Panel II:
The Forward Edge of Theory:
Self Psychology and Relational Responses to a Clinical Case

This panel, introduced and moderated by Christine Kieffer, Ph.D., featured a compelling presentation of a challenging clinical case by Lynne Jacobs, Ph.D., Psy.D., with stimulating discussions by Richard Geist, Ed.D., and Joyce Slochower, Ph.D.

In her case presentation, Dr. Jacobs described her work with Pedro, a single, gay man in his 30's. Dr. Jacobs stated that Pedro "believed that our enterprise was his last chance to live without an empty hole at his center. He also believed that the means whereby his growth would occur was if he could 'be himself,' fully and unselfconsciously in my presence." She added that "he was adamant that he needed a therapist whose subjectivity could be engaged and ...be revealed in our dialogue."

Dr. Jacobs described her feelings of tension in early sessions with Pedro. Pedro often began sessions in the first few years of analysis by letting her know that the continuation of treatment rested on whether or not Dr. Jacobs could "say the right thing" in the current session. He described himself as having a "tiny bull's eye" inside him and it was imperative that Dr. Jacobs be able to hit it. Interestingly, however, Pedro and Dr. Jacobs came to understand that "hitting it" meant responding with her most authentic truth as best she knew it. Dr. Jacobs's sharing of her reactions, together with her welcoming their mutual exploration of her subjectivity, especially her experience of their relationship, "enabled him to question deeply held beliefs that he was doomed to intractable isolation because he did not fit in among humans."

One of the "fields of play" for their reciprocal discovery process was in the area of Dr. Jacobs' limits and how they lived with them. Dr. Jacobs' examples revealed instances in which Pedro made requests for concrete accommodations which Dr. Jacobs could not make. In each instance, however, Dr. Jacobs and Pedro together were able to discuss the resulting impasse and find the needed understanding that had given rise to the request. As Dr. Jacobs put it, Pedro had presented a concrete demand and Dr. Jacobs had reacted anxiously to the concreteness, rather than to the metaphoric dimension of the request. She stated, "It turned out that Pedro was quite able to work with the request on a metaphoric level, as long as he also experienced me as taking the concrete dimension seriously. Also, it appears that Pedro's request 'escalated' into a concrete demand for action as a reaction to his belief that he was not being well understood in the first place."

Dr. Jacobs described a suicidal crisis that arose in the third year of their work together. After a number of sessions had passed in almost total silence, with Pedro talking about feeling empty and like "nothing" inside, Pedro announced that he realized he did not fit in the world and that he was free to leave the world. He felt that deciding he was free to commit suicide was a rare experience of making an authentic choice.

Dr. Jacobs initially responded by quietly affirming the excitement and sense of vitality Pedro felt at being free to determine the course of his life. Over the course of the next number of sessions Pedro became increasingly serious about his plan to kill himself. When Dr. Jacobs began to discuss with him her discomfort with his intentions, he burst into tears, asserted that he did not want to do any more exploring, saying "One explores when one has hope!" He then insisted that the only thing that could heal him would be if Dr. Jacobs could be his mother and she could not be his mother.

Pedro then called to cancel further sessions. Dr. Jacobs sought consultation with a trusted colleague. The colleague pointed out that Dr. Jacobs could not collude with Pedro's belief that there was no symbolic "mothering" available from Dr. Jacobs. The colleague suggested that Dr. Jacobs should refuse to stand aside and let Pedro die and should ask him what a mother would do in such a situation. When Dr. Jacobs called Pedro, using the perspective gained from the consultation, Pedro softened and agreed to come back for a session to talk further about her perspective. As they began to speak about all that had transpired and the meanings engaged, Pedro re-engaged with Dr. Jacobs and with life.

In discussing Dr. Jacobs' work with Pedro, Dr. Geist remarked on aspects of the case presentation that highlighted differences between a self psychological and a Relational approach. The first difference he articulated was that a self psychological approach places a greater emphasis on health, as exemplified in the concepts of forward edge strivings and selfobject transferences, rather than pathology, while a Relational approach, he asserted, tends to focus on understanding and reshaping pathological relational configurations.

A second difference proposed by Dr. Geist was the way a client like Pedro's need for absolute control over the therapist's responses is understood. He stated, "For self psychology, the attempt to have absolute control over one's therapist represents a life or death struggle to force selfobject responsiveness that restores self cohesiveness or repairs a structural deficit, particularly when the patient anticipates or experiences a sense of being misunderstood." "For many Relationalists," Dr. Geist added, "this attempt at absolute control represents a power struggle, which is used clinically to demonstrate to the patient the pathological impact of his behavior on the therapist and others in his real world. For Relational theorists, the need to highlight interpersonal patterns takes precedence over the understanding and acknowledgement of emerging developmental needs and subjectively experienced injuries when the patient feels misunderstood."

A third difference focused on the analyst's sharing of his or her own subjectivity. Dr. Geist suggested that Relational theorists emphasize alterity in the concept of subjectivity and locate therapeutic value and progress in recognizing otherness, while self psychologists hold the idea that the analyst's subjectivity is felt more as a presence within the patient's self (and vice versa) and that therapeutic progress is endemic to the internalization of selfobject function, which eventually allows the spontaneous recognition of otherness.

In focusing on the issue of Pedro's concrete demands and the need for limit setting, Dr. Geist highlighted another area of difference. He asserted that self psychology emphasizes the importance of selfobject connectedness and the empathic understanding inherent in that connectedness that replaces limit setting as a therapeutic modality. For Relational theorists, he added, negotiating conflicting needs between analyst and patient takes precedence over empathic understanding. He describes this as a clinical difference in how empathy is used, adding that self psychology is much less interested in the therapeutic use of enactments as a driving force in treatment and more focused on the disruption repair process. A corollary to the difference between empathic negotiating and empathic immersion is the privileging of authenticity versus empathy. For self psychologist, he stated, empathy guides the use of the analyst's subjectivity.

In her discussion of Dr. Jacobs case presentation, Dr. Slochower focused on the way Dr. Jacobs' and Pedro's work together raised questions about the nature of the analyst's subjectivity and the relationship between holding and mutuality in therapeutic progress. In her view there is "an intrinsic tension, indeed a collision, between the clinical theory underlying analytic holding and that oriented toward intersubjective engagement." Holding, she said, relies on the analyst's capacity to contain her own affect state while remaining closely attuned to that of the patient. In contrast, intersubjective work is predicated on the assumption that our "otherness" will not derail. Dr. Slochower argues for the importance of the holding metaphor as one analytic thread. The holding frame, she states, establishes a temporary illusion of attunement, an illusion that is co-constructed and maintained. In describing Pedro's seemingly contradictory demands--that Dr. Jacobs function as a selfobject but also be disclosing of her authentic truth--Dr. Slochower suggests that Pedro's explicit insistence on knowing Dr. Jacobs' subjectivity may actually be "code for an underlying longing for acceptance" and an antidote to his fear of abandonment thereby fortifying a sense of holding. She additionally comments on the fact that it was Dr. Jacobs' emphatic separateness in the matter of Pedro's suicide plan that restored a sense of safety and holding between them.

This was an extremely rich and engaging panel, which stimulated a high degree of interest and participation in the discussion which followed it.