In responding to this chapter, I want to start with an appreciation for Jane Hall's efforts to make her therapeutic efforts, “patient centered,” acknowledging that rules need re-examining and that, “ONE SIZE DOES NOT FIT ALL” (her emphasis). Her presentation is mostly stripped of jargon, but I think we can go further in talking to each other in an experience-near manner, consistent with Hall's wish to level the field between patient and therapist so as to make the therapeutic dialogue one in which the patient is empowered to participate as the expert on what is in his/her mind and potentially enabled to identify how what's in their mind got there. I will quote selectively from Hall's chapter in considering the advantages, and potential pitfalls, of moving even further in a jargon-free direction.
In her introductory section, Hall suggests, “One common way to remain connected while at the same time separating, albeit in a compromised manner, is via identification with the aggressor.” I would like to unpack this idea in my beginning attempt to illustrate what I have in mind. Describing human motivational states is complicated because motivation is complicated. Divergent aims are part and parcel of human behavior, which leads to the notion of “compromise formation.” While our theories have leaned on this notion in reference to drive derivatives seeking expression, as well as to psychic defenses, the idea of compromise need not carry with it baggage from a particular metapsychological theory (e.g. drive theory). Hall is suggesting that for a child raised in a traumatic or abusive or neglectful environment there is often a need to find ways to both retain a needed attachment and to express rejection or hostility towards the attachment. “Identification with the aggressor” is a concept which suggests both (e.g. “I will take in my tormentor, emulate him/her, and dispense toward an other that to which I was subjected,” complicated by the fact that the identification and the aggressive behavior are both determined unconsciously). This all makes sense to me, but I'm not
sure how much the idea of “identification with the aggressor” adds to our work with patients. Using the concept is our own way of identifying with teachers, supervisors, authors, analysts who came before and letting each other know that we are from the same tribe. Clinically, I think the important principles are that we recognize a life-long need for and pursuit of attachment, and we recognize that relationship difficulties, including especially early difficulties with caretakers, make this a complicated pursuit.
As I wade into the interface between theory and the clinical setting which Hall presents, with her focus on patients whose sub-optimal early life experiences have contributed to chaotic experiences in relationships as they age, there is reference to “splitting,” to the therapeutic task of translating action into words, to “strengthening the ego,” and to regulating the patient's degree of regression. All of these concepts are familiar to analytic clinicians, but are they the most helpful way to describe what happens in the clinical setting? I choose these because of how commonplace they are, and my question/critique can apply to much of our usual use of clinical theory.
I'll start with the idea of splitting. The theory of defensive splitting comes from object relations thinking, with the notion that good images of self and other are kept separate from bad images so as to avoid catastrophic experiences of badness either attacking one from the inside or coming at one from bad others. Splitting is pictured as protecting a good sense of self or a benign experience of the other from these threats. OK, but I want to argue for the importance of recognizing that split states may arise from other than defensively motivated purposes. Extreme experiences of childhood overstimulation or abuse may be segmented off internally due to their extreme nature, not necessarily because it is too threatening to integrate them into one's encoded experiences of self or other. A patient's memory of being told by her beloved father that she is so much better than her peers is clung to because it carried with it a feeling of pride, goodness, superiority, a feeling of being loved most of all. Extreme affects lay down memory traces that preserve associated experiences and are not necessarily the result of “splitting.” How do we tell in a given situation what gives rise to extreme, polarized portrayals of images of self/other and or to affective responses that are hard to
account for because of their intensity? The answer, as it is in most (all?) clinical situations, is to remain curious without assuming that extremes of either/or represent defensiveness.
What about translating “actions into words”? Hall sees this happening when her patient, in a state of depression with vegetative symptoms is able to do the work of mourning and eventually to “say goodbye to a grandiose self” with the help of her therapy. Sometimes when therapists ask patients to put something they are enacting into words (facial grimaces, tears, hitting oneself or other versions of self-abuse), it comes across as if the therapist has a theory that action replaces words, and that maybe this replacement is defensively motivated, i.e. that it is too painful to entertain the words for what one is feeling. There is room for debate as to what extent psychoanalysis (or psychoanalytic therapy) is primarily a verbal form of treatment, in that much goes on, whether attended to or not, nonverbally. But there is something important about being able to put experience into words. Verbalizing a feeling requires being able to achieve sufficient distance from it, and sufficient perspective, to be able to capture the feeling in a manner that can be considered with another party. But I'm not sure that considering this movement from nonverbal to verbal is a “translation,” and sometimes the preferred therapeutic movement is from just words to something felt that is beyond words. I think the back and forth between verbal and nonverbal is richer and more complicated than referring to it as translation makes it appear.
What about “strengthening the ego”? Late in his career, Charles Brenner moved away from the version of ego psychology to which he had been a major contributor. In positing that rather than seeing conflict as involving competing psychic structures, compromise involved competing trends within the psyche, e.g. experiences that arouse unpleasure might be warded off by more pleasurable content (see Brenner, C. (2006). If we are to look at psychic functions rather than reified psychic structures, we might be pressed to clarify what it is that we refer to as strengthening the ego. I have in mind such phrasing as building affect tolerance, increasing reflective capacity or mentalization, or loosening attachments to pain-inducing situations. While any of these could be seen as strengthening functions that structural theory assigned to the ego, perhaps we can let go of structural thinking, which I think is more experience-distant than the clinical situation deserves.
As for regulating regression, Hall tells us of a period of time when she and her patient met face-to-face, rather than the preferred use of the couch. She tells us, “I struggled with how much regression I thought we could and should tolerate. Sometimes we agreed that using the chair was preferable to the couch because looking at each other did serve to hold her together when fragmentation threatened.” This interesting observation, connected to Hall's wish to help strengthen the patient's ego, can be thought about in different ways. Clearly, sitting up face-to-face changes the perspective and the stimuli most readily available for both parties. Being able to access the analyst's facial expressions may be a source of information that is lost with the lack of visual contact; the analyst's capacity to take in the patient's nonverbal responsiveness is increased relative to sitting outside the patient's sight with the patient in a prone position. This greater access of both parties may contribute to a less depriving (and therefore potentially less “fragmenting”) atmosphere for patients, but is this more outer-directed than inner-directed connection necessarily less regressive? Perhaps it depends on the analyst-patient pair or on the stage of treatment; in any case, I'm not sure we are so much able to control the patient's degree of “regression,” though we can surely provoke anxiety states or states of heightened affect by being more distant and depriving.
So, I'd like to encourage Hall to go further with her critique of certain traditional ways of viewing the clinical situation. I'd also like to encourage her to be more forceful in critiquing positions of authority in analytic work. I will select a few examples from her discussion to illustrate my points.
Hall tells us that when a patient is coming from a background where deprivation led to impaired capacity to trust, in the face of such lack of trust, “explanations and conversations work far better than interpretations with such patients.” I am uncomfortable with the idea of giving patients explanations, though I certainly agree that we are trying to help them find explanations, and this task may be facilitated by tentatively offering a hypothesized explanation of our own. While I applaud Hall's wariness of interpretations given in a way that conveys the analyst's position of authority in relation to the dilemmas patients bring, does the idea of “explanation” move us away from such a position? Perhaps the crux of this lies in how one delivers one's comments, whatever we call
them. What is involved in the search for explanation is really an alternative perspective. For example, a patient may assume that he/she deserved to be treated abusively. Hall says that in such situations, “It is important to remember that what is familiar, no matter how painful, feels safe.” We might approach such a patient with the perspective that they blame themselves because 1) they were blamed by others; 2) it gives them some feeling of both familiarity and control (if you were responsible, you could have avoided punishment by being better, and that idea is preferable to the idea that your caretakers were hateful or crazy or arbitrary in their punishment); 3) self-blame is intended to avoid the feared criticism coming at them from others. In the face of this dynamic, we offer the possibility of freeing themselves from extreme self-criticism, with the certainty that they need no longer fear abuse from others upon whom they are dependent.
The kind of explanation involved in bringing an outside perspective to patients' maladaptive formulations is arrived at slowly with much back and forth, so that it is truly a joint project. I imagine that Hall would agree with this and perhaps say that this is exactly what she said or implied. She says, “Food for thought is all we can give, but it is given with love.” My point is that I think her saying that “explanations and conversations work far better than interpretations with such patients,” implies a level of authority for the explanation-delivering analyst that in other places she is appropriately challenging.
One thing about the power of different perspectives being delivered in conversation is that this conforms with my understanding of building mentalization. In Fonagy's writings (e.g. Fonagy, 1995; Fonagy & Target, 1996; Target & Fonagy, 1996), the pre-stage of mentalizing is “psychic equivalence,” which involves the conviction that what is in one's mind is what is real and therefore what is in everyone else's mind. The revelation in the context of a meaningful psychotherapy relationship that there are alternative ways to think about one's perceptions contributes to the strengthening of mentalization capacity.
Hall refers to the inability to mentalize as a box, akin to “borderline” into which we put patients such as her patient, Lois. A difference, though, is that the inability to mentalize is both something that is common to all of us under certain conditions (e.g. relationship stresses, anxiety states)
and “borderline” is a designation that often implies “difficult to treat” and even “untreatable.” Mentalization vulnerabilities are certainly treatable (though they may pose difficulties for the therapist).
Hall suggests: Try as we therapists do to compete with the bad enough object by offering ourselves as a new object, we sometimes fail and lose hope. This is understandable and not everyone is cut out for such difficult work. It is rarely gratifying and may even be considered as masochistic to try. So those who do hang in deserve appreciation.
At the end of the chapter, she suggests, “if we therapists are patient and courageous, connection can happen…. Two people take a journey during which new growth occurs and although the travel can be exhausting the rewards make it well worth it.” I agree heartily with this statement. In my experience the work of connecting with someone with a problematic or abusive past can be extremely gratifying, and I don't think this experience is so rare. As I think about the course of my career, some of the most gratifying people to work with have also been those who struggle to form a connection. Upon further reflection, and with some fear that people who have not been so difficult to engage might feel slighted if they read this, I would say that every treatment has its potential gratifications for the therapist, but the slowly developing capacity to allow me to make mistakes (as happens inevitably) and then to still take in my observations/reflections is certainly a gratifying development in the treatment of those with limited initial capacity to mentalize.
So, I encourage Jane Hall to stay with the optimistic streak that runs through her chapter: change is possible for patents quite damaged by their early upbringings and participating in such change is gratifying to the therapist who does so. Techniques of working in such treatments can be described without resort to jargon, even to jargon that is so often used in our field as to be commonplace (dealing with “splitting,” turning action into words, strengthening the “ego,” monitoring regression, etc.). Two other phrases which Hall introduces are “self-murder” and “bad enough object” experience. I don't think either of these constructs helps her argument, and for me they detract.
I'll start with “self-murder;” I remember when I first became familiar with Shengold's Soul Murder (1989), to which Hall refers. I thought it
was a terrific title, capturing the deadening effect on the adult internal world among those who suffered unspeakable abuse as youngsters. The people who commit such acts on children have problematic attitudes toward the children, highlighted by a hostility to the child's need to have his/her sense of self recognized and nurtured. This phenomenon is captured by the idea that they are engaged in interpersonal acts which kill off important elements of the child's self. Hall's self-murder is a related term. She tells us that it, “applies to self-states that reside in the whole self … [the term] is a literal way of saying that a cohesive self has not been achieved or that self and object differentiation has not occurred.” It is observably the case that suicidal states of mind often include the wish to murder something inside, and this reflects a lack of realization that murder of one part of oneself is deadly for the whole self. It may be that that which one wishes to kill involves the internalization of an “other,” or an “object” from one's earlier life. If this is what Hall has in mind, we are in agreement about the concept, but I don't find her terminology helpful. I would rather see a description of the nature of the depressive state, including elements of hopelessness and rage, which dominates the clinical picture.
Finally, does the “bad enough” construct help us in our work? It is useful to be reminded of Winnicott's notion of “good enough,” but I think this idea was important as a reminder that one cannot, and should not, aim for perfection. Children, under optimal circumstances, grow from cycles of mistake and repair, as long as the loving, caring parent is able to stay present. I don't think there is an analog to “bad enough.” I would say not good enough is bad. Period. We may shy away from saying that a certain mother or parent was “bad,” and maybe “bad enough” is a tad less accusatory, but we need to be able to tune into patients' experiences of, and descriptions of, misalliance or insensitive or hostile parenting and recognize this as problematic or pathogenic.
For most of the 1990's I was the Director of a partial hospital program at Chestnut Lodge Hospital in Rockville, Maryland. I organized this program in response to the realization that many of the patients we saw with extreme Axis II difficulties did not need long-term hospitalization and even became more disorganized if treated in a confined setting. My work with staff and patients in the program was facilitated by my discovery of Peter Fonagy's papers on mentalization. Viewing our patients as
struggling with mentalization vulnerabilities, rather than as defensively attacking members of staff, allowed staff to maintain greater empathy and to remain thoughtful in the face of hostility rather than becoming reactive. I think this is the essence of Hall's description of her work with Lois. Seeking to facilitate and sustain connection with disorganized patients is the therapist's task. It is what we strive for. To the extent that this has been a critique, it is not a critique of Hall's work but of how she talks about it. Leaving jargon, or theory, out of our descriptions to the extent possible can enrich our descriptions and invite conversation with our readers or listeners. This is to be desired.