Since the issue of interpretation has been discussed on our listserve, sometimes in such negative terms that one risks generalizing to a point which may eclipse its potentialities at helping patients recover and in furthering re-integration of split off affects and unconscious aspects of self- and other which are anxiety provoking, and despite Winnicott's aphorism that he interprets to show the patient the limits of his understanding (what some in the Sullivanian tradition would understand as a counter-projective technique designed to clear away toxic and paranoid projections from the interpersonal field), I have decided to share some thoughts on this subject which have emerged from a contemporary Post-Kleinian tradition. Also, I would highly recommend Roy Schafer's (2003) "Insight and Interpretation: The Essential Tools of Psychoanalysis" published by Other Press (as well as his "Bad Feelings" also published in 2003 by Other Press), for an interesting integration of contemporary Freudian and Post-Kleinian theory and practice. Again, as I have noted previously, to distinguish insight/non-relational from supportive/relational aspects of psychotherapy can be quite artificial and certainly, in my experience, not reflective of what actually takes place in long-term psychotherapy. Emotional insight is achieved within a deeply relational context.
Transference Interpretation: Post-Kleinian Perspectives
For Grinberg (1997) as well as many other post-Kleinian psychoanalysts:
“It’s the transference interpretation that achieves the transformation of repetition into modification – that is, into dynamic changes in which the patient’s ego can perceive his emotional experiences and become conscious of his impulses just when they are being actively directed towards the object, the analyst, in the immediate relationship” (p.3) According to Grinberg, the negative transference has a positive aspect because it allows the patient the opportunity to re-experience a needed sense of autonomy and control within the psychoanalytic setting, and may prove very useful if properly understood and interpreted by the analyst.
Rosenfeld (1987) observed that severely traumatized patients are driven to repeat post traumatic interactions and situations in the analytic situation. According to Rosenfeld, one of the most important facts which has to be considered is the traumatic experiences with which the patient has had to cope with all on his own. The patient therefore tries to involve the analyst in his experiences by very forceful projections, sometimes so violent that they appear as attacks. If the analyst interprets these projections as attacks, the patient may feel rejected and therefore may withdraw. Rosenfeld believed that the violence of the patient’s projections will gradually diminish if the analyst succeeds in correctly interpreting the patient’s anxieties and in addition, her need to share her experiences with the analyst.
Grinberg (1997) offered us some cautionary comments on the inappropriate use of transference interpretations of depressed patients that arises out of a failure of containment. “...renouncing grief is like renouncing the lost object once and for all, with no possibility of repairing or recovering it by working through. Missing the suffering and wanting to go through it again implies a wish to meet up again with the object; otherwise it would be necessary to confront its absence, which might lead to absolute despair. Suffering is sought because it occupies the place of the lost object and of the aspects of the self felt to be lost together with the object. The manifestations of this mourning, or lack of mourning, usually appear in the transference explicitly (in the form of grief or suffering) or concealed by feelings of anxiety, rage or excitement. Such feelings are, of course, projected into the analyst, who on occasion tries to protect himself by projective counter-identification in order to experience them in himself, or to avoid the re-activation of his own mourning by countertransference reactions. One form of protection might be immediate interpretation of the transference, which would thus become a reprojection into the patient, that is, a lack of containment.” (p. 5)
Grinberg pointed out that even those psychoanalysts who proclaim the importance of transference and the use of transference interpretations often are afraid to “penetrate to the deepest and most regressive levels of the transference because they unconsciously fear that this might commit their emotions excessively. In other words, they remain on the level of ‘K’ knowledge (talking about psychoanalysis) instead of becoming ‘O’ (being psychoanalysis), which constitutes the deepest form of knowledge, rooted as it is in experience (Bion, 1970)” (p.5).
Bion (1992) hypothesized a psychoanalytic territory with its own reality and rules. Such realities are available and accessible through an intuition that is not too clouded by memory, desire and cognitive understanding. I believe that it may be this intuitive, unmediated emotional grasp of what the patient is or is not trying to communicate that is the art in the science of psychodynamics.
If the analyst experiences the transference projections as having the quality of concrete realness attached to them, she might experience anxiety that is so intense that she may use any means available of denying the importance of the transference. The bind analysts often find themselves in during these situations is aptly described by Grinberg (1997):
“On the one hand, he is afraid of being invaded by the most regressive and psychotic contents and persecutory objects of the patient’s material, with the threat of loss of his mental balance. On the other, he may fear damaging the patient with his own fantasies of retaliation or of not being a good container” (pp. 5-6).
Another way of understanding this situation, according to Grinberg, is the inability to endure a time of catastrophic change, which carries with it the opportunity for psychic growth, as well as the risk of psychotic disorganization. A process of temporary suspension of identifications may occur, which encourages a kind of working through in silence [perhaps similar to Harold Searles’ concept of a therapeutic symbiosis]. Grinberg suggested that the nature of our work exposes us to the taking of such risks and that: “If the experience proves to be privileged, within a fruitful transference-countertransference interchange, the result will be mental growth on the part of both patient and analyst, which will help with the emergence of new identifications. If not, the result may be a catastrophe (a psychotic episode or acting out, etc., on the part of the patient, or a serious emotional disturbance in the analyst)” (p. 6).
Brian Koehler
New York
The following is an example of the patient's arrival at an insight (in Sullivan's terms -- he believed that psychiatric 'cure' consisted of the person as known to others is the person known to her/himself) as a result of a relational enactment within the context of long-term psychotherapy.
This patient, years ago, was given a very poor prognosis -- documented on a film in which she participated. However, since she has been in long-term psychotherapy, she has no longer needed to return to the state hospital, can live successfully in the community, is no longer psychotic (her meds have not changed for years -- she was on them during her long years in a state hospital), has a boyfriend, is now seeking employment in a health-related field. Our sessions are increasingly permeated with playfulness and therapeutic symbiosis (as opposed to years of a more 'pathological' paranoid relatedness).
Cynthia, an overweight individual in her early forties with the diagnosis of schizoaffective disorder and obsessive compulsive disorder with severe masochistic tendencies, is in psychoanalytic psychotherapy with me twice weekly for a few years now. She is a good example of Freud’s view of the ‘melancholic superego’ as a pure culture of the death instinct. I believe that her illness can be more usefully understood from the perspectives of attachment theory and a more relationally based psychoanalysis. Cynthia and I began our psychotherapeutic work together upon her discharge from a state psychiatric hospital. She was terrified of hurting others, particularly vulnerable others such as babies, children or the elderly.
One could think of this as her attempt to kill off her own vulnerability in others, and perhaps this contains some truth. At the same time, it is very much a defensive reaction to an identification with an aggressor (in her case, I believe it is an aggressive paternal introject -- he has physically and emotionally abused her -- which has, in a way, crowded out and diluted her own sense of self). As with most symptoms, this one was multiply determined and also contained elements of anticipatory anxiety, an attempt to be constantly on guard, lest this toxic introject be unleashed unmercifully on the world.
In addition, her strong inner sense of badness of the self may very well be as a result of all the pain and suffering she endured developmentally, perhaps as a result of states of organismic panic, its associated affects of rage and depression, along with parental misattunement and a lack of mutual parent-child cueing. (Pao 1979) Cynthia agonized whenever anyone got close to her, physically or emotionally, as she was then plagued with fears of damaging them. I have come to believe that underlying these fears is a profound sense of helplessness, lack of control of herself and others, separation terror from others upon whom she feels her existence rests, as well as persecutory and depressive guilt/anxiety.
One day Cynthia asked if she could call Madison Square Garden to get information on a rock concert, since it is difficult calling from her psychiatric residence or a pay phone. I responded that it would be fine and quickly witnessed her helplessness in carrying out a relatively simple task. Looking back, I believe that Cynthia wished for me to see what a dilemma she can get into on a daily basis (besides the constant obsessions). She enlisted my help so that as she spoke on the phone, I pushed the buttons at her command in order for her to get into various mailboxes. She was clearly overwhelmed and became agitated and self-disparaging. When I did not push the buttons fast enough, she ragefully exploded at me and I quickly had the feeling that I was about to be hit by the phone (she later confirmed this but managed to refrain from such an enactment). I immediately snapped back, “No, I won’t push the buttons, I am doing you a favor and I don’t like being yelled at like that!” This quickly led to her becoming sad and reflective, she said that she was treating me the way her parents usually treated her, with impatience and severe criticism, and at times, tied to physical abuse. Here I would prefer to invoke Freud’s concept of identification with the aggressor and contemporary attachment and relational theory rather than a putative death instinct.
Brian Koehler
