2005 Presidential Keynote Address
The Analyst's Participation in Co-Creating
the Analytic Relationship:
Implicit and Explicit Dimensions of Analytic Change
by James L. Fosshage, Ph.D.
My task this evening, as I see it, is to highlight and contribute to the theoretical context for our deliberations over the next several days. To do so, I thought, I must take a bird's eye perspective, or perhaps a more contemporary image is a Good Year Blimp perspective, to provide a schematic overview. And after all, look at the vast terrain that we will cover at this conference: transference, relationship/enactment, and dramatic and spontaneous moments in creating clinical momentum toward analytic change. An overview helps to keep us oriented; yet, it can be frustrating because so many of the intricate details must be left out, so many of the salient questions must remain unaddressed. Well, in my inner dialogue, what if on occasion I dive down or zoom in for a closer look, homing in on some of those issues that entice me and, hopefully, will entice you, and then to bound skyward again for a more aerial view.
So, in light of my conclusion on how to contribute to our theoretical context, I first will delineate, ever so schematically, the revolutionary paradigm changes that have been taking place in psychoanalysis over the past twenty-five years, the new model of transference with implications for the concept of enactment, and the implicit and explicit dimensions of analytic work, leading to what, in my view, is the conceptualization of two fundamental pathways to analytic change. I will then conclude with a focus on the radical ongoing extension of the analyst's participation, using, as an example, the co-creation of analytic love and providing several brief clinical illustrations. The leading edge question guiding my discussion is, "How does analytic change occur?" So let us begin.
Throughout the history of psychoanalysis a running battle has been waged between interpretation/insight and relational experience as focal points for therapeutic action (Fosshage, 2005). Interpretation/insight gained its preferential momentum in the first two-thirds of the twentieth century from the positivistic science and objectivism of the day that positioned the analyst to become the purveyor of objective "truth," truth, it was thought, that the patient's ego would know how to use to bring about needed psychological change. The subsequent ongoing transition in paradigms from positivistic to relativistic science and, for some to hermeneutics, from objectivism to constructivism, catalyzed by Heisenberg's Uncertainty Principle, dethroned the analyst from a protected, elevated position of objectivity and boldly confronted the analyst with an increasing recognition not only of the influence of the analyst's subjectivity in constructing interpretations but also of the analyst's participation in co-creating the analytic relationship.
This epistemological transition, in turn, catalyzed a second paradigm shift from intrapsychic theory to relational, intersubjective, or systems field theory. Relational field theory posits that psychological development, transference, and the analytic relationship are not primarily intrapsychically generated, but emerge within and are shaped by relational systems. Absenting the analyst's objectivity and revealing the analyst's participation implicates relational experience to be the crucible of therapeutic action. I (Fosshage, 2005) recently wrote, "So important is the relational interaction that exploratory/interpretive analytic work is best subsumed as one, and only one, aspect of analytic relational experience that itself can only be understood within the context of that experience" (p. 517). A systems or relational field perspective reveals the participation of the analyst and the analyst's subjectivity more fully in the analytic relationship "than," to paraphrase Shakespeare's Hamlet, "our philosophies ever dreamt possible."
A central analytic task from a constructivist/systems perspective is for the analyst and patient to understand as best as they can through a collaborative "spirit of inquiry" (Lichtenberg, Lachmann and Fosshage, 2002) "Who's contributing what?" to the patient's experience and to the analyst's experience in the analytic interaction. The empathic listening/experiencing perspective, formulated out of an emergent constructivist sensibility (first by Kohut and meaningfully elaborated by Evelyn Schwaber whom we are fortunate to have participating at our conference), is, especially for self psychologists and Schwaber, primary in analytic exploration and reflects the asymmetrical focus on the patient in analytic inquiry. Yet, it, in my view, is precisely because of the complexity of the patient and analyst variable contributions to the relational interaction and the need to participate in different forms of relating that requires us to use other listening/experiencing perspectives, what I call the other-centered and the analyst's self perspectives. The other-centered perspective refers to the analyst's experience of the analysand as "an other" in a relationship with the patient-what it feels like to be the other person (Fosshage, 1995). Information garnered from this perspective potentially informs us about how the analysand impacts others, about the analysand's implicit patterns of relating, and about how the analysand is expansively establishing new ways of relating. While the empathic and other-centered perspectives are focused on the patient, other occasions require the analyst to be reflective about his own subjective experience from his personal perspective, what I have termed, the analyst's self perspective (Fosshage, 2003). When, for example, the analysand focuses on the analyst's subjectivity or the analyst's reactions to the analysand, the analyst needs to reflect on and assess his subjective experience from his self perspective and, on occasion, to share directly his subjective experience to facilitate exploration of who's contributing what to the analysand's experience as well as to deepen the relational encounter. During moments of intersubjective relatedness, as Jessica Benjamin (whom we are fortunate to have participating in this conference) has so well delineated, juxtaposition of the subjective experience of each can highlight differences and similarities between two subjectivities that can be growth promoting. Countertransference, what, in my view, is more accurately referred to as "the analyst's experience of the patient," may oscillate between any one and several of these listening/experiencing perspectives.
While understanding a patient and a patient's experience is a central analytic task, I remind you that, from the vantage point of relational field theory, this exploratory process is only one, albeit crucially important, aspect of analytic relational experience. Other dimensions of analytic relating will be delineated.
Transference is one of the pivotal, yet most controversial and changing, concepts in psychoanalysis today. The conceptual change emanates in large measure from the paradigm transitions from objectivism to constructivism and from intrapsychic to relational field theory.
Freud's model of transference refers to the transfer or displacement of feelings, wishes and attitudes related to infantile objects on to later objects, especially on to the analyst (Loewald, 1960). If transference emanates from the patient and "distorts" the patient's perception of the analyst, then it follows clinically that the maintenance of anonymity, neutrality and a blank screen best positions the analyst to avoid muddying the waters and to reflect back the analysand's displacements and projections-an elegant intrapsychic model.
The emergent model of transference, what I call the organization model and Hoffman terms the constructivist model, centers on the on-going perceptual-cognitive-affective organization of our lives. A number of psychoanalysts (Wachtel, 1980; Gill, 1982; Hoffman, 1983; Stolorow and Lachmann, 1984/85, Fosshage, 1994; Lichtenberg, Lachmann and Fosshage, 1996), integrating cognitive psychology, have focused on the formation of the predominant ways in which we have come to see ourselves and ourselves in relation to others. What has become central are these affect-laden thematic organizing processes, emergent from lived experience, that variably shape our experience through the use of four affective/cognitive processes: (1) expectancies, (2) selective attention, (3) attribution of meaning, and (4) interpersonal construction (Fosshage, 1994). Transference now refers "to the primary organizing patterns or schemas with which the analysand constructs and assimilates his or her experience of the analytic relationship" (Fosshage, 1994, p. 271).
Many, if not most, contemporary psychoanalytic authors within the various relational approaches are in the process of transitioning into this new model of transference, ferreting out its implications. All relational analysts, using the term broadly, note and work with the patient's repetitive organizations or constructions (Stolorow/Lachmann, 1984/85). A patient's problematic expectancies (Lichtenberg, Lachmann, and Fosshage, 1996), established on the basis of past experience, tend to pull analyst and patient into repetitive vortexes of interaction-what I call repetitive enactments. To explore and understand the meanings of the repetitive interaction serves to extricate patient and analyst from its grips and implicitly creates new experience. Some American Relational authors, Bromberg (1998) for example, believe that new experience only emerges through the analysis of repetitive enactments.
In self psychology a second selfobject dimension or class of transferences, however, is identified referring to a patient's seeking needed selfobject experience. Kohut's motivational model of developmental strivings has created a self psychological sensibility to attend to what a patient is striving for, what Kohut (Miller, 1985) and Marion Tolpin (2002) call the "leading edge." (You will hear the leading edge interventions in Marion Tolpin's clinical presentation tomorrow.) Lichtenberg (1989), in turn, has delineated 5 motivational arenas in which a person strives to grow. Thus, an analyst experiences a second type of interactive pull, the selfobject pull, that involves a patient's hoped-for expectancies to create with the analyst needed growth-promoting, vitalizing experience-what I call a vitalizing enactment. Not only must an analyst hear and understand what a patient is developmentally seeking, but an analyst also must be sufficiently available to participate in co-creating the needed vitalizing experience (what Kohut in 1977 called empathic responsiveness). While other relational psychoanalysts outside of self psychology have increasingly delineated the "new beginning" (Balint, 1968) and the curative impact of new relational experience, their emphases in addressing analytic change has tilted toward the exploratory extrication from repetitive enactments. In my view, the difference in emphases between contemporary self psychologists and other contemporary relational analysts is squarely anchored in motivational theory. Self psychologists, as the Jungians, emphasize strivings to grow, to develop, to actualize. Other relational analysts tend not to address motivational theory in keeping with the postmodern antipathy to the consideration of human "essences." As for all analysts, however, motivational assumptions are implicitly operative in their work and tend to coalesce around attachment strivings. Ghent (1990), an exception in addressing motivation, initially in 1990 posited a "central object-seeking motivation" (p. 110), but subsequently in a paper published posthumously posited two fundamental motivations, one for safety and the other for expansion (2002, p.799), the latter corresponding more closely with the self psychological view.
The analyst, thus, variably experiences two types of interactive pull from the patient: to engage with the patient in constructing familiar repetitive problematic interactions and to engage with the patient in creating the hoped-for, vitalizing experiences. The term enactment, thus, must be expanded to include the repetitive as well as the growth-promoting vitalizing experiences.
Identification of what a patient is striving for, in my view, is one of the most significant clinical contributions of self psychology. To highlight the leading edge of the material, implicitly allying with the patient's strivings, facilitates psychological growth and the therapeutic process. In essence, we need to analyze the repetitive pull while at the same time be sufficiently available and responsive to the selfobject pull to enable patient and analyst to co-create needed vitalizing experience-two pathways to analytic change.
Among a number of centrally important clinical implications of the organization model of transference are issues related to ubiquity of transferential focus and transference/extratransference. Traditional clinical notions that all transferences must be brought into the analytic relationship and that clinical material must be understood as referring directly or indirectly to the transference are based on assumptions from the intrapsychic model of transference and potentially create a noxiously dominating analyst-centric climate. Within the organizing or constructivist model of transference, it is understood that patient and analyst variably co-contribute to the patient's experience of the analytic relationship. To assume and expect that all transferential themes will emerge in the analytic relationship negates the analyst's contribution. Each analyst will affect the transference differently. It is quite possible that a particular analyst might not directly elicit all of a patient's primary problematic organizing patterns, or will not become as embroiled in some of the repetitive pulls. Some of the repetitive themes might be more powerfully addressed in so-called extratransferential relationships. Even more important, to assume that extraanalytic material refers directly to the analytic relationship can easily blur differential experiences and inadvertently rivet the patient to the particular activated transferential themes. If transference is defined, as Gill (1982) did, as the patient's experience of the analytic relationship, then all of a patient's communications within the analytic setting by definition have transferential meaning. To solve this conundrum, I (1994) have proposed that "the meaning…may not be related to the content but to the process of communicating" (p.276). For example, when a patient is describing a shame-ridden abusive experience, most likely the patient is not experiencing the analyst as abusive at that moment, that is, interpreting the content as applicable to the transference, but is experiencing the analyst as sufficiently safe and protective to be able to communicate the painful experience, that is, interpreting the process of communicating as having the transferential meaning.
To continue to use the term, transference, provides continuity in our field; yet, it does not capture the organization or constructivist model. While organizing patterns are established on the basis of past experience, they are not transferred, but remain as active, ongoing perceptual/organizing process. In addition, the core process of organizing activity in the new model precludes a categorical distinction between transference and non-transference for both involve organizing processing. Organizing activity, instead, varies along a number of dimensions-for example, frequency of activation, accessibility to consciousness, and devitalizing to vitalizing. The term, transference, as a categorical distinction, tends to connote perceptual distortion that, in turn, invalidates a patient's perception and closes off inquiry. Identifying organizing patterns opens up the process to find and explore the cues attended to and the attribution of meanings. The cues attended to implicates the analyst's participation. The analyst's acknowledgement provides implicit validation that, in turn, lowers a patient's aversiveness and opens up more reflective space for assessing the patient's and analyst's various contributions.
Implicit and Explicit Domains of Learning, Memory and Knowledge
Most cognitive science models differentiate between two, at times three, memory systems.(Epstein, 1994). I will focus on those models that differentiate between two domains of learning and memory-implicit/nondeclarative and explicit/declarative. These memory systems differ in type of information processed, principles of operation, and neurological structures, and, yet, often more than one system in involved in performing particular tasks (Schacter and Tulving, 1994). Whereas the explicit/declarative memory system involves the processing of information that an individual can consciously recall and "declare to remember" (Davis, 2001, p. 451), the implicit/non-declarative memory system involves the processing of information typically outside an individual's awareness, does not require focal attention for encoding, and, therefore, is less accessible to conscious recall. The implicit/non-declarative system includes several memory systems one of which is called procedural memory. While explorations of implicit procedural memory was first applied to behavioral sequences-for example, riding a bike, playing tennis-beginning in the early 1990's, applicability of the implicit memory system was extended to include social learning, specifically to learned patterns of relating (Clyman, 1991; Grigsby and Hartlaub, 1994). As you well know, Dan Stern (whom we are privileged to have this evening) and his Boston Change Process Study Group have been contributing substantially to our understanding of how these memory systems operate and change within analysis, making "implicit relational knowing" a household term in our field.
A person's senses of self and others are derived from past, present, and anticipated future lived experience, with past experience "housed," if you will, within the implicit and explicit memory systems (Fosshage, 2005). Implicit mental models affect explicit memory, and explicit memory cues evoke implicit memories. The concept ‘implicit mental models,' emerging out of experimental research in cognitive psychology, converges with the neuroscience concept of neural memory networks or maps (Fosshage, 2005). With the integration of cognitive psychology into psychoanalysis, it is not surprising that these concepts resonate closely with a number of psychoanalytic terms-for example, internal working models (Bowlby, 1973), principles or patterns of organization (Wachtel, 1980; Stolorow and Lachmann, 1984/85; Fosshage, 1994; Sander, 1997), pathogenic beliefs (Weiss and Sampson, 1986); mental representations (Fonagy, 1993); expectancies (Lichtenberg, Lachmann, and Fosshage, 1996), and, now, implicit relational knowing (Stern et al, 1998).
While the "implicit and explicit dance" (Fosshage, 2004) in the psychoanalytic arena is extremely complex and far from clear, we know that implicit procedural learning occurs through relational processes often out of awareness and explicit/declarative learning occurs through the more traditional psychoanalytic emphasis on exploration and expanded awareness. Our understanding of implicit procedural learning and memory highlights the fundamental importance of ongoing relational experience within the psychoanalytic encounter, much of which never sees the light of day in terms of explicit analytic focus. The fact that new procedures of relating are learned in the analytic relationship and are central to therapeutic change implicates the magnitude of the analyst's participation and the importance of the analyst's explicit and implicit procedural relational knowing and capacity for intimacy.
The current cutting edge focus is on assessing how implicit and explicit processing and memory are interconnected (I refer you to a paper by Stern, et al, 1998, in the International Journal of Psychoanalysis; to Lyons-Ruth, 1999, in Psychoanalytic Inquiry; to a recent paper by the Boston Change Process Study Group, 2005, in JAPA; and to a paper of my own-my self marketing for the evening-that just appeared in the last issue of Psychoanalytic Inquiry). An issue pivotal for the consideration of therapeutic action centers on the potential accessibility of implicit learning to consciousness. Implicit relational knowing that is not accessible to consciousness can only be changed through new implicit relational learning that either gradually transforms previous implicit knowing or establishes new implicit mental models that become more dominant to offset earlier established models. Stern, Lyons-Ruth and their colleagues have focused on and are delineating this avenue of change. New implicit relational learning corresponds with Loewald's (1960) emphasis on new object experience and Kohut's (1984) noting that ongoing selfobject experience creates change.
Clinical evidence suggests, however, that implicit procedural knowledge varies with regard to access to consciousness. Implicit procedural learning that, for example, begins with an explicit/declarative focus, gradually established as procedural memory appears to be more available to consciousness in spite of the fact that it functions at a nonconscious level of awareness. Exploratory/interpretive focus on this type of implicit procedure, for example, a negative self percept, can contribute to its suspension or deactivation, facilitating the establishment of a new self percept based on new implicit and explicit relational experience.
To summarize, two basic change processes involving implicit procedures and explicit attitudes, in my view, occur in the psychoanalytic encounter. In some instances implicit relational procedures never see "the light of day" (that is, conscious awareness is never brought about through an exploratory process) and are gradually altered, by accommodation or diminished activation, through repetitive new implicit relational experience. In contrast, when implicit mental models are potentially accessible to consciousness, the "spirit of inquiry" (Lichtenberg, Lachmann, and Fosshage, 2002) illuminates both the autobiographical scenarios of the explicit memory system and the mental models of the implicit memory system that contribute to a sense of self and self- with-other. This process, explicitly and implicitly, over time increases reflective capacity that enables a patient to deactivate or suspend the older implicit and explicit organizing patterns, so that new implicit and explicit models based on current relational experience can be gradually established in both memory systems for lasting change. The foreground and background shifts that comprise the dance between the implicit and explicit systems provide an important key to understanding and facilitating the psychoanalytic process (Fosshage, 2005).
The Analyst's Participation
Contemporary analysts of the various relational approaches have been expanding the view of the analyst's participation to include the complex subjectivities of both participants and to expand the range of the analyst's participation.
Bacal's (1985, 1998) "optimal responsiveness," Bacal's and Herzog's (2003) "the specificity of selfobject experience in therapeutic relatedness," Orange's (1995) "emotional understanding," Lazar's (1998) "necessary facilitating enactments," Lichtenberg, Lachmann, and Fosshage's (1996) "disciplined spontaneous engagements," Shane, Shane, and Gales' (1998) "self-transforming" and "interpersonal-sharing" dimensions of relatedness and analysts' expressiveness; Slavin and Kriegman's (1998) description of the need for the analyst to change, and my own (1995b, 1997) use of the "analyst's experience of the patient" (countertransference) and "facilitating responsiveness" are among contemporary self psychologists' attempts to expand our conceptualization of the complexity of the analytic interaction and the analyst's participation.
Contemporary interpersonalists and American Relationists have contributed substantially to expanding the expression and revelation of the analyst's subjectivity in the analytic encounter. Ehrenberg (1992), an interpersonalist, describes "the intimate edge" of the analytic encounter. Amongst the Relationists, Renik (1998) describes the new position of the analyst as "getting real." Aron (1996) invites an analysand to be curious about the analyst's subjectivity. Benjamin (1988, 1990) promotes the expression of the analyst's subjectivity, for recognition of a subjectivity different and separate from one's own can be growth promoting. Hoffman (1994) speaks of those moments when the analyst "throws the book away" and responds in a highly personal way.
In the expansion of the analyst's participation we recognize that anything we do verbally or nonverbally, consciously or unconsciously, is a communication and reveals something about us. We now struggle about what consciously to self-disclose, what to communicate in an effort to facilitate an analysand's development (Bacal, 1998; Lichtenberg, Lachman, and Fosshage, 2002). As an example of this expansion and as a final topic I now turn briefly to the issue of love in the analytic relationship.
To Love and To Be Loved
To love and to be loved is central in developing and maintaining vitalizing self-experience. To love and to feel love involves a deep empathic knowing, liking, respect for, and caring. With various shadings, nuances and emotional valences love experience ranges from parental love, to caregiver's love, to friendship love, to romantic love.
The Analysand's Love of the Analyst
From the beginning psychoanalysts have attempted to unravel the nature of the analysand's love of the analyst. Whereas Freud (1915) thought that the analysand's transference love was anchored in perceptions and feelings of the previous caretakers, he then added that this is true in "every state of being in love" (p. 168), diminishing the difference and the possibility of distinguishing between mature, healthy love and neurotic, transference-based love.
If to give and receive love is central to development and maintenance of vitality, then its emergence in the analytic relationship is not surprising and needs to be welcomed and understood. Loving experience in the analytic relationship always has its forbearers and our task is to illuminate for the purpose of gaining freedom those implicit and explicit patterns that constrict and encumber the vitalizing experience of loving.
The Analyst's Participation in Mutual Expressions of Love
Beginning with Freud and Ferenczi, a battle has been waged between those who have been wary about and those who have emphasized the analyst's love for the patient as central to therapeutic action (Shaw, 2003). Even more controversial has been the analyst's expression of love for the patient with understandable concerns about seduction and exploitation of the patient for the analyst's needs. Loewald (1960), however, spoke eloquently in likening the analyst's position to a parental role in that the parent out of "love and respect for the individual and for individual development" (p.229) helps to foster the child's growth.
As for any analytic participation, whether expressive or silent, dangers exist. In mutual expression of giving and receiving love, the dangers, in my view, are essentially twofold in nature: 1) the analyst's needs for love take priority over the patient's welfare; and 2) the analyst is unavailable to co-create the developmentally needed loving experiences. Let me share some of my personal experience as an analyst in the clinical situation.
While my natural inclination as a psychoanalyst has been to participate more fully, to be more open, and to be less anonymous than the classical model and my classical training would have had it, I, nevertheless, have struggled over the years to extricate myself further from what I consider to be constricting remnants of my training. This was certainly true in the late 1980's when I became increasingly frustrated in finding a way to respond to patients who, during especially mutually touching and poignant moments, would genuinely express, "I love you." To accept a patient's feelings with simply a note of acknowledgement felt, to me, to be an unsatisfactory, non-participatory, and non-facilitating response. To remain interpretively focused asymmetrically on the patient and the patient's capacity to love likewise extricated me from the interaction, diminishing the importance and emotional potency of the relational experience for both the patient and myself. To use different, less revealing, less intense, less risky words, like "fondness" or "liking," on these occasions, to convey how I felt toward the patient, even though I experienced love for the patient, did not feel authentic or reciprocal, and felt undermining of the mutuality of the moment. I remember the day in 1990 when at the end of a deeply emotionally touching session, my patient at the door said genuinely, "I love you." Feeling strongly the same toward her, I responded simply, "I love you too." I closed the door and the traditional analytic models came crashing down in my head. I thought to myself, "What have I done now? Was I seductive? Was I sexualizing the relationship? Did I lose my analytic position?" I consoled myself, noting that it was a mutually genuine exchange, a moment of mutual love that, in this instance, did not feel particularly erotic, an experience, I felt, that would be especially helpful for this patient to build new percepts of her self and self with other. For the patient it so happened that this moment became one nodal experience of loving and feeling loved, thus, validating its importance and making it transformative for me as well.
From today's perspective, might our exchange be viewed as a poignant "moment of meeting" (Stern, et. al., 1998)? In this moment two human beings emotionally touch one another and, in this instance, express their love and caring for one another-not expected as part of the traditional analytic role, but now potentially legitimized by contemporary psychoanalysis through the increased recognition of the importance of relational experience and implicit procedural learning in analytic work.
Multiple variables, of course, enter into the consideration of the analyst's reciprocating expressions of love-including ages, genders, sexual orientations, emotional moment, and the many meanings and comfort level that expressions of love can have for each member of the dyad. Crucially important in these mutual encounters is that the analyst is authentic (Frank, 1999), that is, the analyst is in touch with and speaking on the basis of their affective experience.
A question that usually comes to the fore quickly in discussions of this topic is, "What if the analyst is not feeling love even though the patient has expressed his or her love?" In my view, if an analyst does not feel reciprocal love on these occasions, then he or she, of course, cannot express it and remain authentically engaged, centrally important in analytic interaction.
I will close with a brief clinical vignette. Some time ago a person began analytic treatment with me saying that she had heard me speak, liked it and had followed my presentations for the last 12 years. She had found herself on occasion even getting angry with me during those 12 years for my not greeting her and, finally, realized that I did not know her. When she told me that she had had a relationship with me for the past 12 years, I responded, "I am sorry that I had missed out." After 3 months of analytic work, she caught me totally by surprise when at the door she said, "You know, Jim, I love you." I spontaneously threw my arms up in surprise and exclaimed, "What so fast?" I could not believe that she loved me so quickly. But then it came to me and I added, "Oh you have 12 years on me. I need a little time to catch up." Each of us had been "true" to ourselves. This experience set the stage so that the patient could more readily believe me down the line when I one day was able to reciprocate and tell her that I loved her.
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