[This material - three chapters of a book in preparation - has been sent by Paul Wachtel as background for the discussion of his paper presented on June 12, 2004, at the Annual Meeting of the Rapaport-Klein Study Group] Go to: Chapter 1, Chapter 2, Chapter 3
The extraordinary growth of the relational movement in psychoanalysis in recent years has been paralleled by a larger turn to relational thinking in the entire field of psychotherapy. In almost all branches of psychotherapy, there has been an increased appreciation of the ways in which human behavior must be understood in its social, cultural, familial, and interpersonal context and of the powerful role of the therapeutic relationship in promoting (or inhibiting) psychological change. Human beings exist in relationships, whether those relationships be to other people with whom they have ongoing interactions, to imagos of past important figures, to cultural traditions, values, and identifications, or to images and experiences of one’s own past, present, and future self. In his seminal articulation of an emerging relational synthesis in psychoanalytic thought, Stephen Mitchell (1988) argued that a commonality can be found in a number of seemingly different theoretical models which all draw on a common vision that departs significantly from Freud's: "We are portrayed not as a conglomerate of physically based urges, but as being shaped by and inevitably embedded within a matrix of relationships with other people, struggling both to maintain our ties to others and to differentiate ourselves from them. In this vision the basic unit of study is not the individual as a separate entity whose desires clash with an external reality, but an interactional field within which the individual arises and struggles to make contact and to articulate himself. Desire is experienced always in the context of relatedness, and it is that context which defines its meaning. Mind is composed of relational configurations. The person is comprehensible only within this tapestry of relationships, past and present." (Mitchell, 1988, p. 3, italics in original) Notice here that Mitchell refers not only to a relational matrix and an interactional field but to desire and to the individual struggling to articulate himself. In other words, this conceptualization does not pit the interactional field against the distinctive desires and struggles toward self-definition of individuals, but rather points to the former as the context within which the latter evolves. Each is part and parcel of the other. They are not alternative - or even complementary - perspectives; they are intertwined, mutually interpenetrating dimensions of a single living reality. Human experience bursts its bounds, so to speak, requiring us to look now in one direction, now in another, but not to view any one of those directions as holding the single "real" answer.{c} Mitchell’s account converges in many ways with the point of view I am describing in this book. As I have noted in the Preface, our work proceeded for many years in parallel, pursuing somewhat similar visions and motivated by a somewhat similar integrative intent. For both of us, the aim was to explore apparent differences for potential convergences among competing theories and practices but also to clarify where real differences or incompatibilities existed {could be found}. The goal was to redraw the boundaries between approaches in a way that addressed deeper similarities and differences and transcended divisions that were mostly either historical accidents or the result of political or sociological aggregations rather than intrinsic or fundamental [intellectual differences]. In this book, I will attempt to articulate a way of thinking and practicing relationally that has been inspired to a very great extent by the work of Mitchell and other relational psychoanalytic thinkers but that also draws on my simultaneous immersion in the [sometimes rather different currents] [in the bracing currents] of psychotherapeutic thinking outside the psychoanalytic tradition. The concern with relationship and context that is central to the relational vision has been manifested in a wide variety of ways in a wide variety of theoretical settings. Interest in the therapeutic alliance (as well as actual data on its central importance in therapeutic work) has increased exponentially, to the point where it is difficult to cite any one or two references in this regard without seeming to overlook dozens (if not hundreds) of other absolutely crucial ones. Similarly, family therapy has become a major force on the therapeutic scene, and represents an approach in which the contextual and relational nature of human behavior and experience is at the very heart of the enterprise {is of the very essence}. Behavior therapy and cognitive-behavioral therapy, though sometimes seen as quite unconcerned with [the emotional nuances of] relationship, have in fact evolved from a foundation (social learning theory) in which, from quite early, the variability of behavior and experience in different contexts was central (see, for example, Mischel, 1968), and in recent years cognitive-behavioral therapists { - often unbeknownst to therapists of other orientations B} have been paying increasing attention to the therapeutic relationship as a crucial factor in their work. Feminist approaches [(e.g., xxxxx)] have placed the [relational nature of human experience] at the center of their innovations in theory and practice. And, of course, psychoanalysis has been concerned with the relationship - with transference in particular - almost from the beginning. In some ways I will be drawing on all of these developments. The approach described in this book is an integrative one, and I hope it will be of interest to readers from a wide variety of backgrounds and orientations. But the cornerstone of the book, so to speak, is the evolution of the relational movement in psychoanalytic thought and practice. As I have noted elsewhere (Wachtel, 1993, 2000 [EMDR]), every integrative effort has its particular "flavor" or "accent," and mine is clearly psychoanalytic. From the beginning, psychoanalysis has been the key foundation of [the vital center of] my work. As Messer (19xx) has pointed out, even rather thoroughly integrative efforts are likely to be "assimilative" in nature, assimilating new ideas and methods into an already existing {base orientation}. For me that base was psychoanalysis. Heading Here? The Search [Searching] for an Expanded Vision {c} The image of a home base from which new ideas can be explored fits well with an increasingly important element in contemporary psychological discourse, namely attachment theory. It is said of the securely attached infant that he or she uses the secure base of the attachment to mother to permit [in order to launch] increasingly far-ranging exploration of the surrounding environment. In that sense, one might say that my attachment to psychoanalysis is quite secure, because I have used its secure base not for the purpose of clinging to the mother theory but of having the confidence to explore what lies outside. But it must also be said that my explorations beyond the boundaries of the familiar world of psychoanalysis stemmed as well from dissatisfactions with a number of features of psychoanalysis as it was commonly practiced. At the time I began working on a psychoanalytically grounded integrative model (e.g., Wachtel, 1973, 1977), psychoanalysis was still rather inward looking and defensively indifferent or even hostile toward developments in other branches of psychotherapy. Although the seeds of what was later to become the relational movement could, in retrospect, be seen as already largely in place - interpersonal theory was long established, object relations thinking was a central thread in Britain and in some other parts of the world (though it had still not yet had much influence in the United States), and Heinz Kohut had already published some of the work that was the foundation of self psychology - all in all psychoanalysis, especially American psychoanalysis, was still largely dominated in the early 1970s by rather traditional ideas about how to promote therapeutic change and about what constituted proper practice. The mainstream of American psychoanalytic thought emphasized neutrality, anonymity, caution about "gratifying" the patient’s infantile needs, and the primacy of insight. In recent years, largely sparked by the relational movement, the hegemony of the classical or ego psychological approach is no longer. Psychoanalysis is more diverse, more open to new ideas, and, a good case could be made, characterized most of all by relational thinking. One aim of this book is to familiarize the non-psychoanalytic reader with the developments in recent years in relational psychoanalytic thought and to demonstrate to such readers that there is much in this particular kind of psychoanalytic thinking that they can usefully assimilate into their own work. Psychoanalysis, I hope to make clear, is no longer deep in the heart of cathexis. But there is a second aim as well, directed more to the psychoanalytic portion of the book’s readership. Not all features of the contemporary relational landscape seem to me equally progressive. As I hope to show, there are elements of contemporary relational psychoanalysis that are rooted, more than its proponents appreciate, in older, "classical" assumptions that, when their attention is explicitly turned to them, relational writers often vigorously challenge. Especially when it comes to actual clinical practice (in contrast with abstract theory), relational psychoanalysis [relational practice] is sometimes not as different from classical practice as one might have supposed. Interestingly, the very term "classical analysis" is a retrospective rewriting of history that obscures the degree to which it departs from Freud’s own way of working. In an interesting examination of Freud’s actual practices, based on the writings of people who were his patients - and who thus had a kind of access to Freud’s consulting room that those of us who just have Freud’s writings to go on do not - Lohser and Newton (1996) have argued that "classical" analysis was actually an invention of the years after World War II and is of American rather than Viennese origin. Hardening Freud’s evolving and provisional clinical guidelines into rigid rules, these "classical" analysts advocated an approach quite different from Freud’s own practices [Freud’s own way of working], an approach in which, for example, as Lohser and Newton note, "silence and the absence of response [became] defined as technically correct and usually exempt from the suspicion that the analyst is acting out, a suspicion that is applied to talking and other more active interventions. "When in doubt, keep quiet" [became] a generally accepted prescription - yet a scrupulous analytic clinician is going to be in doubt most of the time." (Lohser and Newton, 1996, p. 178; italics added) The further evolution of psychoanalytic technique proceeded against the background of this and other falsely classical conceptions, <<proceeded with this falsely classical view of what it meant to do psychoanalysis as the point of departure.>> The burden of proof was on any ways of working that deviated from this supposed "frame" of the therapeutic work, and as a consequence the burden of proof essentially fell upon those who would deviate from what had become the new orthodoxy. The supposedly "classical" technique became the default position, and innovators had to expend considerable energy in justifying clinical practices that, in some instances, actually resembled Freud’s own way of working more than they did those of what analysis had become in the following decades <<and, ironically, innovators had to expend considerable energy in justifying clinical practices whose "radical" nature was very largely that they reintroduced {whose "radical" nature largely consisted of reintroducing} ways of interacting with patients that were common occurrences in Freud’s [own] consulting room. Heading here? The Shadow of the Classical Model Today, most relational analysts and therapists - indeed, most psychoanalytically guided therapists of all stripes - practice quite differently in many respects from this so-called "classical" model. But the shadow of that model often falls on their practices in unrecognized ways. For relational analysts and therapists in particular, the result is that their ability to creatively follow through on their most progressive and innovative ideas can be constrained and that potentially counterproductive clinical habits are retained that, on close examination, are inconsistent with those very ideas. This may entail not just hesitancy about such matters as "self-disclosure" - a practice that is more common among relational analysts than among their more classical colleagues, but which often nonetheless bears a burden of proof that is not borne by the "default" position of remaining silent or purely "interpretive" - but also more subtle kinds of restraint. I have noticed in students and supervisees ways in which their choice of phrasing, tone of voice, facial expression and body language - at times literally the way they "hold their face," [manifesting a tight expressionlessness that differs markedly from their everyday, more emotionally responsive and "readable" visage] - reflect a close-to-the-vest caution (and consequent distancing) that has seemed not just the mark of inexperience but their unwitting imitation of the expressions of their analysts and supervisors. <<At times this may be evident even in the way they literally "hold their face," manifesting a tight expressionlessness that differs markedly from their everyday, more emotionally responsive and "readable" visage.>> In this and the following chapters, I will examine more closely the assumptions that guide psychotherapeutic work {and especially the ways in which those assumptions may be unrecognized or unarticulated or in which their impact on practice is insufficiently appreciated). I will concern myself both with older and more venerable assumptions (whether they derive from Freud, from the post-Freudian "classical" approach, or from sources such as cultural axioms and values widely shared by psychoanalytic and non-psychoanalytic therapists alike) and with the newer conceptions that characterize the work [the viewpoint] of relationally oriented analysts, family therapists, and constructivist therapists from both psychoanalytic and cognitive perspectives [(e.g., Hoffman, 19xx; Mahoney, 19xx; Feixas, 19xx)]. My aim in this is to clarify the foundations on which psychotherapy is grounded, to consider where common practices and habits are rooted in premises that are contradictory and insufficiently examined, and to spell out in some detail the implications for clinical practice of this examination. These assumptions and guiding axioms are not mutually orthogonal or independent, of course. {The assumptions and guiding axioms that undergird clinical work do not form a totally orthogonal set, of course.} They overlap and represent different takes on the same set of issues and observations. The reader will therefore find herself going over related themes in different chapters, but from different vantage points and in the context of different clinical examples and questions. The aim [intent] is to describe a way of working clinically that is rooted in the relational point of view and to spell out the thinking behind it sufficiently so that the reader can gain a better sense not only of how to practice but how to think about clinical practice, how to feel oriented to the patient and to the task. Put differently, the goal is to enable the reader to feel more confident in translating theory into practice, in having sufficient clarity about the aims and assumptions of the work that she can feel she knows what she is doing.[1] What Is a Relational Approach? What Does It Mean to Be "Relational?" Defining "Relational": Glandular Sentences and Transformative Conversations As the term "relational" has come into broader and broader use in recent years, there has been a corresponding decrease in the degree to which it communicates a clear or unambiguous {c} meaning. This is perhaps an inevitable cost of success - relational perspectives have become increasingly prominent in the field of psychotherapy, and we have reached a point where many people want to jump onto the bandwagon. But as more and more people use the term, often more as a taken of membership in a club to which they wish to belong than as a substantive reference to a clearly specified set of theoretical premises and practices, the ripple of meanings makes a phrase like "relational psychotherapy" less than ideally precise. Labels like "relational," "object relational," "classical," or "contemporary Freudian" often serve less as a means [facilitator] [medium] of discourse than as a functional activity of boundary-making akin to the way our animal cousins leave their scent to mark off the boundaries of their territory. "I belong here, you belong there," may be a sentence; but it is a sentence whose meaning [function] [purpose] is not very different from what is conveyed by the glands of our mammalian kin. The term relational has not infrequently been employed in essentially "glandular" sentences, marking a boundary in disputed conceptual territory more than promoting a process of conversation [rather than contributing to a genuine conversation]. In a real conversation (at least in the kind of conversation I value) words are employed not just to maintain boundaries but to alter and complicate them. I do intend in this book to articulate the boundaries that demarcate relational approaches from others both similar and obviously dissimilar. It will become apparent, however, that the boundaries are rather permeable and shifting. There is no one meaning of relational that captures [characterizes] all who fall on one side of the boundary and excludes all who fall on the other. Rather, we will find, the term refers to a [loosely coupled] [loosely correlated] set of ideas and set of distinctions that are shared by some relationalists and ignored or even explicitly rejected by others. Some of these elements {some of these separate elements} in the [relational configuration] [configuration of relational ideas] [matrix of relational thought], moreover, are endorsed by at least some who do not view themselves as relational and even some who view themselves as critics of the movement (see, for example, Bachant, Richards, Wilson, etc.). {C} In exploring the complexities of this conceptual terrain, then, my aim is to engage in a conversation about the relational point of view rather than just to leave my scent and mark the boundaries. I aim, that is, to engage in that uniquely human activity in which the very process of stating what we know can contribute to changing what we know or how we see things. Such a description, of course, could as readily be applied to the process of psychotherapy as to conversation. And indeed, my implicitly drawing a parallel between conversation and psychotherapy is no accident. One way of thinking about the relational view of therapy is that relational therapy is an approach to psychotherapy in which the fact that it is a conversation - rather than a one-directional examination of one person by another - is at the very heart of how the approach is understood {of how the therapist understands what he or she is up to [is engaged in]}. B Heading? Psychotherapy as Conversation (or not if "glandular sentence" heading is included?) To describe the process of psychotherapy as a conversation is at once [is simultaneously] a bland commonplace and a radical departure from the early roots of modern therapeutic thought {thinking about therapy}. What went on between Freud and his patients was, of course, a kind of conversation, but one so strikingly different from most conversations we have in our lives that it deservedly assumed a new name - psychoanalysis. Psychoanalysis was, for many years, a therapeutic approach so thoroughly rooted in this new (and strangely different) kind of conversation that its virtual denial of the conversational heart of the enterprise was almost a defining feature of what it meant to be psychoanalytic at all. That is, within what has come to be called in recent years the "one-person" approach to psychoanalysis or psychoanalytic psychotherapy (see below), the therapist or analyst was largely conceived of as an observer of what "emerged" or "unfolded" from deep within the patient (Wachtel, 1982). And although the analyst too spoke at times, his or her participation was not really [basically] [primarily] understood as engaging in a dialogue, a bi-directional conversation between two people, but as offering interpretations of an inner monologue, emerging, often in confusing fashion, from the unconscious of the patient[2] One key element in the contemporary "relational turn" in psychoanalysis - especially as it bears on therapeutic technique rather than on more abstract theoretical matters - entails, in essence, a recognition [an acknowledgment] of the conversational nature of the enterprise. But like the Freudian conversation out of which it grew, it is a conversation unlike most others, a concertedly transformative activity which, while bearing more resemblances to the more "ordinary" conversations of our lives than had previously been appreciated - this is one of the key relational insights - is simultaneously unique [and, at least potentially, uniquely powerful]. It is a conversation with a special capacity to be both unsettling and reassuring, and often to be both at once. "One-Person" and "Two-Person" Approaches {N.B. First paragraph implicitly points to structure of future chapters} Perhaps the most common way in which relational approaches are characterized in the literature employs the distinction between "one-person" and "two-person" models. This is a conceptual distinction that bears very centrally on understanding the relational approach and its implications for clinical practice, and it is one I will address and draw upon substantially in what follows. But it is also a distinction that is laden with a number of potentially confusing ambiguities and contradictions. Hence it is useful for us to consider in detail [to consider in this initial chapter] what this distinction refers to and where it does and does not [do a satisfactory job] [serve us well]. {Next paragraph contains implicit structure for future chapters}Perhaps the most common [criterion] [distinction] [rubric] is one-person vs. two-person. Useful in certain ways - I use it too - but potentially confusing <potentially confusing {misleading} for several reasons . Used in several ways, as I shall spell out. Also, the very idea of "one" and "two" is flawed. I shall end with that There are numerous other potential points of departure for clarifying [further clarifying] the nature of the relational point of view in general and the specific version I am advocating [describing] in this book. I will, for example, be considering in subsequent chapters the relative roles of insight or new experience in generating therapeutic change; the relation between exploration and intervention and {the question of whether} {the ways in which} they are contradictory or complementary; issues of neutrality, anonymity, and self-disclosure; the impact of prevailing cultural assumptions regarding help-seeking and help-offering, dependence and interdependence; the role of biology, both in its implications for the use of medication and in its bearing on notions such as "drives;" and a variety of other themes that are of central importance for understanding how to proceed as a therapist and what distinguishes a relational therapist from one operating from different premises. But there is perhaps no theme so frequently cited or so subject to misunderstanding as the one-person two-person distinction, and hence this seems the logical place to begin a more in-depth exploration of what relationality does and does not entail. When the distinction between one-person and two-person models is made, it is usually very clear {there is rarely any confusion as to} which term is intended to refer to which approach: the older, Freudian, or classical models are "one-person" models and the newer relational models are "two-person" models. In at least a rough way, this distinction makes a good deal of sense, and does point us to a number of differences between these approaches that are both important and real. I myself use the terms one-person and two-person quite frequently as a shorthand when I teach, and it is a useful rubric for capturing in a single phrase what is in fact a rather [multifaceted and] complicated set of differences in both assumptions and practices. The problem is that it is just a single phrase, and as such it is inadequate to capture the multidimensional complexity of the actual differences among currently influential approaches. As a label or starting point it is fine. As a serious conceptualization of the issues, it is not [it is inadequate] [it is insufficient] [it is misleading]. To begin with, it is worth noting that the distinction is almost always employed by putative two-person thinkers, as a critique of one-person modes of thought. There are rather few writers who defiantly proclaim, "I am a one-person theorist and proud of it," though there are in fact many writers who declare themselves to be proponents of the models that are called one-person models by two-person theorists. Writing as someone who, if the dichotomy is usable at all, would without question fall on the "two-person" side of the divide, I must say I find it disquieting to be characterizing competing theorists in a way they do not acknowledge as the basis of their own thinking. This lack of acknowledgment on the part of "one-person" theorists, of course, does not in itself invalidate the critiques. It is certainly possible that critics of one-person models are recognizing something about the theories they are criticizing that their advocates do not. Indeed, in important respects [in certain respects] I myself believe this to be the case. It does, however, raise a question as to whether there might be a way to frame the critique that would be more illuminating and experienced as less of a straw man by more traditional theorists. [As I will elaborate below,] I have suggested, only partly in jest, that in fact, it comes closer to the truth {that it is [probably] more accurate} to characterize the competing perspectives as one and a quarter person theories and one and three quarter person theories.[3] What I mean by this is that most one-person theorists ,{especially contemporary one-person theorists}, do not ignore the context or the [influence of the observer] as much as the label "one-person" implies and that "two-person" theorists are not so lost in [immersed in] a field theory that the singular properties of individuals disappear. (Recall here the earlier discussion of the quote from Mitchell, with its emphasis on desire and the individual’s struggling to articulate himself.) Three Meanings of the "One-Person" and "Two-Person" Distinction The confusions surrounding the terms one-person and two-person arise in large measure {arise in part} because the distinction has been used in at least three different ways - to refer to issues of theory, of practice, and of epistemology. These are certainly not unrelated contexts; each in part influences and is influenced by the others, and certain key ideas and assumptions tend to show up in all three realms. Nonetheless, they are by no means totally equivalent, nor do they always map onto each other [unambiguously] [consistently] [in easy one-to-one fashion]. B-Heading? (Or A?): "One-person" and "Two-person" Epistemologies In the epistemological realm, two-person theorists emphasize the strong and inevitable influence of the therapist’s behavior, personal characteristics, and even mere presence on what is [seen in the session]. From the two-person perspective, it is pursuing an illusion for the therapist to attempt to get a "true" or "uncontaminated" picture of the patient’s inner world by diminishing her own input. "Keeping out of the way" or being "unintrusive" in order not to "distort" the transference or influence what "emerges" or "unfolds" from the depths of the patient’s unconscious will simply reveal to us what the patient experiences or reveals in relation to "keeping out of the way," since keeping out of the way is a way of being with another person that is no less real, specific, or even evocative than any other. From the vantage point of a two-person epistemology, the impact of the observer is so pervasive, continuous, and inevitable - so intrinsic a part of the field of observation - that to attempt to eliminate that impact is not only to engage in self-deception but actually to generate a less accurate or reliable picture. In part, the decrease in accuracy is due to the self-deception itself. If the therapist is not alert to her influence on what is being observed, if she denies or minimizes it, then it is difficult to take it into account, to understand that she is not really observing "the patient," but the patient in relation to a particular kind of interpersonal relationship with a particular individual who has particular qualities and is responding to the patient’s own qualities in particular ways. The therapist who does not appreciate this tries to solve the wrong equations, so to speak; she works with equations that do not include the factor of her own influence, and hence yield misleading solutions. A two-person epistemology does not completely eliminate the problem, of course. Knowing that one is influencing the observations does not abrogate that influence. It does, however, enable the therapist to at least ask or consider how she enters into the equation. It enables her to try to triangulate, so to speak, to gain a better understanding of what, on the one hand, is pervasive in the patient’s makeup and manifested in a very wide range of relationships and contexts and what, on the other, is more specific to the circumstances of observation that the therapy itself offers. {C} This triangulation is afforded by comparing how the patient feels, behaves, fantasizes, and desires in relation to the therapist [in the consulting room] and how he does so in the other arenas of his life.[4] The gain in accuracy, it is important to appreciate [acknowledge], is only relative. Which events in his daily life the patient recalls in the session or chooses to talk about and how he talks about them (whether, for example, he presents it in dry "he said, she said" terms or includes his feelings, fantasies, and desires) - all this is itself influenced by the therapist’s presence and by her characteristics and behavior. <So judgments about whether the patient is an affectively alive or affectively constricted person that can seem to be based on the patient’s descriptions of what transpires outside the therapist’s office are always also pervasively influenced by what is transpiring within the office [since the latter affects what the patient remembers and the affective tone with which he describes it] (and how it affects memories of what has happened outside) . The patient might well remember.... >> He might well remember quite different events in his life in the context of a different interaction with a different therapist, and these different events, combined with the different way of relating them that also can derive from a different relational context,[5] can give a quite different picture of what the patient’s life outside the consulting room is like . [Thus] Even when the patient reports events and experiences from his "outside" life or from his past, he is reporting those too as he can or does in relation to this particular therapist at this particular time. [Thus], here too, we cannot obtain an "objective" account but must settle for one that is pervasively relational. Indeed, even if the therapist actually invites the patient’s significant others into occasional sessions in order to be able to experience them directly, the limits of the observational context of the therapy session are not transcended. Although this option offers the therapist an opportunity to go beyond depending exclusively on the patient’s description - which necessarily reflects the patient’s emotional stake in the individual and the relationship (whether positive or negative) as well as his inevitably selective memory - she is still confined to observing those individuals (and their interactions with the patient) in relation to the particular context and the therapist’s own particularity. I am a strong advocate, for quite a few reasons (see Wachtel & Wachtel, 1986), of including this possibility among the therapist’s options, and indeed I believe it to be one of the many useful expansions of the therapeutic frame that is potentially introduced by a thoroughgoingly relational point of view.[6] Such sessions not only provide us with additional perspective on the significant others in the patient’s life, but also provide us an opportunity to directly observe the patient’s interaction with them and to hear, from the invitee, another perspective on the patient, one that often derives from far more pervasive contact with the patient through his day to day life. But while all of this is of great value, we must not deceive ourselves that now we are directly "seeing it like it is." Here too, the same constraints we have been discussing thus far still hold, both with regard to what the other person is "actually" like and with regard to how he or she and the patient "actually" interact. These are new - and very useful - observations, but they too, inevitably, are relational and contextual. The foregoing does not imply, by any means, that the effort to understand the patient [to understand another person] is futile or self-deceiving [spurious] [illusory] [quixotic]. Our understanding of other people is always infused with and mediated by our own subjectivity, but we could not have survived as a social species if it were completely arbitrary. Even if imperfect, our understanding is often quite capable, to borrow from Winnicott (19xx), of being "good enough." The aim of a two-person epistemology is not epistemological nihilism but a more sophisticated understanding of the ways in which we can potentially mislead ourselves in order to increase the odds that our understanding will be "good enough." {C Heading} The Illusion of Constancy and Its Consequences The achievement of that "good enough" understanding is impeded by a further common consequence of [a one-person epistemology]. When the therapist believes that what she is observing is what spontaneously "emerges" or "unfolds" from the patient’s unconscious, rather than one angle on the patient’s experience and dynamics, a picture significantly colored by the particular circumstances of observation and which could look quite different if the patient were with a different therapist, or even if the same therapist behaved differently in the sessions, then she is motivated to minimize what she views as the "distortion" introduced by her own presence and her own participation. Under such guiding notions [rubrics] [ideas] as "neutrality," relative "anonymity," or avoiding "gratifying infantile needs" so that those needs will build up and emerge more strongly and clearly, therapists [operating from a one-person epistemology] have often tended to restrict their own behavior in the session, attempting, in effect, to bracket out their own behavior [their own influence] so that what is observed comes from the patient.[7] This does not mean that the analyst is necessarily enjoined from being subjectively responsive to what is transpiring in the session. From the beginning, the attunement of the analyst’s unconscious to the patient’s was viewed as a central source of understanding the patient’s unconscious dynamics. To be sure, in some versions of psychoanalytic thought, this view was tempered (perhaps even significantly contradicted) by a radical suspicion that any emotional reaction on the analyst’s part [any emotional reaction by the analyst to the patient’s productions] was a result of countertransference in the negative ( "infantile" or "neurotic") sense of that term. Later and more sophisticated versions of the model [of the one-person model] [of what was still a one-person model] viewed countertransference far less suspiciously - seeing the analyst’s emotional reactions (in a view that begins to converge some with the two-person vision) as not only inevitable but potentially extremely useful as a source of understanding [include references here (e.g., Racker?) ; need to be refs that contain both an acknowledgment of the inevitability and even usefulness of the therapist’s subjective reaction but also still forbidding the actual sharing with the patient of that reaction] . What nonetheless unites all of these "conservative" positions (including, as we will see, some that purport to be relational or two-person models) is their insistence that the analyst keep these reactions in the realm of her own, private, subjective participation rather than as part of what is expressed or discussed in the sessions. <Maybe eliminate or shift this paragraph, and follow the paragraph above this directly with the Gill paragraph below?> One of the clearest and most widely cited statements of this conservative position {One of the clearest and most widely cited articulations of the rationale for this restriction of the therapist’s reactivity [of the therapist’s behavior]} was offered by Merton Gill (1954). Gill wrote that, "The clearest transference manifestations are those which recur when the analyst's behavior is constant, since under these circumstances changing manifestations in the transference cannot be attributed to an external situation, to some changed factor in the interpersonal relationship, but the analysand must accept responsibility himself." (Gill, 1954, p. 781) In this statement, Gill is specifically addressing the patient’s transference manifestations, but his point clearly is intended to address the larger issue of understanding virtually all of the material that emerges in the course of the analysis, and it clearly has an epistemological grounding. It is a statement of how the real insides of the patient, so to speak, {of how the patient’s inner reality [deepest and most defining psychic structures]} are best revealed by minimizing the distorting effects of the therapist’s behavior. By remaining constant, in this view, the analyst’s influence is essentially removed as a variable in the equation of understanding.[8] Interestingly, Gill himself later became one of the sharpest critics of this one-person epistemology. In a series of influential books and papers, Gill (19xx, 19xx, ........) emphasized that the patient’s transference reactions are always a response to something real in the analyst and in what she is doing - and, simultaneously, that this in no way limits our ability to utilize the patient’s transference to illuminate his psychological life or probe the depths of his character. Transference, Gill later argued, is best understood not as a "distortion," much less something made up out of whole cloth, but as the patient’s particular way of making sense of and emotionally reacting to what is happening. What the patient must learn is not that he is "wrong," but that he is selective, and that that selection may be motivated and may be rooted in past experiences in ways he has not understood. Transference, in Gill’s later view, is a matter of perspective, and the question to be pursued, in essence, is "Why this perspective, why this way of seeing things?" (as well as such related questions [such related, and clinically important questions] as "How else could you see it?", "What other perspective might you bring to bear?" or "What keeps you from considering that possibility?") Gill (1984) notes that, for reasons similar to [closely related to] those he outlined in his 1954 paper, many analysts are reluctant to interact very much with their patients, fearing that they will distort the transference by doing so. But, he now argues, "the notion of an ‘uncontaminated’ transference is a myth," {c} and it is a myth that fosters an unfortunate restraint on analysts’ part. This restraint may lead to emotional deprivation for the patient, but it does not provide a superior pipeline to the patient’s emotional truth. Rather, it points to the analyst’s. "failure to be fully aware that because analysis takes place in an interpersonal context there is no such thing as non-interaction. Silence is of course a behaviour too. Nor can one maintain that silence is preferable for the purpose of analysis because it is neutral in reality. It may be intended to be neutral but silence too can be plausibly experienced as anything ranging from cruel inhumanity to tender concern. It is not possible to say that any of these attitudes is necessarily a distortion." (Gill, 1984, p. 168) Elsewhere, in a comment that again challenges the conservative position represented by his 1954 paper and maintained by a significant portion of the psychoanalytic mainstream, Gill notes that "If the analyst remains under the illusion that the current cues he provides to the patient can be reduced to the vanishing point, he may be led into a silent withdrawal, which is not too distant from the caricature of an analyst as someone who does indeed refuse to have any personal relationship with the patient. What happens then is that silence has become a technique rather than merely an indication that the analyst is listening. The patient's responses under such conditions can be mistaken for uncontaminated transference when they are in fact transference adaptations to the actuality of silence." (Gill, 1979, p. 277; italics in original) Gill’s emphasis centers on two key themes - that this mistaken, epistemologically naive position can lead to unnecessary, and clinically counterproductive harshness and withdrawal, and, further in contrast to his earlier position, that it can actually render the analyst’s interpretations less persuasive. Attempting to prove to the patient that his experience of the analyst has little or nothing to do with what she is really like or how she is really behaving is actually a formula for creating resistance. There is more likelihood of common ground, of the patient feeling seen and heard and taken seriously, and hence of the patient being in a position really to consider the alternative view that the analyst is putting forth, if the message takes the form of, "I understand that what I did/what I said/what I failed to say felt to you that I ..... Is there any other way it could also be seen?"[9] The epistemological position taken by Gill and other two-person theorists points to still another implication for how to proceed clinically and for how to {improve [enhance] the quality of our understanding}. <<This additional perspective [implication] [dimension] is not elaborated by Gill, but it seems to me consistent with his [epistemological] position and an essential extension of it. >> When the therapist restricts her [variability and] responsiveness in the sessions, she also restricts as well the contexts of observation [opportunities for observation]. We then get a picture of how the patient reacts [feels] [behaves] [experiences] in certain contexts {in a few restricted emotional contexts}, but do not get a chance to see and do not get a chance to develop formulations about either how else the patient may react or, equally important, in what ways his [behavior] varies with different contexts. The result is a global picture of some (sometimes accurate or useful) general proclivities, but little understanding of the specificities that in fact characterize his individuality. That is, instead of generating overly simple [and overly "internal"] formulations such as, "the patient is primed to perceive authority figures as hostile," we need to develop more [complex (and accurate) formulations] in which the particular context in which this tendency is manifested is identified, and - importantly - in which it is also understood when the patient is not likely to manifest it. (For example, when authority figures are clear and forthright, then they are not experienced by him as hostile, even when they are being critical; but when they are unclear or unforthcoming, this is likely to be experienced by him as hostile). <<In considering these arguments, it is important to be clear that more sophisticated "one-person" theorists do acknowledge that the influence of the analyst is inevitable. Their approach, however, is to attempt to reduce that influence as much as possible, and they believe they can do so effectively enough to gain a reasonably accurate and reasonably undistorted picture of what the patient’s personality and dynamics are "really" like apart from that influence.>> <<More sophisticated "one-person" theorists, it should be noted, acknowledge most of these considerations, but view quite differently their implications for how best to go about understanding the patient or building theory. They recognize that the influence of the analyst on what is observed is inevitable, but they attempt to at least reduce that influence, to set limits on it in order to see more clearly the essential, internal, undistorted reality of the patient’s internal life. [Their approach, however, is to attempt to reduce that influence as much as possible, and they believe they can do so effectively enough to gain a reasonably accurate and reasonably undistorted picture of what the patient’s personality and dynamics are "really" like apart from that influence].>> In one discussion of this issue, in a psychoanalytic group to which I belong, a proponent of {the traditional approach} {of the traditional rules of neutrality and anonymity} remarked that just as we cannot completely eliminate the "contaminating" influence of the analyst, so too in surgery we can never achieve a totally sterile field, yet that does not justify doing surgery in a sewer {that although the "contaminating" influence of the analyst can never be completely eliminated from our observations this no more implies that we should not attempt to minimize that influence than the fact there will inevitably be some contaminants in the operating room too [that the operating room can never be a completely sterile field] does not mean that we should do surgery in a cesspool.} At the heart of the one-person view [both epistemologically and technically], is the conviction that there is something "in there," as it were [something "inside" the patient], that exists independently of the observer and her influence and that can be seen by the observer (or at least inferred by the observer or interpreted by the observer) even if the understanding achieved is less than absolutely perfect. Moreover, the conviction is that what is seen is something that has been longstanding in the patient’s psyche, something that existed before the therapist’s observation and (unless change is successfully initiated by the therapeutic process) will continue to exist long after the therapist’s observations. We may not be able to exclude our influence perfectly or completely, but the effort to do so as much as we can will be rewarded by a more accurate and complete understanding. In contrast, two-person theorists, proceeding largely on the basis of postmodern or constructivist epistemologies, argue that in principle we cannot observe the reality of another person’s psychological structures or experiences apart from <cannot observe the reality of another person’s psychological structures or experiences in an "objective" fashion that is divorced from> the relationship within which we gain access to them. From a two-person view, the very act of observing another changes the other, and - again, in principle - we cannot observe the other apart from our participation in the observation itself. [Moreover], this is not just a matter of observer bias or incorrect interpretation of the observations. It is more intrinsic than that. What actually is changes as a function of the particular observer and his or her behavior and characteristics.[10] Not all two-person thinkers hold to the most radical versions of this position, and the implications of even the radical positions are often misunderstood or exaggerated by advocates for the more traditional psychoanalytic view, who sometimes imply - erroneously - that the two-person position entails denial of the very existence of {meaningful psychological structures or of the possibility of understanding another person and how she got to be the way she is}. In my own work, notwithstanding my clearly falling on the two-person side of the divide [continuum], I comfortably assume that there is a "there" there - that, however limited or distorted by personal limitations and biases [by biases and by our position in relation to them] our perceptions may be (whether in the realm of perceiving the physical world or the psychological), there is something there to perceive. We may not be able to perceive the other "objectively," but neither are our perceptions simply arbitrary. They are meaningful, useful, and refer [and often refer] to something "real," even if they are also infused with our own subjectivity and particular point of view. { - that is, even if they are also partial, in both senses of the word (incomplete and biased).}
C Heading: Freud’s epistemological anxiety
There are certainly a variety of reasons for the "hands-off" or "close to the vest" attitude that characterizes much of psychotherapeutic practice. Therapists are justifiably concerned with not pushing their own values on patients, for example, and with establishing a relationship in which their listening and understanding the other person’s point of view is more central than it is in most relationships in their lives. Moreover, a key aim of psychotherapy is to help the patient to feel more confident in his or her own judgment and to learn to identify his real preferences and feelings; this is difficult to do if the therapist is devoting too much of her attention to getting across how she sees things. Nonetheless, there is much in the way that psychotherapy is practiced and in the way it is understood, especially by proponents of the "one-person" point of view, that derives from what I have called Freud’s "epistemological anxieties" (Wachtel, 1993). Freud has been fairly consistently described by his biographers as a man whose investment was most of all as a discoverer rather than a [curer]. He shifted from a career in research to one in medical practice [clinical practice] only reluctantly and under the financial pressures associated with getting married and establishing a family [cite page in Jones], and he [stated quite clearly that he lacked therapeutic zeal].
Thus we may see that epistemological concerns, far from being [an abstract or abstruse intellectual sideshow] were at the very heart both of how Freud constructed his theory and of how he [developed] [depicted] his practice. In many ways, the relational point of view was born in the effort to overcome the constraints [constrictions] resulting from Freud’s epistemological preoccupations. We will see that reexamining this question leads us to a wide range of new possibilities therapeutically, making the epistemological dimension a matter of quite concrete practical import. But ironically, we will also see that in certain ways the relational movement has been too concerned with the epistemological dimension, in the sense that it has distracted many leading relational thinkers from a deeper examination of the substantive theories (of development, of personality dynamics, of how past experiences are stored, how they are modified, how they influence our behavior and experience in the present, and how their representations are related to the continuing input from new experiences that is intrinsic to being alive). We will see that, although they have challenged quite explicitly the epistemological foundations of psychoanalytic thought, relational thinkers have often not addressed C or even appreciated - the ways in which epistemological concerns [shaped and drove] both Freud’s theories and his practices. As a consequence, the relational critique of Freud’s epistemology has tended not to be accompanied by as sharp [radical] a critique of his theories and, especially, his techniques. Many extremely important innovations and insights have emerged from the relational movement, of course, as from its forebears in the various theoretical strands that make up the contemporary relational [paradigm] [movement] [perspective] [viewpoint] [vision]. But I hope to show that there is still greater potential for therapeutic change and innovation implicit in the ideas that have emerged from the relational movement and that part of the realization of that potential requires us both to see the importance of the epistemological dimension in the very shaping of the psychoanalytic vision {{and - through its heirs, both direct and indirect - of much of the entire field of psychotherapy}} and, simultaneously, to appreciate where more specifically theoretical and technical [technique] concerns need to be addressed apart from or in addition to the epistemological. That will be the aim [challenge] [charge] of the next chapter and, indeed, of this entire book. Everything below comes from chapter 9 of Therapeutic Communication. Sort thru, adapt, rework, and elaborate for the present context. But this is the basic argument. No need to reinvent the wheel: Background to epistemological anxieties section: THE CHALLENGE OF SUGGESTION An ambivalent, if not outright negative, attitude toward suggestion is particularly strong in the psychoanalytic tradition, and this skepticism can in large measure be traced back to Freud and to the roots of his development of psychoanalysis. Psychoanalysis, it might be said, was the child of suggestion;[11] and like the Oedipal child so central in psychoanalytic narratives, it showed noteworthy hostility toward the parent from whose loins it sprang. Differentiating the "pure gold" of psychoanalysis from the supposedly inferior ministrations of the practitioners of suggestion was a lifelong aim of Freud's. As is often the case, however, Freud's own views on the matter were more open, more complex, and more honest than those of many of his followers. While Freud could at times be quite thoroughly dismissive regarding the role of suggestion in analysis or regarding its therapeutic value more generally (see below), there were numerous instances when he acknowledged the pervasive influence of suggestion in all psychotherapy, and even the necessity of explicitly and thoughtfully utilizing it if one is to obtain the best possible results. In _On Psychotherapy,_ for example (Freud, 1904), an early paper which is of note because the question of suggestion is a particularly central concern, he states that "an element dependent on the psychical disposition of the patient enters as an accompanying factor" in all therapeutic efforts and notes that "We have learned to use the word `suggestion' for this phenomenon.... All physicians... are continually practising psychotherapy even when you have no intention of doing so and are not aware of it; it is disadvantageous, however, to leave entirely in the hands of the patient what the mental factor in your treatment of him shall be. In this way it is uncontrollable; it can neither be measured nor intensified. Is it not then a justifiable endeavour on the part of a physician to seek to control this factor [suggestion], to use it with a purpose, and to direct and strengthen it? This and nothing else is what scientific psychotherapy proposes." (p. 251, italics added) This last statement in particular ("this and nothing else") is certainly a rather striking endorsement of the central importance of suggestive influences. Other passages in the paper as well indicate Freud's appreciation of the importance and appropriateness of suggestive influences, while conveying to us as well an interesting perspective on why on other occasions he treated them less than enthusiastically. For example: There are many ways and means of practising psychotherapy. All that lead to recovery are good. [italics added] Our usual word of comfort, which we dispense very liberally to our patients - `Never fear, you will soon be all right again' - corresponds to one of these psychotherapeutic methods; only, now that deeper insight has been won into the neuroses, we are no longer forced to confine ourselves to the word of comfort. We have developed the technique of hypnotic suggestion, and psychotherapy by diversion of attention, by exercise, and by eliciting suitable affects. I despise none of these methods and would use them all under proper conditions. [italics added] If I have actually come to confine myself to one form of treatment, to the method that Breuer called `cathartic' [italics in original], which I myself prefer to call `analytic,' it is because I have allowed myself to be influenced by purely subjective motives. Because of the part I have played in founding this therapy, I feel a personal obligation to devote myself to closer investigation of it and to the development of its technique. (p. 252) A number of features of this passage are noteworthy. Certainly not the least of them is Freud's forthright indication of his personal motives in confining himself to what might be called the "pure form" of psychoanalysis, one in which suggestive influences are largely ruled out. In effect, he is acknowledging that the determining factor in the way he approached therapy was not necessarily what provided maximum benefit to the patient in his office; his approach reflected as well his own interests in pursuing his research and his destiny.[12] It could be argued that Freud's less than thorough repudiation of suggestion here (at least in terms of its therapeutic value, rather than whether it accorded with his personal agenda) is due to this being an early paper, and that once psychoanalytic technique evolved to the point of incorporating more modern and sophisticated techniques of resistance and transference analysis, the suggestive methods lost their last measure of justification. In fact, however, roughly equivalent passages can be found throughout Freud's writings, right up to the very end. In The Future Prospects of Psycho-Analytic Therapy, for example, (Freud, 1910) he suggests that as the prestige of psychoanalysis increases, the results should improve. "I need hardly say much to you about the importance of authority... The extraordinary increase in the neuroses since the power of religion has waned may give you some indication of [man's craving for authority]." (p. 290) He even declares that it is "surprising that any success was to be had at all" without reliance on the therapeutic power of suggestion. To be sure, Freud takes these successes as a sign that there is indeed something valid above and beyond suggestion in psychoanalytic ideas. But his argument clearly implies something quite akin to what I am arguing here - that to attempt to achieve therapeutic results without at all trying to harness the power of suggestion is like trying to work with one hand tied behind one's back. Freud makes a related point in his General Introduction to Psychoanalysis (Freud, 1916): When the patient has to fight out the normal conflict with the resistances which we have discovered in him by analysis, he requires a powerful propelling force to influence him towards the decision we aim at, leading to recovery....The outcome in this struggle is not decided by his intellectual insight - it is neither strong enough nor free enough to accomplish such a thing - but solely by his relationship to the physician. In so far as his transference bears the positive sign, it clothes the physician with authority, transforms itself into faith in his finding and in his views. Without this kind of transference or with a negative one, the physician and his arguments would never even be listened to. (p. 387, italics added) He goes on to note that this phenomenon is a universal one in human beings and is identical to that which Bernheim had earlier called suggestion. "What [Bernheim] called suggestibility is nothing else but the tendency to transference... And we have to admit that we have only abandoned hypnosis in our methods in order to discover suggestion again in the shape of transference." (p. 387-388) Later in that same work, Freud further acknowledges that the analyst makes it possible for the patient to overcome his resistances "by suggestions which are in the nature of an education. It has been truly said therefore, that psycho-analytic treatment is a kind of re-education." (italics in the original). He goes on to say that by "manipulating" the transference, "it becomes possible for us to derive entirely new benefits from the power of suggestion; we are able to control it; the patient alone no longer manages his suggestibility according to his own liking, but in so far as he is amenable to its influence at all, we guide his suggestibility." (p. 392) In these passages we see not only an open acknowledgment that suggestion, when properly used, constitutes one of the most powerful tools available to the psychotherapist, but also a tying of the issue of suggestion to that of transference. Increasingly for Freud these two themes were linked. In his final summation of his thoughts in An Outline of Psychoanalysis (Freud, 1940), he puts it quite clearly. The transference relationship, he says, has the advantage that "If the patient puts the analyst in the place of his father (or mother), he is also giving him the power which his superego exercises over his ego, since his parents were, as we know, the origin of his superego. The new superego now has an opportunity for a sort of after-education of the neurotic; it can correct blunders for which his parental education was to blame." (p. 67, italics in original). Freud does goes on to warn of the dangers of crushing the patient's independence in the process or of trying to create the patient in one's own image, and he emphasizes the importance of respecting the patient's individuality. He argues for limiting the amount of influence exerted to the minimum required by the patient's inhibitions. He adds, however, that "Many neurotics have remained so infantile that in analysis too they can only be treated as children." Freud thus not only points to the indispensability of suggestive efforts on the analyst's part; he also, without intending to, alerts us to a factor which may be much more potent in determining whether the patient is "treated like a child" than is the willingness to acknowledge and openly employ suggestion - namely, the view that the patient somehow remains "infantile." All this is not to say that Freud was sanguine about the role of suggestion. Indeed, determining the proper role of suggestion, both in therapeutic technique and in theorizing about what occurs in the therapeutic process, was one of the most vexing of all issues for him, an issue to which he continually returned and about which he demonstrated noteworthy inconsistency. Throughout Freud's writings one can find a tendency, often in the very same paper, on the one hand to acknowledge in surprisingly straightforward fashion the importance that suggestive influences retained even after the development of psychoanalysis, and on the other, either to sharply contrast psychoanalytic methods with suggestive ones or to hedge the role of suggestion so severely that one wonders what to make of those passages in which he treated suggestive influences as so significant. In the 1904 paper noted above, for example, notwithstanding the passages already quoted acknowledging the centrality of suggestion in all scientific psychotherapy, Freud claims that there is "the greatest possible antithesis" between suggestive and analytic technique. The technique of suggestion, he states, "is not concerned with the origin, strength and meaning of the morbid symptoms, but instead it superimposes something - a suggestion - and expects this to be strong enough to restrain the pathogenic idea from coming to expression. Analytic therapy, on the other hand, does not seek to add or to introduce anything new, but to take away something, to bring out something; and to this end concerns itself with the genesis of the morbid symptoms and the psychical context of the pathogenic idea which it seeks to remove." (p. 254) A similar distinction is offered in the General Introduction, designed in like fashion to temper the implications of his acknowledgment in that work that "we have only abandoned hypnosis in our methods in order to discover suggestion again in the shape of transference." He describes the ways in which suggestion was used at the time by those therapists who were primarily hypnotic and suggestive in their orientation, and differentiates it from the use of suggestion in psychoanalysis: "The hypnotic therapy endeavours to cover up and as it were to whitewash something going on in the mind, the analytic to lay bare and to remove something. The first works cosmetically, the second surgically. The first employs suggestion to interdict the symptoms; it reinforces the repressions, but otherwise it leaves unchanged all the processes that have led to symptom-formation. Analytic therapy takes hold deeper down nearer the roots of the disease, among the conflicts from which the symptoms proceed; it employs suggestion to change the outcome of these conflicts." (p. 392) Perhaps the clearest statement of this general approach to the problem of suggestion appears in an encyclopedia article Freud wrote in 1922. His argument in that article enables us as well to discern more clearly Freud's strategy for reconciling his wish to minimize the role of suggestion in psychoanalysis and his recognition that in fact suggestion plays a key role in all therapies, including psychoanalysis. "Psycho-analytic procedure," he wrote there, "differs from all methods making use of suggestion, persuasion, etc., in that it does not seek to suppress by means of authority any mental phenomenon that may occur in the patient. It endeavors to trace the causation of the phenomenon and to remove it by bringing about a permanent modification in the conditions that led to it. In psycho-analysis the suggestive influence which is inevitably exercised by the physician is diverted on to the task assigned to the patient of overcoming his resistances, that is, of carrying forward the curative process." (Freud, 1922, p. 126; italics added) This last statement points us toward at least a partial resolution of the seemingly contradictory views about suggestion that Freud presented at different times. It suggests that it was not suggestion per se that was ruled out of psychoanalytic practice, but a particular kind of suggestion - that form of suggestion that it was the destiny of psychoanalysis to replace. Prior to Freud's discoveries, suggestion was primarily employed in a manner both unsophisticated and rather authoritarian. The therapist would state quite explicitly, and without any understanding of how the symptoms had come about, that they would now disappear. Sometimes, perhaps surprisingly, that would be perfectly sufficient, and the symptoms in fact would disappear. On many other occasions, however, this technique either failed to bring about the desired results or the results were only temporary. In many respects, it was this rather primitive utilization of suggestion that Freud had in mind when he distinguished psychoanalysis so sharply from suggestion and which he rightly argued psychoanalysis had replaced. In contrast, when the aim of suggestion was the pursuit of uncovering the hidden recesses of the mind and encouraging the patient to give up his defenses and resistances, Freud welcomed this powerful force as an indispensable ally. Such a distinction would seem to offer an acceptable, and quite logical, reconciliation of the differing evaluations of the role of suggestion cited above. Indeed, in its light, the statements are not even so sharply contradictory. Suggestion is indeed an important element in any therapy, and the requirement is only to use it in a sophisticated fashion that furthers the deeper and more extensive aims of the patient and the therapy rather than the short-sighted aim of achieving merely temporary relief. From this perspective, the suggestive elements in the attributional comments described earlier in this chapter would be relatively uncontroversial. Those examples, though employing suggestive influences in a way that differs in important respects from traditional psychoanalytic practice, are also aimed at furthering the patient's efforts to come to grips with warded off experiences and inclinations, not at bolstering the repression of those tendencies. This seeming reconciliation, however, is not quite sufficient. For Freud had still another requirement. _In every other suggestive treatment,_[13] he said, _the transference is carefully preserved and left intact; in analysis it is itself the object of the treatment and is continually being dissected in all its various forms. At the conclusion of the analysis the transference itself must be dissolved._ (Freud, 1916, p. 394) Something akin to this idea is influential as well among many therapists who do not think of themselves as psychoanalysts but who practice some form of interpretive or exploratory psychotherapy. In part this requirement of dissolving the transference reflects ethical and value concerns, concerns centering on the importance of fostering the patient's autonomy, on enabling him to emerge from the therapy as a free person who makes his own decisions rather than living out an orientation to life in which irrational attachments to others determine his views and choices. I have addressed this set of concerns in some detail elsewhere (Wachtel, 1977, especially chapter 12; Wachtel, 1987, especially chapters 10-12). Suffice to say for now that I believe that the formulation Freud puts forth here is neither as feasible nor as desirable as he implies. The idea of _dissolving_ the transference is one of those initially appealing rhetorical tropes of which Freud was such a master. Its empirical substance, however, much less any reliable evidence for its occurrence, is not so close at hand. Moreover, if one examines carefully the basis for preferring such an outcome, it turns out to rely upon a set of ideas, rooted in the highly individualistic ethos of our social and economic structure, that are far more problematic than they first appear to be (Lukes, 1973; Lux, 1990; Rieff, 1966; Schwartz, 1986; Wachtel, 1989). Freud's epistemological anxieties I wish now to turn to another, less commonly remarked upon reason for Freud's effort to present psychoanalysis as a therapy in which the role of suggestion was somehow transcended. Perhaps the most weighty factor in Freud's opposition to openly embracing the role of suggestion was epistemological - indeed, one would not be exaggerating very much to refer to his concerns in this regard as epistemological anxieties. In the very paragraph in which he ends up arguing that the transference is "dissolved" at the end of the analysis, Freud takes up quite explicitly the challenge that "regardless of whether the driving force behind the analysis is called transference or suggestion, the danger still remains that our influence upon the patient may bring the objective certainty of our discoveries into doubt; and that what is an advantage in therapy is harmful in research."[14] He notes further that if this claim were justified, "psycho-analysis, after all would be nothing else but a specially well-disguised and particularly effective kind of suggestive treatment; and all its conclusions about the experiences of the patient's past life, mental dynamics, the unconscious, and so on, could be taken very lightly." This, clearly, is Freud's real nightmare. The apparent inconsistencies in Freud's view of suggestion and the evident struggles discernible in his efforts to come to grips with it can be best understood, I believe, if we recognize that Freud was struggling with two quite different implications of suggestion, one therapeutic and one essentially epistemological. As the passages cited earlier indicate, Freud was too honest and perceptive an observer to deny the highly significant role of suggestion in psychotherapeutic change. Though he endeavored to develop a therapeutic method that was more than mere suggestion (and succeeded in this endeavor quite considerably, I believe), he could not - as much as he wished to - consistently argue that he had replaced or eliminated suggestion as a therapeutic force. The most he could do was to claim that he had harnessed it, that he had turned it to the purposes of analysis: to uncover the hidden and rejected portions of the psyche and overcome the resistances, rather than to bolster those resistances and achieve relief at the price of once again burying what was struggling to come to light. From the perspective of the therapeutic function of psychoanalysis, such a recasting of the role of suggestion in analysis was quite enough for Freud; as we have seen, on those occasions when he was directing his attention to the therapeutic process, he was inclined to give suggestion its due. But being a psychotherapist was never the central core of Freud's professional identity. As numerous observers (including Freud himself) have noted, Freud's commitment to psychoanalysis as a method of research was much stronger than his therapeutic zeal. It was most of all as a researcher and as a theorist, as a discoverer of new facts about the mind, that Freud hoped for immortality, and it was on these grounds that he experienced suggestion as a specially dangerous and alien presence. If we can appreciate how strong a threat suggestion was to the veracity of the data of Freud's new science, how powerful was the motivation on these grounds for disavowing the suggestive elements in the method that was simultaneously his therapeutic and research tool, we may be in a position to reassimilate what he himself had recognized (albeit never without considerable discomfort and ambivalence) about the considerable role suggestion plays in the therapeutic effectiveness of his method. We may then conclude, following Freud, that suggestion is an almost inevitable element in all psychotherapeutic efforts, certainly in those that are successful. But we may further note that the development of psychoanalysis - and later of other modern therapies derived both from psychoanalysis and from other sources - opened up possibilities for incorporating suggestions into an entirely new context, changing their use in ways that made old distinctions anachronistic. Rather than simply suggesting away the symptoms that brought the patient to treatment, the suggestive element in modern psychotherapies (whether implicit or explicit) is employed in a wide range of ways to enable the patient to confront the conflictual issues in his life. As depicted earlier in this chapter, for example, the patient can be helped temporarily to gain the confidence to face what he has fearfully avoided, or to take the steps necessary to change a troubling life pattern. The initial pivot of change includes suggestion as a central element; but if the therapy is grounded properly, the processes brought into play by the actions initiated with the aid of suggestion create changed psychic circumstances that are independent of the original suggestive influence. Once the patient starts moving in a direction that furthers his psychological growth, new forces come into play differing from those which led to that movement. One may see a parallel here to Freud's claim that the suggestive element in the transference is dissolved by the end of treatment, but the parallel is a loose one. It is not through interpreting the suggestive element itself that it is transcended. It is that the changes initiated have further consequences that enable consolidation of the improvement to proceed. In this, the interlocking set of processes that have been addressed throughout this book again must be taken into account. The psychological import of suggestion is not fully appreciated from within a strictly intrapsychic model. Viewed interpersonally, suggestions can be understood as a way of initiating a process which then gets maintained by its effectiveness in eliciting new and different responses from other people in the patient's life. This in turn contributes to further intrapsychic changes in the patient or to preserving those changes which have accrued. It is in this sense most of all that the effects of suggestion are transcended, to be replaced by the forces which, in any life, are responsible for sustaining psychological structures and patterns of interaction and relationship. Without an appreciation of this transactional dimension, understanding of the suggestive element in the therapy is limited and distorted. Predictive interpretations and tacit knowledge Suggestions can be understood as essentially predictive interpretations, interpretations directed toward inclinations or possibilities in the patient that have not yet found adequate expression. Not just any prediction, however, can be effective; the suggestion will only have a chance of being met by a positive response on the patient's part if it is in fact a reasonably accurate interpretation of the patient's potential experience. A suggestion that is not rooted in an understanding of the patient's conflicted inclinations will have little impact. Fears that attending to the suggestive dimension of the therapeutic interaction in the way described earlier in this chapter will somehow rob the patient of his autonomy actually do the patient a disservice; they show insufficient respect for the individual's ability to resist directives that do not accord in some way with his own real, if as yet unrealized, dispositions. Indeed, even in hypnosis, much less in the context of the gentle and empathic suggestions advocated here, there is evidence that suggestions that are not consonant with the individual's own value system are rejected (Orne, 1972; Orne & Evans, 1965). In some ways, this argument for the legitimacy of attending explicitly to the suggestive dimension in therapeutic practice dovetails with considerations offered by Freud as a further part of his defense of the epistemological foundations of psychoanalytic discoveries. Addressing the possibility that suggestive influences might account for the findings of psychoanalysis, Freud argued that "Any danger of falsifying the products of a patient's memory by suggestion can be avoided by prudent handling of the technique; but in general the arousing of resistances is a guarantee against the misleading effects of suggestive influence." (Freud, 1922, p. 126) In his paper on Constructions in Analysis (Freud, 1938), he further argues that "the danger of our leading a patient astray by suggestion, by persuading him to accept things which we ourselves believe but which he ought not to, has certainly been enormously exaggerated. An analyst would have had to behave very incorrectly before such a misfortune could overtake him." (p. 363-364) Resistance, one might say, has a silver lining. Although it can be a powerful impediment to therapeutic progress, it is also in a sense a guarantor of the legitimacy of the process. Patients are far from putty in the hands of the therapist. And if the therapist's efforts are at cross purposes with those of the patient, her efforts will be ineffective but are unlikely to move the patient very far in a direction he does not wish to go. Perhaps one of the most useful ways to think of the suggestive dimension of therapists' comments is in terms of the philosopher Michael Polanyi's notion of tacit knowledge (Polanyi, 1958; 1966). In offering attributional interpretations, we are helping give shape to an urge or tendency that is in process, that is becoming something but is as yet still partly inchoate, or as Polanyi might put it, that is as yet tacit. As therapists we help to give voice to those implicit dimensions of the patient's experience, and in doing so we contribute to the shape that they take. But the basic architecture is always supplied by the patient. Taking this a step further, and consistent with the view guiding the entire approach described in this book, our attempt to give voice to the patient's tacit inclinations is paralleled by an effort to help the patient also find actions that can further define and develop his evolving sense of how he wants to be in the world. Thus, the suggestive dimension described in this chapter can be seen as part of a broader attempt to aid the patient in shaping his life in accord with his continually changing and emerging sense of self. Footnotes [1] Obviously, this does not mean eliminating all sense of uncertainty or confusion. It is a regular feature of therapeutic work that our immersion in the conflicts and anxieties of another person inevitably means that there are times in the work - often times in every session even - in which we are not clear what is happening or where to go. But it is my hope that the considerations offered in this book will at least make that experience somewhat less frequent, and that even when such experiences of confusion inevitably arise [do arise], the clarifications offered here will aid in the task - so central in psychotherapeutic work - of using that confusion productively to understand the patient better and help him to proceed less conflictedly in the pursuit of his deepest aims. [2] To be sure, it was often a conflicted monologue, one in which not only were different affectively powerful inclinations vying for expression but in which, especially with the advent of object relations theories, different voices could be said to be expressing themselves. Whether the conceptualization of these different voices meant, however, that the patient’s associations constituted [reflected] an inner dialogue, is a matter requiring further discussion. I shall address this issue below in discussing the idea of one-person and two-person models. [3] Part of what makes this suggestion a whimsical one is that even a version of Aone" and Atwo" that is cosmetically improved with fractions or decimals does not address the larger context that is always part of psychotherapy. Sullivan, for example, has suggested that there are always [A8 people in the room"] ({each party’s parents and grandparents)}, and others have made related points about the imagos, personifications, or internalized objects representing the viewpoints of parents and other important figures not physically in the consulting room. Similarly, beyond the two physical bodies in the room there is the important influence of the larger social context, its mores and values, the ways it assigns merit or lack thereof to each party, and so forth. In recent years, this dimension of the larger reality represented in the room has been addressed with concepts such as an Aanalytic third" (Benjamin, 19xx; Ogden, 19xx) and analytic Afourth" (Altman, 19xx). I will discuss later what I find problematic about this particular language for discussing the issue [the problem], but the point that even in so-called Aindividual therapy" there are {multiple influences and perspectives in the room, not merely one or two} is an important one that I will discuss further as we proceed. [4] One very important implication of what I have just noted is that it is an error [an epistemological error] to base one’s understanding of the patient too preponderantly on what is manifested in the transference. This is something that two-person theorists {relationally oriented therapists} most of all should recognize, but as we will see in discussing therapeutic technique, the error of overvaluing the informational yield of the transference is perhaps as pervasive among relationally oriented therapists as among more classically oriented therapists [as pervasive among therapists who putatively operate from a two-person model as among more Aone-person" practitioners. [This is an important point - should this be in text in this section and not in a footnote? - or is it ok to have it be footnote since it is basically a foreshadowing of a point that will be discussed in the text at a later point in the chapter?] [5] Think of your own way of relating the same events to those people with whom you feel the most loose and comfortable and those with whom you feel the most constricted or self-conscious. [6] The reader should be clear that I am referring here not to converting an individual therapy into family therapy or couples therapy, but to expanding the frame of individual therapy through the occasional introduction of such modifications in the therapeutic frame. For a fuller discussion of the use of such Acast of characters" sessions, as well as a more detailed discussion of when one might choose individual therapy and when couples or family therapy, and, in the former instance, how one may incorporate these occasional sessions without the work automatically being converted into family therapy, see Wachtel & Wachtel (1986). [7] As we shall see, this attempt to restrict the Adistorting" influence of the therapist’s spontaneous reactivity [the Adistorting" effects thought to result from the therapist’s reactions to the patient’s behavior or his range of interactional behavior more generally] actually limits our understanding of the patient, restricting it to an understanding of how the patient behaves and experiences in a relatively narrow range of contexts. [8] It is important to note {It should be noted} that in addition to his epistemological point about how to provide the analyst with the most accurate knowledge, Gill is also addressing a significant matter of technique and of the theory of technique. He is centrally concerned in this paper with the conditions for persuading the patient that these transference manifestations come from within him rather than as a response to anything the analyst is actually doing. I shall have occasion below to consider further the implications for clinical technique [to examine some quite important implications for clinical technique] of Gill’s subsequent rethinking of the position he took in this paper [in this 1954 paper]. [9] I will have more to say about the Amagic" [wonderful] [clinically significant] word also in a later chapter. [10] This position is often likened to Heisenberg’s uncertainty principle or to the ideas in relativity theory about the way such fundamental dimensions as time or distance, once thought to simply Aexist" independently of the conditions of observation, are dependent on the position and relative motion of the observer. No doubt, the ways in which both quantum theory and relativity theory shook to its core our very notion of reality had a profound effect on our thinking in all realms, including the psychological. But the resemblances to these two highly mathematical conceptualizations - addressed to phenomena occurring at close to the speed of light [or to the ways in which the specific properties of photons limit our ability to know simultaneously the precise position and momentum of a subatomic particle] [or in the realm of the almost unimaginably small] - are at best very loosely analogical. Ideas about Auncertainty" or Arelativity" in the psychological realm must stand on their own feet, without the borrowed prestige of these quite different kinds of theories. [11] The psychoanalytic method evolved out of Freud's efforts to utilize, and then to modify, the suggestive therapies that were the dominant therapeutic approach when Freud began his practice. Influenced first by the theories of suggestion of Liebeault and Bernheim, and then by the results of Breuer's (and Anna O's) experiments with hypnosis, Freud began as a practitioner of suggestion. Over time he progressively modified his use of suggestive methods until, eventually, the psychoanalytic method he developed seemed to bear little resemblance to the approach from which it evolved. As the discussion below indicates, however, the role of suggestive influences in psychoanalysis was never as minimal as is sometimes supposed. [12] Freud only reluctantly, and under financial pressure, turned from a career in research to one as a practitioner. He acknowledged on a number of occasions that he was _lacking in therapeutic zeal_ and that his interest in the psychoanalytic enterprise was above all an interest in the research possibilities it afforded. He argued, of course, that there was a necessary convergence between his interests as a researcher and the patient's interest in being cured. There is reason to think, however, that this fortunate harmony was considerably exaggerated. (See Wachtel, 1987, Chapter 12.)
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