this woman's life outside of the therapy and in this particular transcript, the relationship was almost exclusively to genetic material, not between the therapist and the patient, which would be the dialogue, and not between the patient and the rest of the world, which would be the field. So that the...what I would like to hear is some of the discussion on that at the treatment level, methods and philosophies of psychotherapy and get away from the particular case. Because we can go on with that, I think, forever. This is the other important part. Thank you.
BRICKMAN: Maybe I could comment on that. First of all, I think that Gestalt took a very important step in breaking away from mainstream psychoanalysis many, many years ago and insisting on the importance of the focus on phenomenology and really finding the very terse intellectualized, very dense, metapsychology of drive theory not the best avenue to approach understanding the human inner world in depth. And I believe, and I...interestingly enough I find myself feeling very much at home in this room in the sense that I'm talking with people who really are very much focused on the dialogue, the here and the now, and what's happening between the two of us at this moment. And mainstream psychoanalysis is still debating, very much, about the importance of dealing with transferential experiences in the here and now and not making interpretations about drives and defenses against drives as though they exist within an isolated self, having nothing whatsoever to do with what's transpiring between the therapist, the analyst and the patient. Merton Gill who is one of the, you might say the mainstream contributors to transference psychoanalytic theory has made a very strident point about the importance of focusing on the hereandnow experience between the analyst and the patient and so I personally feel that that's really where the wealth and the richness of all material lies in understanding the ebb and the flow of the patient's experience of themselves in the context of how they are feeling with the therapist and how they perceive the therapist and they give us tremendous information about how they are experiencing us in the dialogue and it's for us to really pick that out and understand how that impacts their ability to express themselves in the fullest dimension of themselves.
YONTEF: Would you also, then, include in that, the therapist's focusing on how the patient...focusing the patient on their process of self-interruption?
TROP: Could you elaborate a little more?
YONTEF: For example, the clients who start to have a feeling come up, squeezes themselves, changes the subject, intellectualizes, do something that interrupts the...that which is emerging in their awareness. Would you actually spend time looking at that process of their phenomenology?
BRICKMAN: Oh, absolutely. I think that the...Evelyn Scwabber has been one of our very powerful and productive creative contributors dealing with these very minor kinds of fluctuations in the flow of the patient's experience where there might be some minor changes in the tonal expression of the patient, interruptions as you mentioned where the pay dirt really lies in careful attention to what just occurred, what is transpiring within the patient at this particular moment. And with particular attention to how the environment is affecting their sense of freedom to go ahead with saying what they were about to say. They often are not aware that they just interrupted themselves because of a fear of being shamed or criticized or whatever it is, and until we focus our attention on that...on their inner experience, we're not going to find out.
YONTEF: Would it also include as part of what you're talking about for the therapist to express their own affect toward the patient?
TROP: My answer to that would...it would depend.
YONTEF: If appropriate and the timing is right, etc.
TROP: It would depend. Yes. I think it would depend on lots of things, but I don't think I could respond to that in a general sense.
YONTEF: Would you exclude it in a general sense?
BRICKMAN: No. No, and in fact, I think you can be very affectladen. I think the issue there is that there is not an adequate theory that delineates when to express it or not to express it. You know, I think the answer is if you can have some concept that expressing your affect will be developmentenhancing, then you do it. If it's...if you know that your affect is really from your reaction to somebody else's experiences says much more about you and your problems than it does about you, then you keep silent, but if you can have a view that it's going to enhance development, then it's essential...I mean the way I operate is I sort of keep a lid on my affect...because I sometimes worry about being inundated so I just keep low key, but again, I don't see the explicit difference, when you talk. I feel like Bernie. I have a real affinity for most of what you presented as criticisms. I didn't experience it as a criticism.
A MAN: Would not the patient see the lid on your affect?
TROP: Yes. I think patients do. They see our affect. They see the lid.
MAN (CONTINUED): What, then, are they seeing?
TROP: I don't know. You'd have to ask. Right? You'd say, "What are you seeing? What do you feel?"
MAN (CONTINUED): They'll say, "I see that you're holding back from me," won't they?
TROP: They might. They might.
MAN (CONTINUED): My point is you don't keep the silence. You're always expressing.
JACOBS: If it's an interest...that would become an interesting dialogical issue to be addressed, right? That Jeff might be putting a lid on his feelings and his motivation that he's conscious of might be to protect the patient from being impinged on. The patient may experience it as a withdrawal, relate it to a depriving therapist or some fear that the therapist is withdrawing out of repugnance, and they could work with that, presumably together.
MAN (CONTINUED): The structure of your agreement is that you are in a dialogic meeting together. And it seems to me impossible that you can put a structure, a lid, on your affect, which is not at the same time part of the interaction that's going on, which is the equal status interaction that is the platform of your therapy in the first place.
A WOMAN: But you do have to leave some moments for the patient to respond.
BRICKMAN: I'd like to just comment on this for a moment. I'm thinking of a person I've been working with for several years who stirs up on many occasions feelings of irritation, sometimes frank disgust, dislike, although those are by no means the only sorts of affects that I have had with this person which have also included affection, warmth, love, and so on. But much of our work has focused on his experience that I don't like him. And from time to time he'll say, "Well, you really don't, do you?" And I am absolutely convinced that it is worth keeping a lid on that because any time that I have ever confirmed some of his negative...his sense that I have some kind of negative subjective experience of him it has been devastating. It has never furthered the treatment and it has always been best to just let his perception be his perception without any specific confirmation on my part because it seemed that at those time where I was tempted to validate or confirm his experience at certain times, it turned out that he saw that feeling in me as the only feeling I have toward him and he was quite unable to see that I had also a gamut of very warm positive feelings as well. And it was devastating. So I think one has to be very careful about at what times one discloses affective experiences and sometimes it's much better to keep a lid on.
A MAN: I want to address that too, in a minute but first I want to appoint myself as spokesperson for the audience, since nobody else has done this directly, to thank you, Lynne, for putting yourself on the line this way. I appreciate it and I think we all...
JACOBS: Can I just say really quickly, I appreciate the care with which people are making their comments, by the way.
A MAN: And now in a slightly roundabout way I want to address what Richard just raised. I studied, was a client of, a friend of, in a peer group with Laura Perls for many, many years, and she said many, many things. The thing, the one statement she made that has stuck with me more than any other -- I don't know if this is true for her other students, trainees, friends, and so forth -- is this: Give as much support as necessary and as little as possible. And that's been my rule of thumb in working. But it wasn't enough. It was extremely helpful but not sufficient, and that's where self-psychology came in to help me. Because -- by the way, for those who haven't read self-psychology, the people on the panel perhaps might be able to offer some books to read. Mostly, I found Kohut himself impossible for me to get through except for one book called -- I think it's called, Why Does Psychoanalysis Cure?. But there are some other interpreters or translators that have been extremely helpful, plus I've had the good fortune to be in a peer supervision group in which one of the members is a self-psychologist. But what I got from self-psychology, without being seduced into becoming a self-psychologist, I remain a card carrying Gestalt therapist, is really something that Ronald said and maybe didn't reach too many people very clearly. When you talked about certain interventions might lead to -- I forget exactly how you put it...
ALEXANDER: Driving the patient's experience inside?
MAN (CONTINUED): No. It had to do with cohesiveness of the self.
ALEXANDER: Cohesion and fragmentation.
MAN (CONTINUED): Yeah, right. Cohesion and fragmentation. Which you can explain better than I. But what I got from self-psychology was the nuances of that statement, "Give as much support as necessary and as little as possible." And that has helped me in my interactions with the people that I work with as to trying to assess at this given moment, and at this given moment in the length and the depth of our therapy, will keeping the lid on...or put it another way, will expressing what's going on for me be fragmenting or not for this individual. If so, despite my strain, perhaps, my discomfort, even my ideological problem with it, it's better to keep the lid on, is what I believe. Now...so in that sense, I may disagree with Gary, but...and Richard. But I also wonder in this particular case, with this individual, probably only you, Lynne, know whether...I mean, we can easily and facilely say, "Well, ten years. I mean, after all, in ten years this person should have reached the place where she can deal with this kind of stuff." But I don't know that that's necessarily true. Ten years or maybe her whole lifetime. And maybe she'll be with you for the next, you know, twenty or thirty years and you still may...
JACOBS: Good thing I like her...
YONTEF: Lynne, have you planned what you're going to do with her after you retire?
MAN (CONTINUED): Well, I think all of us -- not all of us but some of us have clients like that that are with us for the duration and are never going to be able to move beyond a certain point. And that's the way it is and it's incumbent upon us not to have too many of them at the same time. One or two. So those are my thoughts about this whole thing. I think it's very useful to integrate or at least to look at how the two therapies kind of dovetail. I'm sure there are many other points where they part company, but in this particular area that's how self-psychology has been very helpful for me and also this discussion.
ALEXANDER: Thank you. We have to finish up at this point because of the arrangement with the hotel so I'd like to once again thank all the panelists, especially Lynne Jacobs, for her case and her openness and of everyone in the audience for the lively and exciting and stimulating discussion.
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