Relational Psychotherapy

Downloaded by [New York University] at 13:36 13 August 2016 Relational Psychotherapy

Relational Psychotherapy: A Primer, 2nd ed., offers a theory that is imme- diately applicable to everyday practice, from opening sessions through intensive engagement to termination. In clear, engaging prose, the new edition makes explicit the ethical framework implied in the first edition, addresses the major concepts basic to relational practice, and e lucidates the lessons learned since the first edition’s publication. It is the ideal guide for beginning practitioners but will also be useful to experienced practitioners and to clients interested in the therapy process.

Patricia A. DeYoung, MSW, PhD, is a relational psychotherapist, clinical supervisor, and a founding faculty member of the Toronto Institute for Relational Psychotherapy. Downloaded by [New York University] at 13:36 13 August 2016 This page intentionally left blank Downloaded by [New York University] at 13:36 13 August 2016 Relational Psychotherapy A Primer

Second Edition Patricia A. DeYoung Downloaded by [New York University] at 13:36 13 August 2016 Second edition published 2015 by Routledge 711 Third Avenue, New York, NY 10017 and by Routledge 27 Church Road, Hove, East Sussex BN3 2FA Routledge is an imprint of the Taylor & Francis Group, an informa business © 2015 Patricia A. DeYoung The right of Patricia A. DeYoung to be identified as author of this work has been asserted by her in accordance with sections 77 and 78 of the Copyright, Designs and Patents Act 1988. All rights reserved. No part of this book may be reprinted or reproduced or utilised in any form or by any electronic, mechanical, or other means, now known or hereafter invented, including photocopy- ing and recording, or in any information storage or retrieval system, without permission in writing from the publishers. Trademark notice: Product or corporate names may be trademarks or registered trademarks, and are used only for identification and explanation without intent to infringe. First edition published by Routledge 2003 Library of Congress Cataloging-in-Publication Data DeYoung, Patricia A., 1953- Relational psychotherapy : a primer / by Patricia A. DeYoung. —Second edition. pages cm Includes bibliographical references and index. 1. Interpersonal psychotherapy. 2. Interpersonal relations. 3. Psychotherapist and patient. I. Title. RC489.I55D495 2015 616.89'14—dc23 2014040947 ISBN: 978-1-138-84042-3 (hbk) ISBN: 978-1-138-84043-0 (pbk) ISBN: 978-1-315-72370-9 (ebk) Typeset in Minion by CodeMantra Downloaded by [New York University] at 13:36 13 August 2016 Dedication

To Mary B. Greey Downloaded by [New York University] at 13:36 13 August 2016 This page intentionally left blank Downloaded by [New York University] at 13:36 13 August 2016 Contents

Preface to the Second Edition viii Preface to the First Edition x

Introduction 1 1 Relational Therapy and Its Contexts 11 2 Beginning with the Basics: Structure, Ethics, and Empathy 44 3 Assessment: What’s Wrong When Your Client Feels Bad? 61 4 Relational Trauma: Past and Present, Memory and Now 84 5 The Terribly Hard Part of Relational Psychotherapy 109 6 The Wonderfully Good Part of Relational Psychotherapy 134 7 Ending and Going On 160 8 Twelve Years Later 172

Bibliography 209 Index 213 Downloaded by [New York University] at 13:36 13 August 2016 Preface to the Second Edition

When Anna Moore, my editor at Routledge, asked me if I would be willing to develop a second edition of Relational Psychotherapy: A Primer, I answered, “Yes, but there’s this manuscript on chronic shame I’ve been working on for a while. I think I should finish it first.” Anna trusted my instincts, I buckled down to write the shame book, and then I turned to this project. I didn’t imagine then that the two books would be linked. I simply felt that I had cleared my mind and would be able to speak in my own voice going forward. When I considered the Primer revision, two things came to mind: (1) Twelve years haven’t changed the basic principles of relational practice. (2) Twelve years have brought subtle but significant changes to how relational theory is articulated. Could a revision do justice to both realities? Would I start from the beginning of the Primer and try to weave these subtle changes into the original text? I thought not. It might be easier and more useful to write a completely new book! How then to revise? I proposed an experiment. I would draft a new last chapter (Chapter 8) that would summarize key new articulations of relational theory, explain how they interact with previous theory, and illustrate the changes with some case material. We would then send the new chapter, along with the first edition Primer, to impartial reviewers to see Downloaded by [New York University] at 13:36 13 August 2016 whether the experiment worked, whether this new format would extend the cogency and usefulness of the first edition. Anna welcomed the idea. I felt liberated to write—and grateful that she once again believed in my process. As I worked my way through the four new ideas I wanted to address, exploring their impact on the overall system of relational theory, a certain case kept coming to mind unbidden. Not only did it illustrate the theory in question, it was also a case discussed in the first edition. Thus it could be a perfect example of how new theory creates new meanings, even from material already understood in relational terms. It was, however, my own case, Preface to the Second Edition ix the impasse with my analyst I had written up in Chapter 5, an event I could now acknowledge as a tsunami of shame that took me years—and writing a book—to understand. I wondered: What kind of narcissism would lead me to write about myself again? What kind of shame am I still exorcising? And so I couldn’t quite write the case, though my head was clear enough to see connections between my case and the new theory, and I had voice enough to speak what I saw. But then, thanks to my peer supervision group—Judy Gould and David Schatzky, who encouraged me to take an hour to speak my case to them, and Bonnie Simpson, who wholeheartedly endorsed my first nervous draft—I could write it. Off it went to the reviewers, and their solid support of the project in this form was a great relief. Thanks to Steve Tuber for his helpful questions about the connections between mentalizing, empathy, and compassion. Thanks to Donna Orange for the warm welcome she gave to my personal story and for linking the chapter to an “ethical turn” in relational theory, which inspired me to add the final section, “The Ethics of Showing Up.” Many readers of the Primer’s first edition, mostly students of the Toronto Institute for Relational Psychotherapy (TIRP), have asked me after reading Chapter 5, “So what happened? How did it turn out between you and your therapist?” I’m happy finally to be able to give them substantial answers to their questions. And I owe them thanks for asking—for letting me know that something was missing in the story and in the theory about it. I hope that readers familiar with the first edition will find clarity gained and nothing essential lost in the edited version of the chapters that come before Chapter 8. I am grateful again to my clients, from whom I have learned how to put the new theory into practice. They have taught me that when they show up for real—in need of my personal, emotional presence—good things happen if I, too, can show up for real, with the skill and care I owe them. I have learned with them that there need be no shame in any of the emotions between us, not even when it’s affection we feel. I can’t sign off on this second Preface without thanking those who always Downloaded by [New York University] at 13:36 13 August 2016 help me with my writing. My wordsmith daughter Adriel Weaver came up with good catches in a final edit of Chapter 8. My partner Mary Greey persists in believing that I and all my projects are wonderful (in essence, if not constantly). Sometimes I’m shy about how much her delight matters, but luckily she hasn’t been shy to show up and show some emotion about the new chapter—in which she gets a cameo appearance, as well she should. Pat DeYoung Toronto September, 2014 Preface to the First Edition

This book wouldn’t have seen the light of day without the editors at Brunner-Routledge. Bernadette Capelle was the first to take an interest, George Zimmar proposed a format that would work, and Shannon Vargo and Cindy Long suggested useful revisions. I’m grateful that the Brunner- Routledge team saw value in what I had to say and helped me fashion an appropriate vehicle for it. Graduates and students of the Toronto Institute of Relational Psycho- therapy will recognize that the gist of the book is what they have heard from me over the years. They taught me how to translate relational theory into language they could understand and use. Faculty colleagues Louise Gamble, Rozanne Grimard, Mary Greey, Carl Moore, Jim Olthuis, Rita Fridella, and Catherine Comuzzi all contributed to the relational synthesis that has emerged at TIRP. My understanding of self psychology has been deepened in supervision/ study groups with Howard Bacal, Ellen Lewinberg, and Alan Kindler. A self psychological psychoanalysis with Sam Izenberg has taught me from the inside out what it’s like to benefit from a relationship of consistent empathy and thoughtful understanding. Peer supervision groups have been another rich resource for learning how to put relational theory into

Downloaded by [New York University] at 13:36 13 August 2016 practice. Thanks to the members of my current group—Pat Archer, Midge Breslin, Judy Lester, Susan Marcus, Sonia Singer, and Lisa Walter—not only for what I’ve learned from them, but also for their support for the book project. Thanks, too, to members of another study/supervision group— Diane Johnson, Alisa Hornung, Harriet Tarshis, and Jan Turner—for their helpful response to an early version of the text. My clients have taught me as much about relational therapy as anyone, for one by one they teach me how to be with them. I’m grateful for what we have discovered together and for permission to use some vignettes of our work. The longer case histories I have included are composites of stories Preface to the First Edition xi I’ve heard over the years—except for Lucy’s story. I appreciate her gracious permission to use her story as I have written it. I owe special thanks to those colleagues and friends who read early versions of the manuscript with a critical eye and a willingness to challenge my ideas and agendas: psychotherapist readers Midge Breslin, Pat Archer, Sonia Singer, Susan Marcus, Mary Greey, Betty Kaser, and Cathy Schwartz, and writerly readers Adriel Weaver and Adrian and Johanna Peetoom. I owe special thanks of another kind to Mary Greey, who has been not only a TIRP colleague and a careful reader of early versions of the text, but also a loving partner who has welcomed the presence of this book in our daily lives. Her unshakable confidence in me helped me keep the faith in difficult times, and her good-natured support made it all so much easier than it might have been. Pat DeYoung Toronto September, 2002 Downloaded by [New York University] at 13:36 13 August 2016 This page intentionally left blank Downloaded by [New York University] at 13:36 13 August 2016 Introduction

In a small, quiet room, two people sit facing each other. One of them listens attentively as the other talks, trying to explain what’s troubling her. She speaks in hurried, broken sentences, her shoulders hunched, her face tense with worry. When tears spring to her eyes, she dabs at them with a crumpled tissue. The listener puts a box of tissues within the speaker’s reach and continues to listen without interrupting her. These two people will be here together for exactly fifty minutes. Both of them hope that by the end of that time, the listener will have been able to offer meaningful help to the one in distress. They will meet again next week at the same time for another fifty minutes, because the trouble is complicated and the help isn’t a quick fix. You are the one who sits and listens. You are the psychotherapist. One hour at a time, one person at a time, you listen to the trouble people have living their lives. You hear about how anxious, frustrated, and depressed they feel. They confess to you the self-destructive patterns they’ve fallen into as they’ve tried to do their best. They’re stuck. They’re at the end of their rope. They’re in pain. You listen to them one by one, and every hour you think carefully: What meaningful help can I offer this person? Every time you answer that question, every time you offer a comment,

Downloaded by [New York University] at 13:36 13 August 2016 a suggestion, or an intervention, you do so with conscious or subliminal reference to a theory of how psychotherapy works. The theory gives you a conceptual filter for understanding what’s wrong in the picture, and it gives you a matching set of ideas about what needs to change if this person is to feel better. The theory also guides you, the therapist, to make certain moves to facilitate those changes. General theories of psychotherapy—psychodynamic, feminist, solution- focused, or cognitive-behavioral therapies, for example—view many kinds of psychological problems through the same lens of assessment and treatment. Other theories of psychotherapy address specific problems such as 2 Introduction phobias or eating disorders. Most experienced therapists work from a general theory of psychotherapy, integrating into it specific theories of how to work with particular problems their clients bring. This book puts forward a general theory of psychotherapy, a theory I call relational psychotherapy. It’s not entirely new, for its roots are in psychodynamic and humanist therapies that have been around for many years. It also owes a lot to feminist theories about a fundamentally relational self. But at the same time, relational psychotherapy, understood in its own terms, is a new phenomenon. In recent decades, a relational perspective has opened up new vistas for psychoanalytic theory. And of course analysts aren’t the only therapists who read psychoanalytic theory. Through books and articles, in conferences, therapist training programs, and collegial reading groups, relational theory has become a force to be reckoned with. There are good reasons for the strength of this growing movement: First, relational theory is a powerful general theory of psychotherapy; second, a relational approach provides a strong foundation for responsible, coherent eclecticism; and third, relational psychotherapy is a flexible alternative to goal-oriented, expert-driven models of psychotherapy. Relational psychotherapy is a model driven, instead, by the client’s experience and the client’s needs. It pays close attention to how those needs are understood and addressed within the therapy relationship. Since relational psychotherapy is so client-centered and experience-near, I have written this primer in a way that tracks very closely a client’s experience of relational psychotherapy. Since a relational therapist is always personally engaged in the process of therapy, in parallel process I will speak to you, the relational therapist, with as much personal immediacy as a written text allows.

The Book: An Overview

The first seven chapters of this book are laid out in a sequence that mirrors Downloaded by [New York University] at 13:36 13 August 2016 a client’s experience of therapy. Chapter 1, Relational Therapy and Its Con- texts, responds to questions a client might ask before beginning therapy with you: What does relational therapy offer compared to other therapies? How does it work? The chapter is a useful resource when clients come from other experiences of therapy or are looking for a therapist for the first time. Even if clients don’t ask about your theoretical orientation—and most don’t—they pick up on your confidence in your own way of working. Con- fidence comes from experience, but it also comes from knowing where you stand and what you think. Chapter 1 gives you a sense of where a relational therapist stands in relation to other therapists. I sketch the primary themes Introduction 3 of relational therapy, and then I compare and contrast various contemporary theories of psychotherapy from this vantage point. This relational point of view is not the property of one school of therapy. Relational theory is spoken in many voices. In the last part of Chapter 1, I review the sources that contribute to the working synthesis I propose. Chapter 2, Beginning with the Basics: Structure, Ethics, and Empathy, begins with the assumption that the client has decided to give you a try. So we discuss the clarity you need about the structure, boundaries, and ethics of relational therapy. What clients can expect above all when they show up for sessions is empathy. As a relational therapist, you won’t predict a particular course or outcome of therapy, but you will do all you can to understand your client from inside her own experience and to share your understanding with her. Empathy is such an apparently simple method that clients may be nonplussed in its presence. Often they want more guidance or advice. They wonder, “How can just ‘being understood’ help me?” But your active empathy only seems to be a simple process. In this second chapter, I explore the complexities of empathy and how it becomes effective treatment. Chapter 3, Assessment: What’s Wrong When Your Client Feels Bad?, addresses the question of assessment. As your client tells you the story of his trouble, how will you understand what’s wrong for him? I spell out one of the basic tenets of relational psychotherapy: What’s wrong is neither entirely inside the client, in his psychological makeup, or dysfunctional patterns, nor entirely outside in the world, in forces that impinge on him. Instead, according to a relational model of psychotherapy, the problem exists in those spaces or activities where outside influences and inside responses interact to create the shape and feel of a “self.” I explain how patterns of interaction between self and others become principles that organize a personal psychology, and I show how these patterns quickly become woven into interactions between therapist and client. Noticing these patterns as they emerge between you and your client is part of an in-process relational assessment of what’s wrong for him. In Chapter 4, Relational Trauma: Past and Present, Memory and Now, Downloaded by [New York University] at 13:36 13 August 2016 I take up the issue of the relationship between past and present, especially a traumatic past and the work of healing in the present. The principles that organize a client’s sense of self-in-relation came into being over time and in certain relational contexts. When clients need to recover from the effects of relational trauma suffered early in their lives, they often have to work long and hard in therapy. Their trauma may have included emotional neglect and physical or sexual abuse. Relational therapy helps clients understand how the past remains alive in the present, undermining their well-being, and it trusts that new, positive relational experiences can reduce the destructive power of the past. 4 Introduction Past trauma can be repeated as here-and-now emotional struggles between client and therapist. This phenomenon, called negative transference in traditional psychodynamic theory, is what I address in Chapter 5, The Terribly Hard Part of Relational Psychotherapy. I call it “the terribly hard part of relational therapy”—because that’s what it is, both for you and your clients. As clients share themselves with you, they hope that you will understand them ever more deeply and completely. But at the same time, their painful relational history leads them to expect that you will fail them. And inevitably, usually in small ways, failure happens. Moments of misunderstanding rupture the relationship, and repairing the ruptures takes careful empathic work to understand how things went wrong. If you can attend to what’s happening in a way that validates your clients’ need to be understood and that keeps their pain inside the relationship with you, you can support and steady them through these difficult times. The hardest part of this work is to stay close to what’s happening, to not be afraid to feel it. As fate or luck would have it, when I came to write Chapter 5, I had just fallen into transference trouble with my own relational analyst. To help myself through it, I wrote about what was happening, trying not to be afraid to feel it. Then I included my story in the chapter, because looking at the terribly hard part of relational therapy from this up-close, personal perspective seemed a very good way to ground theory about “transference” in felt experience. This work can be as hard for the therapist as it is for the client.F eeling deeply mistrusted makes even the most committed relational therapist want to pull back from a relationship. What if you do get hurt and defensive? What matters is what you do next, because if you don’t catch yourself (with help in supervision), the relationship may spiral downward into an angry, despairing standoff. It’s possible to catch those downward spirals before they get out of hand. The point of chapter 5 is that relational impasses can, indeed, be resolved in therapy. In fact, this is sometimes the most effective work you and your client will do together. In Chapter 6, The Wonderfully Good Part of Relational Psychotherapy, Downloaded by [New York University] at 13:36 13 August 2016 I move from what’s very hard about relational therapy to what’s very good about it. The chapter is about the everyday health and well-being that relational therapy makes possible for clients—through subtle but profound changes in how clients can experience themselves with others. I briefly introduce several models of development that give us language for these changes, without making a special case for any one model. They all envision psychological health and well-being as products of healthy relationships from infancy onward. Within any one of these systems, dependency can be redefined as your clients’ ways of connecting with you in ways that help them grow stronger and more connected to others and to themselves. Introduction 5 Chapter 7, Ending and Going On, describes how relational therapy ends—in its own time, and when clients feel significantly better than they did when they began. As clients feel more at ease with themselves, more secure with others, and more confident in their abilities and dreams for the future, they become ready to let the therapy relationship become a memory. This is more than the end of a treatment process, however; good-byes must be spoken between persons who have come to know each other deeply. Your clients will need time and space to feel the loss of the relationship, and to sense how it will continue as memory. Then a good ending can become a good beginning for a new phase in your client’s life. In seven chapters, from beginnings to endings, this is the story the book tells about how relational psychotherapy works. Then comes a final chapter, Twelve Years Later, and written twelve years after the first edition of 2002. Chapter 8 introduces four new themes that have emerged within the dynamic system of relational psychotherapy theory, themes that both affirm and transform the fundamental principles of relational work. To illustrate these themes, I return to my own case from Chapter 5, follow it forward ten years, and offer a new discussion of the case in terms of the new ideas. Thus Chapter 8 is both an update and an epilogue to the original story. Before we get into that story, however, I have two more introductory topics to cover. The first is about identifying the clients who need and get the most out of relational therapy. The second is about identifying the therapists who are best suited to this kind of work.

Who Needs Relational Therapy?

Relational therapy can be effective treatment for a wide range of psychological and emotional problems, since so many of them are rooted in troubled relationships, past and present. Often clients don’t know how helpful it can be to talk through their problems and symptoms in terms of Downloaded by [New York University] at 13:36 13 August 2016 context—what’s happening in their lives right now and the history behind what’s happening now. They have no idea how to tell their own relational story, or what a difference careful, empathic listening can make to their self-understanding—and then to their symptoms. Many models of psychotherapy also fail to recognize the significance of a person’s relational context. They treat problems as if they are only a person’s internal dysfunctions, and they focus on the therapist’s ability to help the person change his problem thoughts and behaviors. From a relational perspective, such treatment addresses only the symptoms of s elf-in-relation problems, and when it leads to change (which is quite possible) the change 6 Introduction may be due more to the relational care with which the nonrelational model is delivered than to the model itself. Let me explain. Therapists of many persuasions want to be helpful and understanding. Sitting down with any one of them can be a powerful new relational experience for clients who have been alone with their distress. Suddenly their trouble makes sense to someone. That person is listening and understanding. Help is possible; they don’t have to be alone. Thus a treatment delivered with respect and empathy may not be relational by definition or intent, but it can change what clients can expect from their relational worlds. Furthermore, if a structured treatment shifts clients’ patterns of thought and behavior, their relationships with other people will change, too. From a relational perspective, these more positive interpersonal interactions may have more to do with the clients’ subsequent improvement than the “internal” changes they have made. A relational perspective also explains why these clients don’t need a specifically relational approach (even though it might be good for them, too). Even when stressed and needing help, these clients live within a sense of self- with-other that is relatively flexible and open to change. They can receive interpersonal help easily and try out new strategies. They don’t need a specifically relational therapy in order to change how they think about themselves or how they interact with other people. Other clients aren’t so fortunate. They live within a much more dangerous self-with-other world, though they may not know this is true. They know about their anxieties and addictions. They are constantly warding off insecurity, shame, and insidious worries about failure and incompe- tence. They may have tried self-help books, self-improvement programs, and other therapies, but nothing much has changed for them over the long term. They suspect that maybe nothing can change for them. And yet their unhappiness draws them back to therapy, for it seems clear to them that there’s some kind of psychological problem going on. Someone with a story like this needs intensive, specificallyr elational therapy more than she needs more goals and strategies. So far her Downloaded by [New York University] at 13:36 13 August 2016 self-improvement efforts have done nothing to change what she feels with others. Her self-with-other knowledge keeps telling her that she’s defective, not trying hard enough, and bound to fail, and these convictions, though mostly unconscious, are far from flexible and open. Whether she knows it or not, she can’t help but see you as one more person who will judge her, feel disgust about her feelings and needs, and ask things of her she can’t produce. Your kindness and good intentions may barely register against the strength of what she secretly believes. Unless you and she can find ways to address these relational problems between you, therapy will become for her just one more round of self-protection, compliance, and secret shame. Introduction 7 On the other hand, if you can address these problems and thus make way for new kinds of interactions between you, therapy can become a matrix for profound, long-lasting change. Sometimes these clients who have already worked hard to change themselves will ask, “How do you think you can help me?” That’s a difficult question to answer because although you want to be honest, you don’t want to say something that will frighten or shame them. Clients protect themselves from even knowing that they feel interpersonal fear and shame. As a relational therapist, you know that they will come to trust you only insofar as you respect their self-protection. You know that this long, slow interaction of understanding and trust will take time, lots of time. You also know that these clients would rather locate their trouble inside themselves than in their relational world—which they “know” can’t change. The last thing they can bear to imagine is trouble between themselves and their therapist, because for them interpersonal trouble leads directly to win-or-lose, and of course a therapist would win and they would be the blamed, shamed loser in the wrong. All that being said, there are some simple ways to talk with a client about the essence and advantages of a specifically relational course of psychotherapy. Often, after I have developed some rapport with a client, I say something like this:

I’m a relational therapist. So while I understand that you feel bad inside, I think that those feelings are relational, too. They’re questions like: “How do other people see me? Am I good enough for them? Am I worth something?” When the relational answers aren’t good, you feel bad about yourself. And those bad feelings can really wear you down. In relational psychotherapy, we spend a lot of time on relational feelings. They turn up in three main ways. First, there are your everyday relationships with the people in your life right now. We’ll look at what happens there that leaves you feeling bad about yourself. Patterns of feeling bad in your everyday life might make you think of important earlier relationships in your life. That would be the second way relational feelings turn up in therapy. When those early relationships come to your mind,

Downloaded by [New York University] at 13:36 13 August 2016 we’ll talk about how they told you who you are and what you’re worth. The third kind of relationship we’ll keep in mind is the one between you and me, how you and I are working together. It will be especially important to notice if you feel misunderstood or judged by me in some way, and for us to sort that out together.

What I don’t say in this uncomplicated explanation is that this is how relational psychotherapy proposes to “make the unconscious conscious.” It’s worth saying here, though, because it bears on the question: Who needs relational psychotherapy? In the language of theory, the answer is: R elational psychotherapy is especially good for people who need to 8 Introduction be released from the bonds of punitive, constricting unconscious organizing principles. In this view, developed within relational and intersubjectivist theories of psychoanalysis, the unconscious isn’t a place or a thing; it’s a self-perpetuating patterning or organizing of self-in- relationship that remains out of a person’s awareness but shapes all of his self-experience. In this understanding of the unconscious, relational therapy takes a position that has traditionally been reserved for psychoanalysis. Traditional psychoanalysis is treatment that probes for the unconscious conflicts that cause tenacious psychological symptoms. Relational psychotherapy is treatment that addresses the unconscious relational patterns that underlie tenacious psychological symptoms, symptoms that don’t give way in shorter-term, more goal-oriented psychotherapies. Whether a particular client might need a relational therapy comes down then to questions like these: How longstanding is this trouble? How tenacious? How deeply does it threaten the client’s sense of being a cohesive, worthy self? In short: How bad is it? If it’s pretty bad, a relational therapist will begin contemplating a longer term, intensive relational approach to therapy with this client. But let’s not forget that a relational therapist envisions most psychological difficulties as symptoms of unsatisfying relationships with others and self. You take this approach in all of your work. So when you begin to think that intensive relational therapy might be what a client needs, you’re thinking not of a different approach to this client, but of attending even more carefully and specifically to the client’s relational history and relational struggles and of focusing the therapy as explicitly as possible on the patterns that develop within the client–therapist relationship. With a client in this group, a more intensive treatment often emerges organically from your general relational understanding of the problems your client brings. This kind of development serves you both well, for the client has time to test your trustworthiness, and you have time to discover something about how the relationship takes shape Downloaded by [New York University] at 13:36 13 August 2016 between you. Not everyone who could profit from intensive relational therapy has the patience or interest to do the work. On the other hand, sometimes the most unlikely candidates settle in for the long haul, if only out of desperation. I think that any client who can allow himself to want or need something from you in the therapy relationship can be a candidate for relational therapy. No matter how conflicted the want or how muted the need, if the client has invested some personal passion to be understood and you can meet that need with personal, responsive presence, the therapy relationship can begin to form and move. Deeper capacities for reflection can develop as the therapy progresses. Introduction 9 Who Makes a Good Relational Therapist?

Relational psychotherapy isn’t for every client, and it certainly isn’t for every therapist, either. Often therapists who are drawn to relational work have come from families of origin in which relationships were tense, conflictual, and unrewarding, and they’re likely to have carried away from that formative familial experience a certain combination of characteristics: (1) a profound longing for relationship that is meaningful and supportive; (2) a sense of responsibility for supporting fragile, unhappy family members, especially unhappy parents; and (3) personal psychological organizing principles that leave them with a somewhat fragmented, precarious, or depleted sense of self. In other words, therapists drawn to relational work are often first of all very good candidates for relational therapy themselves. In fact, if they don’t do their own therapy first, therapists who come from such families are likely to repeat their histories in their work—feeling at first both stimu- lated and overwhelmed by responsibility and then fragmented or depleted as they lose themselves in their efforts to help. On the other hand, therapists who have come to terms with their own relational history, however traumatic it may have been, don’t have to keep repeating that history in their personal or professional lives. They have discovered that it’s possible to develop ways of being with others in the world that leave them feeling much more whole, alive, and secure in themselves. If they’re drawn to practicing relational therapy, it’s likely that the relationship with their own therapist was transformative. They know what a difference it makes to be understood deeply and consistently. They know that feeling connected makes possible slow, quiet movement from anxiety to contentment, from insecurity to confidence, from isolating depression to vital engagement with other people. I imagine that you recognize something of yourself in this picture. But you might still ask, “What does it take to practice relational psychotherapy for thirty years?” It takes the passion for the healing power of relationship that I’ve just described. But like any other profession, it also requires spe-

Downloaded by [New York University] at 13:36 13 August 2016 cific traits of mind and personality. If you enjoy being a relational therapist, you enjoy entering into the stories of people’s lives. Though these stories are sometimes hard to hear, you also find them meaningful, like powerful plays or novels. You’re not afraid of your clients’ strong feelings, and you can feel your own feelings deeply. You’re good at pattern recognition, and also at putting complicated ideas into simple, evocative language. You can think on your feet and take quick, considered risks, but you’re not impul- sive or reactive. You understand and manage your own emotions well. You can sit quietly for long periods of time, and you have an abundance of patience with long, slow processes. You are able to balance your life: for all 10 Introduction the time you spend listening and caring, you spend plenty of other time being active, self-expressive, and connected to others in ways that invigo- rate and nurture you. These personal characteristics are integrated into a professional relational therapist-self through specific training in relational psychotherapy, training that includes both book learning and practical learning from closely supervised work with clients. And though you may be exquisitely well-suited for the work and quite well-trained, to thrive for 30 years in a relational therapy practice, you also need a strong community of peers with whom you can continue to grow and learn. You may have noticed that I haven’t mentioned whether you’re a social worker, an educator, a psychiatric nurse, a family doctor, a pastoral coun- selor, a psychiatrist, or someone trained exclusively in psychotherapy. I haven’t distinguished between work in an agency or hospital and work in private practice. This is because I believe it’s possible for relational therapy to be done by persons in many professions and settings. It’s a portable model with significant efficacy even in settings that restrict the number of sessions available to a client. Perhaps the most likely setting for relational psychotherapy is the office of a relational psychoanalyst, where it may be called either analysis or therapy. But that doesn’t mean that relational psychoanalysis is the benchmark for relational treatment. In fact, many relational analysts no longer make a sharp distinction between analysis (on the couch, several times a week) and therapy (face to face, once or twice a week). In either form, relational treatment happens when the therapy explores patterns of the patient’s relational experience, especially as they emerge in the therapeutic relationship. The relational theory I’m about to explore with you is informed by relational psychoanalytic theory. A wealth of relational psychoanalytic theory has appeared in recent decades, giving relational psychoanalysts plenty to read. I’m writing not to them so much as to the rest of us, who want to learn how to put this wealth of insight to work in a psychotherapy practice not defined as analysis. Practitioners who aren’t analysts make good relational Downloaded by [New York University] at 13:36 13 August 2016 therapists, too! One final note: since I identify with lay psychotherapists in a nonmedical tradition of therapy, I have always spoken of the people I work with as clients, not patients. But I trust that if “patient” is the word that works for you, you’ll make the translation for yourself. 1 Relational Therapy and Its Contexts

If you want to understand what relational therapy is, you need a basic definition, and you also need to understand that definition in the context of other psychotherapies. The central idea of relationalpsy chotherapy is that the patterns of our thoughts, emotions, and b ehaviors, whether healthy or unhealthy, are directly related to the patterns of our in terpersonal relationships. I’ll expand briefly on this idea and then explain it by contrasting it with what a relational theory of therapy is not: it’s not a medical, individualistic, or rationalistic theory of therapy. With these “nots” in mind, I’ll discuss how certain other models of therapy differ from a relational model. Then I’ll introduce the relational theories of psychoanalysis and psychotherapy that do contribute to what I’m calling “relational psychotherapy.”

It’s about Self-with-Other

First of all, relational therapy is about self-with-other. This self-with-other focus means that whether a client talks about yesterday or the distant past, as a relational therapist you listen for whatever was going on between him

Downloaded by [New York University] at 13:36 13 August 2016 and other people in his story. You see your client’s history as a relational history. You work with the relational principle that we are all creatures of familial, social, and political contexts—that we are always being formed by our interactions with others and by our internalized knowledge of what they expect from us and how they will respond to us. Therefore, when a client tells you a story as if there were no other people in it—last night he was desperately trying to finish a project while fighting off his personal demons of perfectionism and procrastination—you know how thickly populated that scene really is. You know that just out of his awareness, there’s how hard it is to please his father, and how his mother is 12 Relational Therapy and Its Contexts on another planet, no help at all, and how his older sister can do whatever she sets her mind to. You keep the relational story in mind. It’s as true for him today as it was twenty years ago, though different actors (a boss, a wife, a colleague) are playing the main characters now. You know that public school taught the kids of his generation that grades mattered more than creativity; you know that as a middle-class North American man he believes that individual accomplishment is the mark of a successful life. But as far as he knows, working hard to finish his project, this is just his internal, individual struggle to dodge inevitable failure. As a relational therapist, you swim against this stream of “isolated- self” thinking. You nudge your client to explore how difficult expectations and painful interactions, past and present, engender his bad feelings and his paralysis. You help him recognize the support and connection he needs to feel happier in his work. As a relational therapist, you also believe that whatever happens in a therapy session can be understood as a self-with-other story. Almost every interaction between you and a client puts into play some kind of interactional pattern. Another of your clients might feel, for example, that she has to say and do certain kinds of things to make this “good” therapy. So she tries hard to bring up important events to talk about, she focuses on her authentic feelings, and she recounts insights she’s had over the week. You sense how hard she’s working to please you, and you don’t deny her your positive feedback, but mostly you pay close attention to whatever she’s thinking and feeling as she talks with you. Bit by bit, she grasps that what you want is to understand her, not for her to do therapy “right.” As she experiences your empathy, being understood begins to matter more to her than your approval. A particular self-with-other meaning she carries around—that only her performance matters to others—begins to be undermined. All of this is important relational work, though not a word has been spoken directly about it. After a while, your client does say something about this different way of being with you, and you respond with words that recognize what she’s Downloaded by [New York University] at 13:36 13 August 2016 trying to say. This is a relational interpretation, particularly helpful because it emerges as a shared discovery. When you and your client talk about this changing experience, she’s likely to make connections to current relationships where her pattern of high performance is powerful and to past relationships where it first took shape. This is how the two of you will link a relational story of her life, past and present, with the relational story that develops between you. Learning happens as things change between you and your client, and words can make the learning more real. You talk about history, make connections, and track shifts in behavior and feeling. But in all of this you’re Relational Therapy and Its Contexts 13 careful not to be the therapist who knows, who sees what’s really going on. Instead, the two of you are figuring things out as you go along. Your not-knowing stance may have felt strange to her at first, when she came in seeking an authority to guide her. But you continue to invite her into collaboration, which itself creates new self-with-other experience. You are doing something different with her than was possible when she first came in; something different is happening in her self-with-other world, and that’s what matters most.

It’s about Self-with-Other in Action

This emphasis on doing something different is also fundamental to relational therapy. Relational therapy is by nature performative. I don’t mean to say that the therapy is a performance. I mean that the material with which therapy works and the changes that therapy sets in motion can all be found in the various kinds of doing—actions, thoughts, words, silences, feelings—that exist and play out between self and others. Thus, from a relational perspective on therapy, particular insights (“my family history formed me in this way,” “these are my self-defeating patterns,” and so forth) have no power to change anything for a client unless they are performative insights, or insights that are connected to active relational/emotional experience. The essence of therapy isn’t in insight or interpretation—those ideas that you and your client figure out together. It’s in everything that you and your client do together—how you interact to create stories, how meanings move both of you, how your interactions change over time, and how you reflect together on those changes. In this model, you can’t be an expert observing a client from outside of the relational story the two of you play out together. You have to enter right into the story, knowing that relational problems are going to turn up between you and intending to work through the difficulties to make a better relationship possible. This is not, of course, your therapy; you’re there to Downloaded by [New York University] at 13:36 13 August 2016 help your client understand himself. But you must still be a full participant in the relationship. In this model the problem is definitely not inside the client. You and your client will discover how the interactive performance of his self-with-other knowledge sends him off the rails over and over again, wrecking his well- being and self-esteem. Sometimes you will help send him off the rails, but if you both pay close attention to how this repetitive “wreck” unfolds, you can find a way to perform your interactions differently. Whatever keeps going wrong will turn into a story you can tell together, and then there will be a way to bring a new story into being. In other words, things will change 14 Relational Therapy and Its Contexts when the two of you can do your relationship in a significantly different way. That’s a performative therapy. These, then, are the two most important characteristics of relational psychotherapy: its focus on self-with-other experience and its emphasis that the doing of such experience is what both hurts and heals. In these two ways, it’s different from many other kinds of therapies. It’s possible to explain that difference in negative terms, too, which is what I’ll do now, very briefly: (1) relational therapy isn’t a medical model of therapy; (2) relational therapy doesn’t hold an individualistic view of the client; and (3) relational therapy doesn’t give rational, linear, cause-and-effect explanations of how change happens.

Not a Medical Model

People go to therapy because they are suffering some kind of emotional pain, and most of them hope that an expert, a “doctor,” will make the pain go away. When clients come to you seeking such relief, you have to gently disappoint their expectation of a cure administered by an expert. As a relational therapist, you offer them a different kind of experience. You say, “I don’t believe I have the answers for you, but I do want to understand what the trouble is, how it feels to you.” You move away from the position of expert in order to put yourself on the client’s side. You risk the client leaving therapy, but it’s a risk worth taking—since you can’t fix him anyway. Any client who is suffering enough to search out a therapist feels isolated in his pain and at a loss to understand it. Beneath his desperation for immediate relief, there lies a profound, unspoken longing to be understood, not to feel so all alone. As you do your best to understand his troubled thoughts and feelings, he may be able to let go of his hope of being quickly “fixed.” Why? Perhaps because he senses that “fixing” isn’t what he needs after all. Being understood in depth and in detail soothes his feelings

Downloaded by [New York University] at 13:36 13 August 2016 of hopelessness and powerlessness. As he “makes sense” to you, he starts to feel stronger. He feels hope just because you have listened with respect and care. Your risk is beginning to pay off. You hope that over the longer term he will come to know that his distress isn’t due to a defect or illness inside of him. Instead it has a lot to do with feeling all alone with trouble he can’t talk about. What therapy offers isn’t a doctor to cure him but a fellow human being who will understand his longings, losses, hopes, and fears, someone who will be right there with him as he struggles to work out a happier, healthier way of being with himself and with others in the world. Relational Therapy and Its Contexts 15 Not Individualism

As a relational therapist, you don’t take on the job of “fixer.” You also refuse to see your clients as self-contained, individual objects that need fixing. You make that refusal every time you try to find out what happened between a client and somebody else that left the client feeling so bad. You make that refusal when you immerse yourself in your client’s world of experience and when you acknowledge that your own behavior can have a profound effect on your client’s well-being. A therapy that’s all about self-with-other experience stands in sharp contrast to individualistic views of therapy. Relational therapy debunks the myth that each of us is responsible for our own happiness, that somehow we can each find our own way to well-being. It undercuts the belief that mental health is something we individually have and enjoy—or we don’t. It doesn’t buy that if we’d just work on ourselves, we could manage to claim our power, increase our self-esteem, and improve our confidence. It doesn’t promise to produce self-fulfillment, self-authentication, or the autonomous, self-responsible, fully realized individual who is evolved and conscious. It doesn’t put much faith in self-help. As a relational therapist, you suggest to your clients that, on the contrary, they need good connections with others in order to feel better. You encourage and support your clients’ relationships, and you struggle to have an honest, complex, and rewarding relationship with them in therapy. You do this because you believe that an individual can feel genuine power, agency, and well-being only in the context of healthy interpersonal connection.

Not Rationalism

It’s not surprising then that relational psychotherapy also takes a turn away from rationalism. Most Western ways of thought begin not just with the individual, but with the individual mind, with Descartes’ “I think,

Downloaded by [New York University] at 13:36 13 August 2016 therefore I am.” The mind establishes and validates reality, and it does so through logical processes. Psychoanalysis has lived firmly within this tradition since the time of Freud. Freud saw himself as a modern scientist; his medical model of treatment, which seeks to understand and change what is wrong within the individual patient, is a model well-grounded in a rationalistic, scientistic view of human nature. According to this model, access to what’s wrong is through the irrational—through dreams, fantasies, instincts, and emotions. Reason is pitted against emotion, feeling against thought, id against ego. Therapy facilitates the translation of “primary process,” the stuff of dreams and 16 Relational Therapy and Its Contexts emotions, into “secondary process,” the stuff of thought and mastery. In everyday language: Therapy is about getting into your feelings and then making sense of them—rationally. Now it might seem that a nonrationalist stance, by contrast, would mean being on the side of feelings and dreams and against making rational sense. But nonrationalist relational psychotherapy takes a different tack, believing that this split between reason and emotion is another tricky form of rationalism. Relational therapy doesn’t work to get clients to be more rational about their feelings, but neither does it say they should get out of their heads and into their feelings. Relational therapy doesn’t buy into that split between mind and emotion. Instead, as a relational therapist, you believe that in all of their activities of daily life your clients are putting into play different interconnected systems of self-with-other experience that include—all at once—actions, beliefs, thoughts, body-feelings, images, self-states, emotions, and energies. If things are wrong for your clients, things are wrong in those complicated systems of thinking/feeling/responding, and before your clients can start to feel better, whole systems need to start working in different ways. Not only does rationalism specialize in either/or thinking—either thought or feeling, mind or emotion—it also specializes in linear cause-and-effect thinking. But relational therapy departs from the linear sequence of “working on issues,” having a catharsis or an insight, and then feeling better. As a relational therapist you know that change happens in complex, systemic, nonlinear ways. For example, when change begins from the inside of a client’s relationship with you, the client will gradually experience many small, interconnected differences in how she experiences herself and others outside of therapy as well. These departures—from the medical model, individualism, and rationalism—help make relational therapy what it is. These departures also distinguish relational therapy from other therapies, allowing us to define relational therapy further by noting what it is not. Downloaded by [New York University] at 13:36 13 August 2016 Not Freudian Therapy

Sigmund Freud was the physician who invented talk therapy as a cure for mental illness, and his influence on what clinicians and the general public understand about the therapeutic process remains profound and powerful, even among those who disagree with his position.1 In the opinion of classical Freudians, there is no real therapy relationship besides the formal one of doctor–patient (in which patient compliance is called “therapeutic alliance”). Feelings that arise in the patient toward the therapist are the Relational Therapy and Its Contexts 17 patient’s transference upon the therapist of the patient’s past feelings toward someone else. This may evoke some countertransference feelings within the therapist, which the therapist recognizes and puts aside in order to understand and interpret the patient’s material correctly. As we have noted, the patient’s material of dream, feeling, and fantasy is seen as a product of the irrational unconscious. “Material” includes transference, which becomes a very important projection of the patient’s illness, played out on the blank screen of the therapist’s neutral presence. The goal of classic psychoanalytic treatment can be stated in medical terms: to cure the patient of the symptoms of neurotic illness. This can be done by bringing the contents of the patient’s unconscious into conscious awareness. How is this accomplished? The doctor interprets to the patient the real meanings of his instinctual, irrational mental processes as they are revealed in dreams and in transference feelings and fantasies. Symp- toms are cured as a patient addresses previously unconscious conflicts with rational thinking and decision-making processes. Individualism is a given in this medical scenario; a patient is cured through a process of change that takes place entirely within the patient’s inner world. The process is fundamentally rational, both in the sense that it brings reason to the irrational, and in that it takes place in linear cause-and-effect sequences. This Freudian perspective is far from obsolete. It’s alive, for example, in the popular understanding of repressed memory: What you can’t remember may be the cause of your depression, anxiety, or self-medicating substance abuse. To get help for these symptoms, you need to find a therapist who will help bring back your memories, especially the feelings of the memories. When you get the feelings out and make sense of the m emories— when you truly know the story hidden in your unconscious—then you can be well. Let me illustrate this way of doing therapy with an example. “Jane” is the oldest child of a father whose alcoholism exploded into violent rages and a mother whose depression drifted into despair and neglect of her children. Downloaded by [New York University] at 13:36 13 August 2016 Jane learned early to be wary of her father, to cover for her mother, and to look after herself and her younger siblings. The competence she learned young has served her well: she put herself through university and social work school, married, and is now a working mom of sons aged eight and six. She has come to therapy because she often feels depressed for no reason she can identify, she’s afraid of a growing distance from her husband, she worries a lot about being inadequate as a professional and as a mother, and on the whole, she feels “lousy” about herself. Classic psychoanalytic treatment focuses on Jane’s history and hopes to unearth the feelings of abandonment, sadness, anger, loneliness, and 18 Relational Therapy and Its Contexts despair that she buried in order to take competent care of herself and others. As the therapist listens to what’s troubling Jane, she also asks about her past, and she interprets to Jane the links she observes between her past and present. The therapist expects that Jane will sometimes see her as the attentive mother she never had (positive transference), and sometimes as the unavailable, neglectful mother she did have (negative transference). The therapist slowly brings this transference material into the conversation too, as a powerful way for Jane to retrieve the conflicts and emotions hidden beneath her system of defenses. As this unconscious material becomes conscious, often with the help of dream interpretation, the therapist helps Jane work through it, make psychological sense of the story of her life, feel her own emotions within the story, and mourn her losses. In the end, Jane’s ego, or conscious sense of self, will emerge far stronger and far less burdened by old feelings of anger, helplessness, and shame. The therapist will have helped Jane find and feel her inner conflicts, enabling her to leave a lot of those old feelings behind, “resolved.” That’s the classic story of how therapy works, and it’s a good story—a far better story than the one in which Jane is simply prescribed antide- pressants because there’s no visible reason for her depression. How would relational therapy tell a different story? First, in the relational story, the question is not, “What’s wrong with Jane?” but rather, “What’s wrong for Jane?” That is to say, the “wrong” she brings to therapy isn’t an illness to be rooted out or cured. The trouble can’t be located only in buried memories and their symptomatic effects, because what’s wrong is entangled with everything Jane knows and feels about being in the world—especially about being with others in the world. So it’s not a sickness, and it’s not an inner, individual problem, either. Her system knows from experience what’s safe to do, feel, and say; it tells her who will listen, and with what kind of attitude and feeling toward her. It also tells her, very clearly, what’s dangerous. For good reason, Jane is convinced that she needs to protect herself from the threat that comes with Downloaded by [New York University] at 13:36 13 August 2016 interacting with others in the world. As a relational therapist, you will not try to uncover and treat Jane’s internal illness; instead, you will try hard to understand with her how her relational world works. And so, in your work together, you will focus first of all on the present, not on the past, and not on particular repressed feelings, but on how Jane makes sense and safety for herself in the world. As a relational therapist, you’ll be saying to Jane, in one way and another: “You’re making the best sense you can of the cards you’ve been dealt; you’re protecting yourself as best you can in a dangerous interpersonal world. That’s not illness, but a mark of survivor health.” Relational Therapy and Its Contexts 19 You’ll also notice, however, how costly Jane’s ways of surviving can be. Jane’s extreme competence covers for a lot of self-doubt, and her driven pace is a product of anxiety. In therapy, you let her know, “Here you don’t have to produce or perform.” But performing hard and well is Jane’s way of connecting with others and feeling like she matters to them. She may be burning herself out and missing real connection with her husband and sons, but without her performance, she can only feel lousy about herself; she’s nothing but lost, anxious, and depressed. This relational dilemma is the core of what is wrong for Jane, and soon it’s right there in her performance of self with you. But slowly she lets herself relax. She shares more of her vulnerability with you as she realizes that you don’t interpret her thoughts, feelings, or dreams to her; instead, you join her in a collaborative process of making sense together. Above all, you keep offering her a way of being together that lets her be less worried about outcomes, less driven, less anxious, and less lonely than she’s been before. As she feels better with you, she slowly starts to feel better in her life, too. As Jane gets well in this therapy, you attribute her progress not to the release of repressed emotions, nor to increased “ego functions” to master those emotions. What you understand is that Jane is no longer so trapped in old patterns of self-with-other interactions and feelings. Jane feels more real, more competent, and more worthwhile in her daily life because she’s having more relaxed and open interactions with her therapist, her husband, her sons, her friends, and her coworkers. That’s what’s making her feel better! And that’s not how classical psychoanalytic theory would explain the process or the outcome of a successful therapy.

Not Jungian Therapy

Carl Jung was one of the first psychoanalysts to learn from Freud and then to move in his own unique direction. Like Freud, Jung was a physician, but one who brought the spiritual and transpersonal to the problem of mental Downloaded by [New York University] at 13:36 13 August 2016 illness. In Jungian therapy and its derivatives, cure comes through a self- transformational journey of the soul that’s more complex than uncovering unconscious memory. For Jung, as for Freud, dreaming is a royal road to the unconscious. Jung’s unconscious, however, is archetypal as well as personal. Jungian therapy is about resolving complexes that cause symptoms, and although those complexes are rooted in a client’s relational history, they are also related to archetypal problems we all have to solve, and have been solving since the first myths were told. This journey, then, leads to a kind of medical–spiritual cure; it involves the realization of Self understood as Soul. Jungians offer a kind of spiritual–medical model of therapy.2 20 Relational Therapy and Its Contexts Jane’s Jungian therapist encourages her to write down her dreams. In many of them, large male figures threaten violence while Jane trembles and hides. In others, Jane notices women lying wounded in the shadows, but she can’t stop—she’s behind schedule, and the faster she hurries, the more things keep falling apart. The therapist and Jane talk about how these male and female figures aren’t just images of her parents; they are also shadow images of Jane herself. Since masculine energy has been a threat to her, she can’t count on the masculine side of herself (which Jung calls her animus) to help her think clearly and act with grounded confidence in the world. Her internal image of “woman,” learned first from her mother, has become her own woman-self, lying badly wounded and helpless as she hurries by. As Jane continues to dream and talk, new dream figures and land- scapes appear. Male figures become less threatening; in her journals, Jane can imagine negotiating peace with them and even getting them on her side. The women in her dreams take on many new shapes—dangerous, angry, alluring, lively, and wise. Jane begins to enjoy meeting these women as both emissaries of a power beyond her and also as parts of herself. In Jungian terms, Jane is beginning to individuate, disentangling herself from the complexes of her personal history in order to discover the self she was meant to be. This sketch shows that although Jungians offer a different kind of cure than Freudians do, it’s still a cure for something within the client. This “within” is related to a world of archetypes, myths, and symbols, and the client’s relationship to the external world is mediated through this sense of its symbolic meanings. There’s a world of complexity within, mirroring a symbolically complex world without, but change happens within, and only secondarily in the relationships between within and without. In short, Jungian therapy reinforces individualism. Jungian therapy also makes linear connections between symbols, dreams, and images and how clients can use them to understand and live their lives better. The world of archetypes and symbols, something other than the world of everyday thoughts and actions, directly affects our every- Downloaded by [New York University] at 13:36 13 August 2016 day experience in ways that are hidden but discoverable. From a relational perspective, what’s missing in this picture is the world of countless interactive experiences of self-with-other that teach us everything we know about what it is to be human. These experiences are what give rise to shifting symbols, dreams, and images. Symbolic images, whether personal or archetypal, are important expressions of experience, but from a relational perspective, they can’t be seen as the ground or primary data of experience. Jungian work can help clients deepen and expand their vision of “self.” Changes in one’s symbolic view of self can also affect how one experiences self with other. I would argue, though, that this is a circuitous route to Relational Therapy and Its Contexts 21 self-with-other change, and it carries the risk of getting stalled within an inner, symbolic world. Relational therapy encourages clients to come out where other people are. Here, it argues, is where you can work directly on what troubles you. Your inner world is certainly involved, but it’s just part of the whole picture. The whole picture can certainly be grasped through symbols, and your experience of it can be painted, danced, and dreamed. Expressing yourself in these ways may help you feel more whole and real. But on the other hand, your experience matters just as much when you use everyday language for it and we see it in the ordinary light of day.

Not Short-Term Solution-focused Therapy

These days, partly due to insurance companies and government agencies that demand quick results for money spent on therapy, short-term, outcome-oriented therapies are often seen as more useful than longer-term psychodynamic therapies oriented to process and insight. Short-term therapy is delivered in many forms; it may, for example, be called cognitive- behavioral, solution-focused, strategic, or goal-oriented. Like the psychoanalytic therapies, these therapies reflect a medical model of mental illness and cure. However, they find mental illness in a different place in the human being. What’s wrong is not in the unconscious, in repressed feelings, drives, or archetypes. What’s wrong are destructive or counterproductive thoughts, patterns of behavior, and interpersonal habits, a point of view not so different from relational perspectives on what’s wrong. Short-term therapists, however, believe they can diagnose, isolate, and treat the problem without addressing the client’s whole context of life- experience. Furthermore, and in even sharper contrast to a relational mode of work, short-term therapies are expert-oriented. The expert, not necessarily a medical doctor, but nevertheless the one who knows and who cures, recognizes and isolates habitual counterproductive patterns of thought and behavior and devises strategies to change them into healthier Downloaded by [New York University] at 13:36 13 August 2016 patterns. In this kind of therapy, Jane will be helped to identify the negative beliefs she has about herself and the words she speaks to herself that reinforce those beliefs. She will learn to turn down the volume on those thoughts, substituting positive messages to herself about her own good qualities and many fine achievements. She will also be helped to see that her depression takes hold when she withdraws from her family in exhaustion. She will learn to notice her exhaustion earlier, ask for some help around the house, allow herself some rest, and find ways just to “hang out” with her spouse and sons. For Jane, this is all hard work and against her nature, but when 22 Relational Therapy and Its Contexts she makes herself think and act in these different ways, she does notice changes in how she feels. Here the doctor–patient interaction is one of rational common sense, and treatment is based on expectations that certain thought and behavior changes will lead to certain predictable changes in feeling. In this sense, reason can conquer emotion. In their favor from a relational perspective, however, these therapies don’t believe that insight cures. They don’t think that just knowing what the problem is and where it might be coming from will produce change. For these short-term therapies, the point is not to tell your life story, outer or inner, in ways which make expanded and transformational kinds of sense—making the unconscious conscious as Freudians and Jungians do—but to set goals, change patterns, and do things differently. When you start to do things differently, different experience will follow. Relational therapy agrees with that premise, but it knows that doing interpersonal relationships differently involves a complicated emotion- laden process of undoing old patterns and learning new ones, a process you can’t do on your own or hurry up with willpower. How individualistic are these therapies? On the one hand, they move the focus of treatment from a client’s inner world of unconscious conflict to her conscious thoughts, behaviors, and habits of daily life, most of which take place in social contexts. On the other hand, these therapies include strong emphases on autonomy, self-assertion, and taking charge of one’s own life. By contrast, relational therapies insist that the emotional quality of life depends on the quality of the relationships that nurture and sustain life. Relational therapies point out, too, that a treatment picture that includes one expert problem-solver and one person with problems is a very narrow slice of what actually happens between a client and a therapist. All kinds of interpersonal hopes, fears, judgments, and feelings are woven into any therapeutic treatment, for better or for worse. From a relational perspective, it just makes sense to acknowledge this reality and then to try to work with it productively. Downloaded by [New York University] at 13:36 13 August 2016

Not Humanist Therapy

Since the 1940s, the humanist therapy movement has confronted the psychiatric establishment with a nonmedical model of helping people who suffer psychological distress. Its practitioners speak of personal growth instead of cure. Carl Rogers and his colleagues insisted on the term “client,” not “patient,” in order to emphasize that therapy isn’t about illness. What clients need, they said, is not a cure, but a selfless kind of love within Relational Therapy and Its Contexts 23 which they can grow into their full potential as human beings. Thisagape love comes to clients in the form of the therapist’s unconditional positive regard, empathy, and genuineness.3 In these ways, a humanist therapist is fully “in” her interactions with a client. She does not aspire to the position of objective expert or fixer of what’s wrong. She believes that the potential for healing lies within the client, as does untapped potential for self-development and self-ac tualization. The therapist’s accepting presence is the medium within which the client sheds his fears and begins to realize his hidden potential. This way of being with clients is a prototype of relational practice. But it falls short of full relational awareness when the therapist sees herself as only a benign, neutral medium for growth, something like a good mix of sun and rain for nurturing healthy plants. The humanist therapist does not become personally entangled in the growth process. Therefore Rogers can give short shrift to what psychoanalytic theory calls transference and countertransference. For Rogers, transference is a constriction the client leaves behind as he blossoms in response to unconditional positive regard, and this warm regard, by its very nature, is given without any countertransferential strings attached. Thus this friendly, anti-medical model of therapy has two strong individualistic aspects: its goal of inner self-actualization and its disavowal of relational entanglements between client and therapist. Some humanist therapies borrow more from psychodynamic theory than Rogers did, giving credence to transference and countertransference. But they frame these relational issues in individualistic ways. Gestalt therapy, for example, encourages clients to refuse the projections laid on them by others, and to withdraw their own projections, the products of their own historical baggage. “Your stuff” and “my stuff” should be totally disentangled—an impossibility within relational thought. For transactional analysis, too, the goal of analyzing interpersonal transactions is to recognize the roles you’re caught in—the games you play unwittingly—so that you can escape them. What’s missing is an awareness of the inescapable embeddedness of self in relational contexts, an interdependency that Downloaded by [New York University] at 13:36 13 August 2016 is as life-giving as it is difficult to manage. How do humanist therapies situate themselves vis-à-vis the rational? They are not tied to insight. Cure comes through new experiences and expressions of self. This is especially visible in gestalt, psychodrama, and transactional analysis (TA/encounter group) versions of humanist therapies, which highlight the embodied scripts we have learned with others and that we reenact forever. Changes in those scripts take place only when we feel and express the pain they cause us, and feel and express a self breaking through constrictions. Changes happen within us as our blocks are released, our feelings are spoken, and our alienated parts of self are reintegrated. 24 Relational Therapy and Its Contexts Let’s imagine Jane with a humanist therapist who uses a range of ways to help Jane find and express her feelings. Early in therapy, Jane talks about fear—fear of making mistakes, fear of displeasing her husband, fear of terrible accidents happening to her children. After a while she can acknowledge that she feels fear in sessions, too, fear of being judged and rejected. The therapist encourages her to fully experience her fear, to breathe into it and stay with it. She wonders with Jane if this is an old feeling. And of course it is; suddenly Jane feels a wave of the terrible tight anxiety that would fill her body when her father had been drinking and a fight between her parents loomed. Later, when Jane feels safer, she will talk about some of the things in her life that make her annoyed and frustrated. The therapist will help her identify these feelings as anger, affirming the energy and power of lucid, constructive anger. As Jane becomes more comfortable with feeling angry, she begins to remember the rage she felt as a child, helpless to change what kept happening. Her therapist says it might help to release some of that rage, and Jane finds herself pounding a pillow and yelling, “I hate you!” And then her rage crumbles into sobs. Beneath Jane’s rage, her therapist explains, there lies a deep well of sadness that Jane has never let herself feel—until now. Now, for a while, Jane will need to cry her sadness—for the hurt and lonely child she was, for how much she needed to be loved, for the way her drivenness has robbed her of happiness. She can even cry about wanting her therapist to be the mother she never had, as she desires this desperately and knows it can never be. So much of what might have been can never be. But through her tears of grief, Jane also feels herself more alive and more real than she has ever felt before. Nothing within her scares her terribly anymore. She knows her blinding fear, her rage, and her wrenching sadness. She may be wounded, but she has herself at last. When she is finally able to look around, she begins to notice some goodness in her life after all, and some hopes and promises for the future. We see here that while the therapist is a skilled facilitator of Jane’s pro- Downloaded by [New York University] at 13:36 13 August 2016 cess, the process is understood to happen inside of Jane. It happens in her feelings, not in her mind. Most humanist therapies make a mantra out of “I’ve gotta get out of my head.” But as I’ve noted, this mind–body, thinking– feeling, head–gut split is one of the trickier forms of rationalism as it appears in therapy. Rationalism appears in another form when humanist therapies lead clients to believe that if they get in touch with their feelings, have a cathartic, authentic experience, release a block, and integrate a part of themselves long alienated, then they can expect that their emotional lives will change dramatically. In other words, humanist therapies tend to suggest linear cause-and-effect sequences in the doing of emotional “work.” Relational Therapy and Its Contexts 25 By contrast, in a relational model, change always happens within relationship with another person, even while it is experienced as change in inner meanings and feelings. This slight shift of emphasis means that in relational therapy the client doesn’t carry the burden of change. Fur- thermore, although having many emotions and expressing them in both strong and subtle ways may be part of a relational therapy, the success of the therapy doesn’t depend on any particular form of emotional release. There’s nothing a client has to experience or express in order to be doing therapy “right.” The work is in whatever happens between a client and therapist as they talk, and in whatever thoughts and feelings arise from that conversation.

Not Narrative Therapy

With its links to theories of social construction, narrative therapy acknowledges the limits of individual self-realization. It suggests that in order to understand yourself, you must locate your place within the power dynamics of your social contexts, for example, as a woman, man, or transgendered person, as a person-of-color or a white person, as a queer or straight p erson, as a person with working-class, middle-class, or upper-class roots, as able-bodied or not. Whatever your location, it says, there are specific political and cultural stories that tell you who you can be in the world, how you can feel about yourself, and what you’re worth. Within these stories, which construct your family, too, there is also your family narrative of you. All of this is imposed on you as if it were your own true story, squelching who you really are, what you really need, and who you really could become. Narrative therapy helps you notice the story you are enacting, and it backs you up to try to break out of the old narrative and into new ones that suit you better.4 With a narrative therapist, Jane discovers that the rules she lives by and the standards she strives to meet are set by forces outside of herself. The culture of her childhood, reinforced by her parents’ behavior, taught Downloaded by [New York University] at 13:36 13 August 2016 her that it was a woman’s place to suffer in silence, to clean up messes, and to keep the family going no matter what. Even as a little girl, she stepped up to the task. Now she realizes that she’s living out that very same story both at home and at work, and everything around her con- spires to keep her in it. But she learns to resist the pressures from her husband, her children, her in-laws, and her boss, who all profit from her hypercompetence. As she resists, she also begins to develop and test out a new story for herself, one in which she matters as much as anyone else, one in which she gets to speak her mind while joining with others in working toward mutual goals. 26 Relational Therapy and Its Contexts From a relational perspective, narrative therapy gets very high marks for understanding individuals in contexts of interdependence. Narrative therapy also knows that it is the client’s performance of narrative that deter- mines the path of his life, his self-image, and his emotional well-being. Therefore, rather than trying to change his self-image or emotions, it supports him to set in motion different performances of different stories, in hopes of altering whole systems of relational interactions. This notion of change resembles relational ideas about how a powerful therapy relationship can change how a client performs relationships in general. On the other hand, and in contrast to a relational perspective, narrative therapy can be expert-oriented and rationalistic in its judgment about which narratives are bad for clients and why. It has links with emancipatory political theories such as Marxism and radical feminism, which propose strong arguments against certain narratives and in favor of others. Relationally speaking, the danger here is that the experts’ judgments for and against certain big narratives can become an agenda imposed on the client. Another danger lies in the assumption that within each person an essentially context-free being exists underneath layers of oppressive social construction. Relationalists protest that there’s no state or moment of being human apart from context, social construction, and relationship. Who we can be is always a negotiation of what’s possible within what we have been given, contextually. In other words, as a relational therapist, you don’t imagine that for any client there’s a true, hidden story of who she is. There’s the self-with-other story she inhabits now, and there are other stories possible, which could be better for her. Better has to do with whether new experiences give her more freedom and support, whether they allow her more joy and self-expression, and whether they support a firmer sense of her goals and principles. As a relational therapist, you work with your clients’ self-with-other narratives, but not to help them find “true” selves—as if the lives they have been living have been false. Instead you help them find more constructive, rewarding, Downloaded by [New York University] at 13:36 13 August 2016 and responsive ways to live as the selves they have always been, within the social contexts that form and sustain them.

Not Radical Feminist Therapy

A fine articulation of radical feminist therapy can be found in Laura Brown’s book Subversive Dialogues.5 Her version of radical feminist therapy has a lot in common with narrative therapy. Brown, too, understands that any client’s sense of self is thoroughly contextual and constructed within Relational Therapy and Its Contexts 27 networks of social power. The depression, anxiety, low self-esteem, phobias, addictions, and other symptoms that clients bring to therapy are all rooted, Brown says, in many kinds of disempowerment and subjection—to which some members of society are more subject than others. However, all members suffer from living in hierarchical or patriarchal social structures that maintain subjection. Dominance is not just a problem for the “losers” but for the “winners,” too, who become alienated from themselves, from their true selves, by the dominating scripts they are performing without a second thought. With a radical feminist therapist, Jane learns that there is a very powerful reason for her pervasive sense of powerlessness: a patriarchal society is engineered to disempower women and children. This was in force when she was a child, crushing and silencing both her mother and herself, and it’s still strong now. Jane’s early experience, supported by ubiquitous cultural stories about a woman’s place, has permeated Jane’s sense of herself. Any story she can tell herself about her life assumes that she has far more responsibility than power in life. Her therapist helps her notice these assumptions and then question them. She enters empathically into Jane’s experience of how different kinds of disempowerment have made her feel. She helps Jane notice when the expectations of her boss or her husband leave her no options but acquiescence. She encourages Jane to claim her rightful power, both right now and retrospectively. The therapist backs Jane in her fight against the oppression she meets every day and the oppression she has internalized, which over the years has become a self-definition. As Jane finds words for what has happened to her, she also finds words for who she is now—her own words, words that resist forces that would define her in their terms. This is the critical move for Jane’s well-being: for her to be no longer a pawn of patriarchal power, but to become someone who knowingly and passionately resists. To this end her engagement in radical feminist therapy is a subversive dialogue. Clearly there’s a certain story about oppression and liberation that the radical feminist therapist tells the client to explain to her why she feels Downloaded by [New York University] at 13:36 13 August 2016 the way she does. Brown holds her political convictions respectfully in her work with clients, but she does allow her beliefs to come through, and for that she doesn’t apologize. On the other hand, Brown allows that we need to be cognizant of the symbolic power embodied in the therapeutic relationship, and she embraces the healing power of empathy—the capacity to hear and speak in the client’s “mother tongue.” Overall, however, in Brown’s presentation of feminist therapy, change comes about through new understandings rather than through new relational experiences. Change is facilitated by an expert who helps the client understand how oppression works. At the same time, that expert is 28 Relational Therapy and Its Contexts intent on empowering the client, telling her that she is the expert on her own experience, and that her voice is what matters. There’s paradox in this model, including the paradox that feminist therapy is done with individuals but strives to build feminist community. Brown acknowledges these conundrums. But working with them is just part of the job, she says.

“Nots” Are Us

I have proposed that relational therapy departs from a medical model, from individualism and from rationalism. I’ve said that relational therapy is neither Freudian nor Jungian. I’ve said that it’s not solution-focused, not narrative therapy, and that although both humanists and radical feminists may practice it, it’s neither humanist nor radical feminist therapy. And yet those “nots” remain part of the relational tradition because relational therapy has emerged from a practical and theoretical history shared with all of these schools. For example, relational therapy isn’t a medical model, but relational therapists do hope to ease suffering, as all therapists do. Relational therapy isn’t individualistic, yet most of the work is done with one person at a time, and when it goes well, these individual persons feel better. Though relational therapy is not a rational model, relational therapists and their clients keep trying to make some sense of what’s happening in therapy—as do all the relational theorists who write books about how it works. Relational theory makes transformative changes to Freudian theory, but it remains heavily indebted to the central Freudian ideas that motivation can be unconscious, that prior experience forms unconscious motivation, and that in the process of intense conversation both motivations and influences become visible in “transference” experience. When a relational therapist has a Jungian kind of openness to the power of dreams and metaphors to speak the nuances of a client’s experience, the dimensions of her empathic understanding expand.

Downloaded by [New York University] at 13:36 13 August 2016 As noted above, relational therapy joins with short-term goal-oriented therapies in suspecting that an intellectual analysis of a client’s unconscious might not help him change much in his life. Relational therapy agrees that change in a client’s sense of self requires change in a client’s actions and experiences. Humanist therapies have created the very possibility of nonmedical therapy—therapy in which clients can expect respect, empathy, and support for their own developmental process, and therapy in which the therapist will be genuinely present in the therapeutic relationship. Nar- rative therapy highlights the power of social context to construct personal narratives, and it shows how the power of those narratives lies in their Relational Therapy and Its Contexts 29 reiterated performances, two themes crucial to relational therapy. And radical feminist therapy reminds relational therapists that social relations of unequal power and enactments of dominance and submission come right into the therapy room with any two persons who enter it. In all these ways, relational therapy joins with other therapies in common tasks and understandings. But if it’s important to acknowledge that relational therapy shares history and important concerns with schools of therapy that do not define themselves as relational, it’s even more important to understand that a relational perspective has been nurtured in several different schools of psychotherapy and psychoanalysis. What I am simply calling “relational therapy” is indebted in different ways to each of them, as we shall see in the next part of this chapter.

Stone Center Self-in-Relation Therapy

The women of the Stone Center for Developmental Services and Studies at Wellesley College have developed a feminist therapy that includes analyses of racism, classism, and heterosexism. They don’t propose, however, that the work of therapy is political subversion; they don’t believe that clients need to understand, above all else, how patriarchal systems oppress them and how they can resist oppression. The Stone Center’s strongest emphasis is on healing that happens through the experience of connection. This emphasis makes it less rationalistic, less insight-driven, and less linear than Brown’s radical feminist therapy. The Stone Center theorists begin with the premise that women’s more connected, relational ways of being with others are healthier than masculine disconnected, autonomous ways of being in the world. Disconnec- tion causes interpersonal trouble, and it leads to the personal troubles that come to be labeled “mental illness.” In patriarchal social systems, painful patterns of disconnection are often handed down from generation to generation in troubled families.

Downloaded by [New York University] at 13:36 13 August 2016 When Jane comes in for therapy, her self-in-relation therapist is especially attuned to Jane’s disconnections—from the people in her life, from her own feelings, and also from the therapist, even while the two of them talk. The therapist keeps listening with care until Jane is able to bring some of her real thoughts and feelings into the conversation. In this ambiance of sustained empathy for her experience, Jane becomes more able to accept the fearful, hurt, and angry parts of herself. Bit by bit her confidence and self-esteem grow. Finally, as her relationships become more trusting and open, her depression starts to lift. But this brief sketch does not do justice to the long, difficult struggle beneath the surface of the therapy. The root of Jane’s emotional distress, a 30 Relational Therapy and Its Contexts profound sense of disconnection and isolation from others, is both hidden and very resistant to change. Stone Center theory explains why this is so, why Jane enters therapy pretending, even to herself, that she is connected, and why this pretense feels absolutely necessary. Like all human beings, Jane has a deep, basic need to connect with others. But the household she grew up in taught her that connection was impossible and dangerous. She “solves” the problem with a disconnected kind of connection, a pretense that gives her just enough connection to get by. She becomes good at being the person others want her to be, first in her family of origin and then in her adult life. Beneath the façade, she becomes isolated from others and disconnected from herself, with a constant anxiety that turns into depression. These symptoms are what motivate her to get help. Without them, she’d hardly know she’s in trouble, for this is life as she knows it. When she comes for therapy with a Stone Center or self-in-relation therapist, Jane is gently invited, again and again, to reconnect with others and with herself. This reconnecting is a long slow process because Jane hangs on tightly to the accommodating, pleasing strategies that keep her safe from dangerous relationship. Her therapist is present to Jane even while Jane stays hidden, she doesn’t give up trying to draw her out, and she shows special understanding whenever Jane shares “unpleasant” thoughts and feelings. As Jane slowly takes in the therapist’s empathy she begins to feel empathy for herself. Then she can begin to accept her own story, her emotions, and the self she has become. This self-empathy allows her, eventually, to find her way to mutually empathic and rewarding connections with others in her life.6 If this expanded story of self-in-relation therapy sounds very much like the relational psychotherapy I’m putting forward, that’s because my definition of relational therapy owes a great deal to the Stone Center. So why not stop here? Certainly we can leave Jane here and trust that her therapy process will be richly relational. But I want to understand more about the process that the Stone Center calls “connection,” a process that surely has both conscious and unconscious aspects and complications of its own. I would like to explore interactions and states of being that can’t be defined Downloaded by [New York University] at 13:36 13 August 2016 as simply connected or disconnected. So I look to relational psychoanalytic theory for more understanding of what might be condensed within the experience and idea of “connection.”

Relational Psychoanalysis—The Big Picture

Relational psychoanalytic theory is an entity of many parts, all of them moving forward. I will describe it in terms of streams: tributaries flowing into major rivers that continue to include diverse currents. Two major Relational Therapy and Its Contexts 31 tributaries flow into the contemporary river of relational psychoanalytic theory—object relations theory, especially as developed within the Brit- ish independent school (e.g. Winnicott, Guntrip, Fairbairn, and Balint), and interpersonal psychoanalysis, an American movement originating in the work of Harry Stack Sullivan. Both interpersonal and object relations forms of psychoanalysis are still practiced; they have fed the main stream of relational theory, but they also continue along courses of their own. For the sake of simplicity, however, I won’t deal with them as relational schools themselves but as precursors of contemporary psychoanalytic theory that self-identifies as “relational.” This contemporary river of psychoanalytic relational theory currently runs in two distinct streams. One calls itself “self psychology” and the other calls itself “relational psychoanalysis,” which I will identify in this text as Interpersonal/Relational (or I/R for short). The I/R stream carries within it many diverse currents: the interpersonalist one, of course, but also constructivist, feminist, and object relations forms of an explicitly relational theory of psychoanalysis. In his overview of the relational field, the I/R psychoanalyst Lewis Aron includes intersubjectivist versions of self psychology in the stream of relational psychoanalysis.7 In my view, however, the self psychology stream runs quite independently, and it will be some time before the two streams agree on a common language and a merger of perspectives and energies.8 Let me outline briefly my sense of the major differences between these two streams of contemporary relational psychoanalytic theory. First, they have different histories. Interpersonalist theory is the strongest force within the wide, eclectic stream that calls itself relational (or I/R) psychoanalysis. Within this stream, interpersonalist theory meets object relations theory and the waters of the two intermingle (with some mixing in of feminist and constructivist waters as well). The interpersonal dialogue of therapy can then be understood as the here-and-now enactment of certain object relations, or patterns of interaction among internal images of self and other. By contrast, the history of self psychology shows little interpersonalist Downloaded by [New York University] at 13:36 13 August 2016 influence. It also has a different relationship with object relations theory, having accepted it in order to transform it. Heinz Kohut, the founder of the self psychological movement, invented the term “selfobject” to focus attention on a particular kind of interaction between inner images of self and others. In a selfobject interaction, the inner object is not separate but exists as part of the inner self; it’s an experience of self-with-other that invisibly sustains a cohesive, vital sense of self from infancy onward. Kohut proposed his idea to make possible a psychoanalytic treatment of people who suffer deep self deficits because they have missed out on the experience of selfobject relationship. He did not intend a new school of theory. 32 Relational Therapy and Its Contexts Kohut’s ideas took on a life of their own, however, as early self psychologists kept on exploring the selfobject relation and how it is created by an analyst’s empathic immersion in a patient’s subjective experience. Even- tually, aware that their own subjectivity survived empathic immersion in their patients’ worlds, self psychologists saw that this therapeutic space of “empathy” is constructed by two interacting subjectivities. Thus the intersubjective school of self psychology emerged, and at this point self psychology began to mature into the fully and explicitly relational theory that I refer to in this text. In short, self psychology slowly found its way toward the question, “What interpersonal interaction is happening in the therapeutic relationship?” That question had been on the interpersonalist agenda from the very beginning, marking Sullivan’s break from the classical Freudian tradition. He and his colleagues went on to expand the terrain of psychoanalysis outside of medicine and psychiatry, especially with the founding of the Wil- liam Alanson White Institute in New York in the 1940s. The inclusion of PhDs as faculty and students of that Institute, along with the Institute’s historical commitment to freedom of thought and its opposition to the constraints of the American psychoanalytic establishment, created expanded space for philosophical and social understandings of the psychoanalytic enterprise. Over the years, various interpersonalist analysts have integrated existentialism, hermeneutics, phenomenology, constructivism, feminism, and post-structuralism into their psychoanalytic theorizing. In many ways the movement that calls itself relational (or Interper- sonal/Relational) psychoanalysis is a direct continuation of the energies embodied in the White Institute. For example, graduates of the Institute fill positions on the editorial board of Psychoanalytic Dialogues and the faculty of the relational stream of the postdoctoral program in psychoanalysis at New York University. Interpersonal/Relational psychoanalysis carries forward the interpersonalist commitment to philosophical exploration and social critique. Consistent with this commitment is the emphasis I/R psychoanalysis places on the mutual construction of meaning in the analytic Downloaded by [New York University] at 13:36 13 August 2016 relationship—the deconstruction of meanings that destroy well-being and the reconstruction of meanings that support health and freedom. By contrast, self psychology focuses more on the transformation of self- experience, especially the experience of self in relation to others. Perhaps there’s not much difference, really, between trying to change a patient’s unconscious personal meanings and trying to change a patient’s unconscious organizing principles of self-experience. Perhaps the two streams might find a point of merged purpose and language here. Yet the differences persist, and they likely come down to a basic difference between the worldviews of medicine and of the humanities and social Relational Therapy and Its Contexts 33 sciences, or between a relatively “objective” scientific view and a more self- consciously constructivist (lately postmodern) view of psychoanalysis. With its historical links to the American medical psychoanalytic establishment and its source in object relations, self psychology tends to couch its understanding of a patient’s self-experience in somewhat scientific/medical terms rather than in philosophical terms. Object relations theory, a medical model of psychoanalysis, taught self psychology to locate a patient’s pathology in damaged internal psychological structures and to understand this pathology as a direct result of faulty interactions with early caregivers. Although self psychology has made radical changes to this picture of pathology, it continues to see its picture of personality development, pathology, and treatment as true in a relatively objective, scientific sense. Interpersonalist theory taught relational psychoanalysis that pathology is located in faulty patterns of making meaning out of interpersonal interactions, and that these patterns are best addressed directly and in the present, so that the patient can come to understand what’s going on and take responsibility to deconstruct the old meanings and construct new ones. I/R psychoanalysis now works in subtle, in-depth ways with regression and transference. Often analysts of this school use object relations language about a patient’s parts of self, defenses, and projections in order to understand and explain their clinical work. But the explanation remains a tool, a meaning-making metaphor. Interpersonal/Relational psychoanalysis does not have self psychology’s interest in infant studies; it doesn’t investigate pathological development in order to understand pathways to optimal adult development. Thus it’s also more protected from the danger of being pulled back into a medical model where an expert doctor treats a patient’s objectively understood pathology. I will go on to expand on each of these two major streams of relational psychoanalytic theory in its own terms, but it’s important to have seen the big picture first. Knowing the family history of the theory you practice gives you a firmer sense of your place in the field of psychotherapy, and it helps you understand the hidden currents that move along within the Downloaded by [New York University] at 13:36 13 August 2016 stream of whatever relational theory you choose.

More about Interpersonal/Relational Psychoanalysis

Since the days of Harry Stack Sullivan, interpersonalist psychoanalysis has maintained that a person’s learned patterns of social interaction are at the root of his psychological problems. Inevitably these patterns will be put into play between a client and his therapist, and so paying attention to what happens in that relationship is the best way to find out what the 34 Relational Therapy and Its Contexts psychological problem is and how it works. Paying attention also starts the process of changing patterns between these two participants in the therapy, and change that happens in the therapeutic relationship will have a powerful impact on the rest of the client’s relationships and self-experience. Contemporary I/R psychoanalysts move beyond the early interpersonalists when they say that a therapist cannot stand outside of the therapy process as a neutral “participant–observer” in order to observe a client’s patterns objectively. They recognize, instead, that client and therapist are both involved in the mutual construction of their relationship. Very intentionally they replace a one-body psychoanalysis with a two-body model. Lewis Aron, for example, writes extensively about the inescapable mutuality of the psychoanalytic process.9 Owen Renik’s metaphor for the therapist’s engagement in the therapy process is “playing with your cards face-up.”10 Darlene Ehrenberg challenges relational therapists to push the therapeutic conversation to that “intimate edge” where client and therapist are having strong, if hidden, reactions to one another moment by moment.11 While maintaining that the essence of therapy lies in the interaction between client and therapist, analysts of this relational stream must also put some words to what’s wrong for their clients and to what happens when their clients start to change for the better. Many of them use object relations language to describe what they call the intrapsychic aspects of the client’s experience. In a series of influential books, Stephen Mitchell explores how theories of intrapsychic reality—both classical and object relations theory—mesh with relational theories of psychoanalysis.12 Jessica Benjamin articulates a feminist I/R psychoanalysis. She defines intersubjectivity as mutual recognition between two subjects—a paradoxical achievement always at risk of breaking down into relations of domination, where one person (often female) serves as object to the other’s (often male) subjectivity. Benjamin does not suggest that psychoanalysis or feminist social action can produce a utopia of intersubjective relations. Human beings must assert themselves with each other; conflicts of needs and of wills are unavoidable; intrapsychic constructions of domination and submission will Downloaded by [New York University] at 13:36 13 August 2016 persist. Benjamin’s point, rather, is that we do well to sustain the tension of recognizing one another as subjects, working through our conflicts, knowing that breakdowns of mutual recognition are inevitable, and also always holding the possibility of negotiating repair between and among us.13 Benjamin protects space for intrapsychic reality, while her vision of intersubjectivity demands the personal, relational presence required by all relational psychoanalysis. When analysis goes well, analyst and patient will sustain the tension of asserting self and recognizing the other. In this vision of relational work, a therapist must be a subject who communicates and negotiates directly with the client, making space for the client’s reciprocal Relational Therapy and Its Contexts 35 subjectivity, not an object who provides for the client’s needs. From this feminist point of view, too, I/R psychoanalysis insists that the problems clients bring to therapy have their roots in problematic relationships with others, past and present. Insight about those relationships does not in itself make change happen. Change happens through an experience of relationship that the client has never had before. Stephen Mitchell, the best known contemporary spokesperson for I/R psychoanalysis, argues that the relational analyst’s expertise lies in her ability to engage the client in the active creation of life-meanings that expand his capacity for personal engagement, authenticity, and freedom.14 The analyst looks for the best mix of safety and challenge to keep the client involved and moving forward. She won’t serve up any particular meanings as truth for the client, because for her what matters is the process of making meaning, and making it in relationship. This is what gets a client sprung free from old, constricting meanings. This is what gets change happening. Doing this process together produces the transformative power of therapy. Clearly this process is not undertaken by an isolated mind, and it’s a process that involves much more than linear rational thought. Would this kind of work feel different than working with someone committed to a Stone Center self-in-relation model? Certain differences would likely emerge. In I/R psychoanalysis, mutuality isn’t a desired state of being-together that signals successful therapeutic work, as it does in Stone Center theory. Instead, mutual influence is seen as an inescapable fact: two persons in relationship will affect one another in countless overt and subliminal ways all the time. For both participants, this mutual influence might feel good—or it might feel horrible. So the I/R analyst won’t concentrate on helping a client move from the “bad” of disconnection to the “good” of connection, from isolation to a steady state of mutuality. She’ll assume that connection and mutuality will include a mix of useful and damaging forms of relating. She’ll wait to see what troublesome kinds of mutual influence will emerge in the therapy relationship. She’ll help the client explore what happens between the two Downloaded by [New York University] at 13:36 13 August 2016 of them, working toward a therapeutic relationship that makes more space for the client’s self-awareness and agency. An I/R psychoanalyst won’t assume that less constricted ways of being together will always feel good. Less constriction means a wider range of possibilities, which might mean opportunities to feel disappointment, aggression, and anger. Working from an I/R psychoanalytic perspective, a therapist will understand that feeling more connected is but one of many new experiences open to a client as he starts to experience self-with-other differently. He might also find new ways to stand on his own two feet, to speak his own truth, and to pursue his own agendas. 36 Relational Therapy and Its Contexts In summary, an I/R psychoanalyst counts on the therapy relationship to unsettle its client’s accustomed ways of being, to stir things up and to get the client moving toward new meanings and options in life. This has a significantly different “feel” than counting on the therapy relationship to provide the client with a core experience of more genuine connection.

More about Self Psychology

We turn now to self psychology, the other major school of relational psychoanalysis. With a self psychologist, a client can always lay claim to the therapist’s empathy. Therapists of the I/R stream believe that such empathy is a limited, one-way connection. Empathy can be infantilizing, they suspect, and they believe that therapy for adults should include learning to deal with both sides of interpersonal differences, even—or especially—when they occur between client and therapist. And so, careful in their way to cause no harm, they share their thoughts and reactions as they occur during the process of therapy. By contrast, self psychologists are wary of putting the therapist’s self into the interaction. They limit the therapist’s contributions to expressions of empathic understanding. Why? To answer that question, we need to return briefly to the historical roots of self psychology. We’ve noted that Kohut invented the idea of “selfobject” to explain how to treat patients whose sense of self is fragile and easily depleted or fragmented. He proposed that they suffer from deficits of selfobject experience. At formative times they weren’t able to count on others to be with them in ways that supported their cohesive selfhood. Such deficits are most likely to stem from patients’ childhood experiences of being parented. In Kohut’s theory, therapists can step into that gap and perform some of those essential “being-with” actions for a while, strengthening the adult patients; cohesion, vitality, and self-esteem. This is the essential action of therapy; anything more or less than the therapist’s empathic immersion in such a client’s world will likely fragment the client’s fragile sense of self. Downloaded by [New York University] at 13:36 13 August 2016 On the one hand, Kohut’s move is deeply relational. It breaks with classical Freudian psychoanalysis and much of object relations theory to say that individual autonomy is a bogus therapeutic goal. It says that we all depend on others our whole lives long for our psychological well-being. Therefore therapists are not infantilizing clients when they support their clients’ legitimate and important needs to be understood, supported, and affirmed. Many clients are in therapy precisely because they have not been well enough understood and supported to develop selves that are sturdy, cohesive, and energetic. A relationship with the therapist is what creates the medium in which derailed self-development can begin again.15 Relational Therapy and Its Contexts 37 On the other hand, however, this classical formulation of self psychology is not yet a fully relational theory. As analysts from the I/R school and Stone Center theorists point out, this approach is still somewhat “one- body” (the therapist is involved only as empathy-provider), individualistic (attention is focused on the client’s self-development), rationalistic (interpretation in service of insight is the main way of working), and linear (self-development follows certain predictable routes when the therapist responds in certain prescribed ways). However, a strong movement within self psychology, most visible in the work of Robert Stolorow, George Atwood, and Donna Orange, has pushed beyond Kohut to explore the intersubjective context of the therapeutic relationship.16 Intersubjectivists describe the therapeutic situation as an “intersubjective field.” The rules and emotions of the games played in “the field” are set up by the interacting subjective worlds of both the therapist and the client. The therapist keeps bringing empathy and a search for understanding to the field, but the changes that happen there aren’t simply responses to his empathy, nor do they happen just because of the client’s new insights or understanding. Most importantly, as therapist and client interact, something changes in how the intersubjective dynamic gets set up and plays out between them. This experienced change in interaction, this “something different” in action, is what leads to change in the client’s self-experience. Howard Bacal’s phrase “optimal responsiveness” brings together the classic self psychological concern for accurate empathy and the intersubjectivists’ awareness that therapists keep finding themselves in very different kinds of intersubjective fields. A therapist seeking to be optimally responsive will let his empathic understanding for each client come through in creative, personal ways that may not look like simple empathy. As Bacal describes his own work, he crafts his responses to each client in order to create the best conditions for positive change in this unique intersubjective field, this two-person relationship.17 Ever since Kohut wrote about repairing self deficits, self psychology has Downloaded by [New York University] at 13:36 13 August 2016 had a strong developmental component. Both classical and intersubjective self psychologists refer to studies that show how infants and their caretakers are involved in intricate dances of mutual influence.18 They believe that healthy development depends on caretakers’ supportive, nonintrusive, emotionally attuned responses to a child’s needs. So do Stone Center theorists, though they generally link attuned response with women’s ways of being in connection. In contrast to both, I/R psychoanalysis speaks of mutual influence in relationships from infancy onward, but it doesn’t commit to any developmental scheme, believing that what matters most is whatever helps clients make meaning of their here-and-now adult experience. 38 Relational Therapy and Its Contexts How does it feel to work with a self psychologist? As a self-in-relation therapist does, a self psychological therapist attunes carefully to the details and nuances of the client’s experience, past and present. He strives for an accurate empathic connection with the client’s thoughts and feelings. His empathic immersion in the client’s experience will help the client develop a sense of connection with him and also help her connect better with her own self-experience. Unlike a self-in-relation therapist, however, a self psychologist understands these connections not as ends in themselves but rather as ways to help the client redevelop many ways of being her own self in the world, especially in the world of her relationships with others. He supports the many kinds of positive self-with-other experiences a self can have in addition to the experience of connection. In no hurry to achieve a “connected” feeling, a self psychologist investigates the dynamics and meanings of interactions when a client feels afraid of him or hurt by him. He helps the client notice when particular relational experiences in and out of therapy leave her feeling fragmented, shaky, or disheartened, and he trusts that this understanding will help her regain whatever sense of self-with-other she needs, be it connectedness, self-delineation, self-assertion, cohesion, or vitality. The differences between self psychological therapy and Interpersonal/ Relational psychoanalysis lie along other lines. An I/R psychoanalyst doubts that empathy unbroken by difference and challenge is the best facilitator of growth. She doesn’t fill in for missed parenting, and she isn’t simply patient with her client’s self-protections until he no longer needs to use them. As a more proactive participant in her client’s therapy, she will share what she thinks and feels in the therapy, and since she doesn’t always look for the hurt child in the anxious adult, she worries less than a self psychologist might about whether a client is ready to hear what she has to say. By contrast, a self psychologist won’t challenge the ways his clients protect themselves. He might explain to clients what he understands: dangerous circumstances taught them to be careful. He might sketch for them a Downloaded by [New York University] at 13:36 13 August 2016 contrasting picture in which children get what they need so that they can trust people more and expect more from life. He wants to explore with clients their memories, thoughts, and feelings about what they missed in their early years, and he is happy to provide for them some of the secure attachment they crave. Practitioners of classic self psychology believe that helping clients achieve insight about their unfulfilled needs is a necessary part of repairing their current self-deficits. A more relational self psychologist believes that a relationally “optimal” way of being with a client can, even without insight, help fill in some of those gaps. For example, for clients neglected Relational Therapy and Its Contexts 39 by distracted, depressed parents, a spontaneous, lively conversation might be essential. On the other hand, a client with intrusive, demanding parents might find that a silent, nonintrusive presence is just what she needs for long stretches of time. These tailor-made ways of being-with are exten- sions of the self psychologist’s empathy, variations on what Bacal would call optimal responsiveness. Many self psychologists, while they know that the concept is slippery (what’s “optimal”?), find that the concept of optimal responsiveness catches the spirit or feel of self psychological work.

Toward a Synthesis of Relational Theory

Despite the different emphases of the relational schools we’ve looked at, I believe that self-in-relation theory, Interpersonal/Relational psychoanalysis, and self psychology are fundamentally more alike than different in what they have to say about how relational psychotherapy works. In later chapters, I will be drawing on all of these resources as I introduce the principles of relational practice. I will take a moment here to show how, in spite of their differences, they each add something to enhance a relational picture of therapy. We will look in on Jane one last time. She’s with an eclectic relational therapist who is using several relational models to understand their work together. Stone Center theory helps the therapist understand how Jane uses strategies of care-taking and competence to stay in a semblance of relationship while keeping herself out of more vulnerable kinds of connection in which she might get hurt. Her strategies, however, are wreaking long-term havoc with her emotional well-being. When her relational therapist thinks along Stone Center lines, she knows that Jane will be helped through reconnection—with the therapist, with herself, and with others in her life. An Interpersonal/Relational perspective allows the therapist to notice how these self-protective and self-destructive strategies are played out again and again between Jane and herself. And so the therapist keeps try- Downloaded by [New York University] at 13:36 13 August 2016 ing to establish real connection with Jane, even if that sometimes means putting her own feelings on the table or challenging Jane’s strategies. But, retaining a self psychological sensitivity, the therapist is careful never to stray far from an empathic grasp of Jane’s experience, and especially of her experience of the therapy. She knows that if she is to provide the support that will help Jane grow stronger, she cannot undercut or second-guess Jane’s experience of reality. Intersubjectivity theory tells the therapist how Jane’s strategies for self- protection arise from unconscious convictions that make sense of her life experiences. Then it compounds complexity by noticing that not only 40 Relational Therapy and Its Contexts Jane’s organizing principles but also her therapist’s organizing principles are creating the field on which the therapy is being played out. Each player has her own strategies for safe connection and safe disconnection, and each player’s strategies will match, miss, excite or upset the other’s strategies, as the two of them move toward being understood and understanding the other. When Jane starts to feel better, Stone Center theory highlights the developing good connections Jane is making with her therapist and with many others in her life. I/R psychoanalytic theory prompts the therapist to celebrate Jane’s developing ability to create new meanings for herself, new possibilities for authenticity and freedom. From a self psychological perspective, the therapist understands Jane’s progress as the robust new development of previously stunted self-capacities. This last look at Jane puts forward a relational psychotherapy that isn’t to be found in only one of the relational schools, but draws freely on different relational theories. Each school has its limits. For example, striving for immersion in the client’s experience can lead self psychologists to believe that their personal presence doesn’t matter. On the other hand, the Inter- personal/Relational question, “What’s going on around here?” can be too threatening for a client to face, or too complex. Sometimes clients don’t want or need to know much about this complexity as long as the relationship is working well for them. At the same time, however, Stone Center theory, with its emphasis on connection that works well, doesn’t quite suf- fice when the therapeutic connection is full of ruptures and conundrums. A synthesis of these different relational theories allows each one to become useful in situations that fit the theory. Yet even the best theory finds itself constrained by hard realities. As relational therapists we know that many of our clients suffer because of systemic relational oppression. Our society does not teach us to recognize each other as subjects across our differences or to negotiate our conflicting intentions and desires with mutual respect. Many of us who are drawn to relational psychotherapy work are also deeply concerned about this larger Downloaded by [New York University] at 13:36 13 August 2016 picture of relational breakdown. Sometimes working with one client at a time can seem like trying to empty an ocean with a bucket. But we persist. Relational therapists of various persuasions speak out about the social and political contexts and meanings of their work.19 Any therapy that calls itself relational must pay attention to the play of social power within the lives of our clients and within each psychotherapy relationship as it develops between a particular socially situated client and ourselves. We also need to acknowledge that our relational theorizing is shaped by our own social location and by our personal and professional history. I’ll say a few words about mine. Relational Therapy and Its Contexts 41 My Theoretical Bias

I have been influenced by each of the relational schools, but the intersubjectivity and infant development branches of self psychological theory have been most formative for me. This happened because my first training in psychotherapy, in both a faculty of social work and a private therapy training institute, was in object relations theory. I learned to think about therapy through those developmental and quasi-medical categories, and as I pursued my special interest in working with trauma survivors who were classified as “borderline,” the self psychology emerging just then from object relations theory gave me both compassionate insight and useful skills for my work. Self psychology has influenced me personally as well as professionally. Over the years I have been a client in several different kinds of therapies, and the therapists with whom I connected most usefully were influenced by self psychology. Most recently I have been in a long-term psychoanalysis with a self psychologist. As generations of therapists and analysts can testify, there’s nothing more deeply formative of a certain understanding of therapy than a powerful and positive experience “inside” it. In my experience as both client and therapist, I’ve become convinced that empathic connection creates a better context for growth and change than explanation or confrontation does. I hope for connection with all my clients, but I believe it’s also important to recognize and understand how together we can sometimes create disconnected relational spaces. I believe that the changes facilitated by relational therapy are best defined as changes in the experience of self-with-other, with or without clear insight into the changes. Profound new relational experience can change what’s relationally possible for a person, even when the change is not articulated consciously. Finally, I believe that infant studies, though observer-constructed and culture-specific, reveal something reliable about how interpersonal dyads work and about how interpersonal development goes off track and can be brought back on track in a therapeutic dyad. All of these convictions

Downloaded by [New York University] at 13:36 13 August 2016 will determine how I go on to tell the story of how relational psychotherapy works. My bias will shine through. If you are new to relational theory, you need to know that bias is inevitable in this complex field. As you try to find your way in it, it will be important that you pay attention, over time, to your own biases and to how they determine what you understand and what you want to pursue. On the whole, it behooves all of us relational therapists to remember that even our theorizing is a relational activity, a self-with-other phenomenon that emerges from interaction and is held in being—for a while—in communities of shared thoughts and experiences. After a while, this theory will be 42 Relational Therapy and Its Contexts on its way to new interactions and new constructions. With this in mind, we can both throw ourselves into the creative tussle of theorizing and also remember to hold our theories lightly.

The Relational Vision: Reprise

In spite of its diversity and complexity, relational theory does rest on some shared givens, and in ordinary language they go something like this: All human beings are indeed creatures formed by their social contexts. There’s no escaping this reality. But sometimes some of us have opportunities to reflect on what forms us, and through that reflection, to make room for changes we hope for. Therapy offers such opportunities. As a relational therapist, you offer a client a chance to put into play with you the relational forces that have formed him. In this real relationship, you respond with your own subjective, “formed” self as your client explores whatever troubles or interests him. You hope that a new story will emerge for him, including a new way of being in relationship with you. You hope that this will change how he can experience himself in the rest of his world—as less depressed and anxious, more connected, alive, and secure, more able to tolerate risk and loss, more empathic with others, more confident in his own agendas, and more firmly committed to important values and ideals. None of these hopes for change is unique to relational therapy. What’s unique about relational therapy is how it proposes to get to those changes— through a relationship lived out for real, together, between you and your client. This relationship is a mutual risk, a joint commitment, an interactive process, a shared journey. The next chapters continue the story of this journey.

Notes

1. Freud’s writings are collected in a multivolume work: Sigmund Freud, The Standard Edition of Downloaded by [New York University] at 13:36 13 August 2016 the Complete Psychological Works of Sigmund Freud, translated by James Strachey and published between 1953 and 1966 by Hogarth Press, London. 2. See Carl Jung and Marie-Louise von Franz, eds., Man and His Symbols (New York: Doubleday, 1964). 3. Carl Rogers, Counseling and Psychotherapy (Boston: Houghton Mifflin, 1942), and On Becoming a Person (Boston: Houghton Mifflin, 1961). 4. Michael White and David Epston, Narrative Means to Therapeutic Ends (New York: Norton, 1990). Also of interest: Sheila McNamee and Kenneth Gergen, eds., Therapy as Social Construction (New- bury Park, CA: Sage, 1992). 5. Laura Brown, Subversive Dialogues: Theory in Feminist Therapy (New York: Basic Books, 1994). 6. Judith Jordan, Alexandra Kaplan, Jean Baker Miller, Irene Stiver, and Janet Surrey, Women’s Growth in Connection: Writings from the Stone Center (New York: Guilford, 1991). Relational Therapy and Its Contexts 43

. 7 Lewis Aron, A Meeting of Minds: Mutuality in Psychoanalysis (Hillsdale, NJ: Analytic Press, 1996), 56. 8. This state of affairs is reflected in the conference history of the relational psychoanalytic movement. Self psychological relationalists attend a conference of their own every year; 2002 marks the twenty-fifth year of the annual International Conference on the Psychology of the Self. Simultane- ously, for many years analysts from more diverse and eclectic relational positions, including many interpersonalists, have gathered and presented papers at meetings of the Psychoanalytic Division (Division 39) of the American Psychological Association. In 2002 a new conference was initiated by a new association, the International Association for Relational Psychoanalysis and Psychotherapy. Named in honor of the late relational psychoanalyst Stephen Mitchell, the conference was designed to engender conversations between the diverse streams of relational psychoanalysis, including self psychology, and to include psychotherapists—not just psychoanalysts—in those conversations. Perhaps this marks the beginning of a new era of common cause and inclusivity among relational psychoanalysts and psychotherapists, but only time will tell. 9. Aron, A Meeting of Minds, 25–26. 10. “Playing with Your Cards Face-up” was the title of a seminar Owen Renik presented in Toronto in 1999. In “The Perils of Neutrality,” Psychoanalytic Quarterly 65, 495–517 (1996), Renik argues for a dialectical kind of learning in psychoanalysis that requires that the analyst own up to his or her intentions to influence the patient in ways that the analyst believes will be in the patient’s best interests. When these feelings and intentions are on the table, the patient can engage with them as the analyst’s personal and fallible opinions, not as moral or scientific authority, and use them to learn more about his or her own reality. 11. Darlene Ehrenberg, The Intimate Edge: Extending the Reach of Psychoanalytic Interaction (New York: Norton, 1992). 12. Stephen Mitchell, Relational Concepts in Psychoanalysis: An Integration (Cambridge, MA: Harvard University Press, 1988); Hope and Dread in Psychoanalysis (New York: Basic Books, 1993); Influ- ence and Autonomy in Psychoanalysis (Hillsdale, NJ: Analytic Press, 1997); and Relationality: From Attachment to Intersubjectivity (Hillsdale, NJ: Analytic Press, 2000). 13. Jessica Benjamin, The Bonds of Love: Psychoanalysis, Feminism, and the Problem of Domination (New York: Pantheon, 1988); and Like Subjects, Love Objects: Essays on Recognition and Sexual Dif- ference (New Haven, CT: Yale University Press, 1995). 14. Mitchell, Influence and Autonomy in Psychoanalysis. 15. Heinz Kohut, How Does Analysis Cure? (Chicago: University of Chicago Press, 1984); and Ernest Wolf, Treating the Self: Elements of Clinical Self Psychology (New York: Guilford, 1988). 16. Robert Stolorow and George Atwood, Contexts of Being: The Intersubjective Foundations of Psychological Life (Hillsdale, NJ: Analytic Press, 1992); and Donna Orange, Emotional Understand- ing: Studies in Psychoanalytic Epistemology (New York: Guilford, 1995). 17. Howard Bacal, ed., Optimal Responsiveness: How Therapists Heal Their Patients (Northvale, NJ: Jason Aronson, 1998). 18. Daniel Stern, The Interpersonal World of the Infant: A View from Psychoanalysis and Developmental Psychology (New York: Basic Books, 1985); and Joseph Lichtenberg, Psychoanalysis and Motivation (Hillsdale, NJ: Analytic Press, 1989). 19. For example, Stone Center theory attends not only to gender but also to culture, race, class, and sex- Downloaded by [New York University] at 13:36 13 August 2016 ual orientation. Jessica Benjamin consistently positions herself at the intersection of feminist and relational psychoanalytic theory. Neil Altman, writing as a relational psychoanalyst who also uses projective–introjective object relations theory to understand the intrapsychic and relational power of social constructs, envisions the realities of economics, race, and class entering the therapeutic relationship as concretely as a third person, with profound effects on both client and therapist and on their relationship: Neil Altman, The Analyst in the Inner City: Race, Class, and Culture through a Psychoanalytic Lens (Hillsdale, NJ: Analytic Press, 1995). Relational analysts and therapists are among the contributors to a collection of essays that explore similar questions about connections between multiculturalism and social diversity on the one hand and psychoanalytic or psychodynamic theory on the other: RoseMarie Pérez Foster, Michael Moskowitz, and Rafael Art Javier, eds., Reaching across Boundaries of Culture and Class: Widening the Scope of Psychotherapy (Northvale, NJ: Jason Aronson, 1996). 2 Beginning with the Basics: Structure, Ethics, and Empathy

First Sessions, First Questions

You’re about to meet with a client for a first time. A week ago she left you a phone message, and you returned her call. She told you things aren’t going well in her life. She thinks she needs some help, but she hasn’t tried therapy before. Could you say something about how you work? You said, “I like to begin with whatever the trouble is right now. We’ll talk it through and try to understand together what’s going on.” You paused, wondering if she needed to hear more. “Okay,” she said. “That sounds good.” So you moved to the practical details: a time that worked for her, your fee, location, parking, and the like. Now, as you introduce yourself to her in the waiting room, she greets you anxiously. As always with a new client, you feel some performance anxiety yourself, but you manage it by concentrating on putting her at ease. You welcome her into your office, and she settles into the chair opposite yours. You begin, “You told me on the phone that things aren’t going so well …” A story tumbles out and you listen carefully. Whenever she pauses, you reflect the gist of what you’re hearing, trying to express the feeling of it in your voice and face. As you near the end of the session, she asks, “So do Downloaded by [New York University] at 13:36 13 August 2016 you think you can help me?” “I think so,” you say. “Right now I think what you need most is that I understand what you’re going through.” Her face says she doesn’t quite get it, so you go on. “Just understanding it together can make a big difference. Sometimes the next part—what to do about it—comes clear as soon as you’ve had a chance to explore what’s really going on for you. We’ve made a good start on that today, I think.” She nods yes to the idea of a good start. Since it’s time to end, you ask her whether she would like to make another appointment for the same time next week. She says she would, and you write her an appointment card. “See you next week,” you say warmly Beginning with the Basics 45 as you walk her to the door. You close the door and sit down for a moment, wondering, “How did that go for her? What’s she feeling now?” It seemed that she felt understood. How did that happen? What did you do to help make it happen? It’s second nature by now—the way you listened with your face and voice to let her know you got it, your “mmmhmm” noises, the quiet words you gave to some of her feelings. You paid attention to what seemed to put her at ease. Some clients need questions to help them talk. This client needed space to find her own way with her story. You didn’t think this out; you just fit your energy and rhythms to hers. Near the end of the session, your client remarked, “That was easier than I thought! The time just flew!” It seems her relational history has given her confidence that she can connect with another person and be understood. You’re glad to be on the other side of that. This is a promising way to begin therapy. Now your client is down the street in a coffee shop, thinking about what happened. She’s told parts of a painful story and you’ve taken it in. She feels some relief in her body and mind. But questions and worries begin to swirl around, too. She wonders, “How does this work? How is it different from talking to a friend?” She remembers that you said understanding helps. She didn’t know what it would feel like, but now she wants more of it. Could she count on you for more understanding? If she were feeling really rotten tomorrow, could she call you on the phone? Would you come to her rescue? What are the limits of this relationship? Because you know these questions will come up, early in the next session you talk about some of the practical boundaries of the therapy, things you didn’t get around to in the first session—policies about cancellations, extra sessions, and how you respond to phone messages. Since you live in the same community, you ask how she’d like to handle accidental meetings. You could say “Hi,” or not—whatever feels comfortable to her. As you pay attention to the many small ways in which therapy is a strange, specialized relationship with its own boundaries and protocols, her anxiety settles. She can relax when she knows that you know how to handle this strangeness. Downloaded by [New York University] at 13:36 13 August 2016 You’ve given the strange situation of a therapy relationship a lot of thought. Behind the parameters and protocols you outline, there’s your professional, ethical understanding of the structure and boundaries of any therapy relationship. You believe that the heart of relational therapy is your commitment to be present, with caring and focus, in the relationship, and you know that you can be most present while in session in the therapy room. You can explain, then, that as a therapist you don’t do emergency on- call work. You will return calls between sessions when your client needs connection, but you’ll wait to talk in person about any issues that come up. 46 Beginning with the Basics You know that the most useful therapy work you can do happens within the boundaries of regular sessions at regular times, and in time your “emergency” clients come to know this, too. As they settle into the rhythm of regular therapy, they also realize how much more available you are to them in session than they imagined could be possible. Those feelings that scared your client after the first session—feelings that she needed your understanding more than she wanted to—may not go away. Her feeling of not wanting to need you may in time get tangled up with resentment that you can’t be available to her all the time. But whatever her feelings toward you may become, as a relational therapist you believe that they are a rich resource for the work of therapy. You want to hear about those feelings. That’s how available you are to her in session. There’s nothing between the two of you that she’s not allowed to talk about, and the more she is able to talk about, the better. This kind of talking may be frightening for her at first, but it makes for powerful learning and change. The boundaries of therapy are what create this safe space for honest talk. No social contact between yourself and your client, meeting at a set time and place, and keeping the important work of therapy inside of sessions— all of this makes for safe intensity in therapy. Because this is therapy, and only therapy, you and your client can explore in depth what’s happening between the two of you. No ordinary relationship could bear this kind of intense work on what happens between two persons, in the interest of one of those persons being profoundly understood. It’s also important to note that for a relational therapist, boundaries are not about blocking a client’s “dependency.” What’s often mislabeled “dependency” can be deeply useful for a client who has suffered relational trauma. A therapy relationship that meets important attachment needs can help a client resume blocked personal growth. A long, slow, often conflicted experience of being able to shift from fear to trust is the core story of such therapy. Relational therapy embraces and protects this kind of dependency. If the “realness” of relational therapy makes your client anxious, you might say something like, “What I get out of this is just to do good work Downloaded by [New York University] at 13:36 13 August 2016 with you, to be the best therapist I can be with you; the relationship is for you.” You might add, “And I find this especially important to say to people who have been manipulated and used in relationships.” You know that if your client has already been abused or manipulated in relationships with powerful people, she will need to hear that said out loud sooner or later. Your saying it won’t dissolve her fears, but at least she knows she can ask, “Who is this for?” And she knows that you know what the question means to her. Your client will be reassured by the details of your professional frame of practice—by knowing, for example, that you will return her telephone calls Beginning with the Basics 47 as soon as possible, that you will give her as much notice as you can of any changes in your schedule, and that whatever she tells you (unless it reveals that a child is being abused or someone’s life is in danger) will be entirely confidential. With more experience with you, your client’s understanding of the ethic of this relationship will deepen. She’ll begin to see how it fits with how the therapy works. The better you can be clear and honest with each other, the better the therapy works. You tell your client that if anything you say or do feels not ok to her, you’d really like to hear about it—because that’s how the therapy can live up to its potential to be helpful. As your client tries to understand what she’s getting herself into with this relational therapy, she might ask how long it will take. What’s an honest and ethical answer to that question? You might say, “I really don’t know. I think we’ll find out as we go along.” To an anxious client you might say more: “Maybe you’ll get your balance back and start to feel better in a few weeks. I hope so. But if you need more time to talk, more time to feel stronger and more okay, we can do that, too. It will be your choice—how long we do this. And I imagine you’ll choose on the basis of whether it’s helping you as we go along.”

What’s All This about Empathy?

When your client begins relational therapy, she enters a particular kind of relationship with well-defined boundaries and ethics. The ambiance or “soul” of this relationship comes not from its structure, however, but from your empathy. A relational therapist without empathy is like a tennis player without a racquet or a lifeguard who can’t swim. Empathy is your relational mode of operation, your way to keep things moving. Let’s take a closer look at this skill that makes it possible for you to be a relational therapist.

Able to Feel Downloaded by [New York University] at 13:36 13 August 2016 What is empathy? Heinz Kohut, the father of self psychology, defined empathy as “vicarious introspection,” or “the capacity to think and feel oneself into the inner life of another person.”1 Years earlier, Carl Rogers built a therapeutic system around the therapist’s ability to deeply understand each particular client, with “no inner barriers [to] keep him from sensing what it feels like to be the client at each moment of the relationship.”2 The empathic therapist, then, is not afraid to feel. She has worked through fearing her own emotions in her own therapy. A therapist who can share the most painful moments of clients’ lives is a therapist who has been 48 Beginning with the Basics helped by someone else to feel what she could not bear to feel alone. This puts a different spin on the Freudian insistence that analysts undergo their own analysis. The point is not that you come to know all there is to know about your own inner workings, but that you develop the inner courage and resilience to be able to feel whatever needs to be felt—that you have, as Rogers put it, no inner barriers. In the humanist tradition of psychotherapy, therapists are often trained in groups that encourage expression of feelings among members. Behind this practice is the belief that intense group experience expands a therapist’s comfort with a wide range of feelings. But however you come to it, if you want to be a relational therapist, this capacity is crucial: the ability to hold within your being many kinds of suffering. You don’t need to have experienced all the kinds of loss, humiliation, abandonment, and despair that others bring to you, but you do need to have felt your own experience of suffering truly and deeply. If you haven’t faced what hurts you, you will shy away from clients’ stories in order to protect yourself from your own history. When you have felt your own history, you can also make links between your experience and your clients’ experiences, the better to understand them. Sometimes you will still feel afraid of a story that’s especially horrific or hopeless or strikes very close to home. But when you have done your own work in therapy, you will know when you feel afraid, and you will know to talk about your feelings in supportive relationships with supervi- sors and experienced peers. Your experience in therapy will have taught you how to get the help you need in order to acknowledge, understand, and bear whatever feelings come up for you as you immerse yourself in your clients’ experiences.

Able to Communicate Feeling

Rogers also believed that it was essential for the therapist to be able to

Downloaded by [New York University] at 13:36 13 August 2016 communicate the flow of her “feeling-with” the client in an immediate, moment-to-moment kind of way. The goal was a careful kind of emotional transparency. Genuine communication of the therapist’s connected empathy would make it possible for the client to be more fully within the stream of her own feelings, integrating them experientially into what humanists envisioned as a fuller, deeper, and more authentic sense of self. As the self-authenticating 1960s gave way to the 1970s, a certain group of psychoanalysts began to emphasize empathy, too. Led by Kohut, early self psychologists described empathy as immersion in the patient’s subjective world. They assumed that this empathy was a tool readily available to Beginning with the Basics 49 therapists, uncomplicated to express, and they saw the communication of empathy not so much as a gateway to the patient’s authentic experience as a gateway to the patient’s insight. For them, the expression of empathy—the product of their vicarious introspection—would lead to the patient’s ability to be introspective herself and thus to develop that marriage of emotional and cognitive insight that would free her from her internal constrictions. In the psychoanalytic world, it was revolutionary to suggest that the therapist’s expression of empathy could be as powerful as the therapist’s interpretations. Self psychologists noted that their empathic understanding eased patents’ shame, opening space for self-reflection. Empathy also invited patients to rely on the therapist for the consistent understanding that had been missing for them in childhood. In the presence of empathic connection, certain kinds of thwarted self-development could begin again, filling in deficits in shaky self-structure. For example, in the presence of someone strong and supportive, a patient could begin to feel safe and strong herself, and in the presence of affirmation, she could begin to enjoy her own competence. In this self psychological use of empathy, the therapist is always searching for an optimal response. For some clients, anything beyond mirroring their experience feels intrusive or controlling. Some need more substance—a response that offers more support or alternative ways to think about things. Others need to feel enough kinship with a therapist so that they don’t feel weirdly alien in the world of human relationships. When empathy is fine-tuned according to the patient’s needs, the therapist is not being simply authentic and transparent. Unlike the humanist therapist, who shares his spontaneous personal response to the client’s flow of feeling, the self psychologist shapes his responses around his understanding of the patient’s experience. Thus these two early sources on empathy propose to use empathy in two quite different ways in therapy. But neither of them has the last word, because several decades after Rogers began writing and a decade after self psychology came onto the psychoanalytic scene, infant studies began to complicate and enrich the picture of how empathy Downloaded by [New York University] at 13:36 13 August 2016 is communicated between infants and their caretakers, and, by extension, between any two human beings, including client and therapist. As we noted in Chapter 1, although Rogers and other humanists had a profound and prophetic understanding of the power of empathy, they still worked from an individualistic worldview. For them, empathy was a neutral medium, created by the therapist’s authenticity, within which a client’s authenticity could emerge. They didn’t pay much attention to how the therapist and client co-created the limits and freedoms of their mutual relationship, the very modes through which “self” and “other” could be known in this relationship. Likewise, although early self psychologists 50 Beginning with the Basics believed that human selves need others like human bodies need oxygen, their understanding of the exchange between these selves was fairly linear and one way—from the provider of empathy (therapist/parent) to the receiver of empathy (client/child). A more systemic and mutual sense of the empathic exchange didn’t emerge until the 1980s, when therapists began to look at what Daniel Stern called “the interpersonal world of the infant.” Baby studies began to show two things about empathy: (1) instead of being a neutral medium one person offers to another, empathy is a system that emerges from active two-way participation between persons; and (2) the communications that regulate a system of empathy are subtle and ongoing, and they include a wide variety of nonverbal and verbal cues. Often, instead of “empathy,” baby-watchers speak of the parent’s attunement to the infant and the infant’s reciprocal attunement to the parent. These attunements, with all of their shadings and near-misses, become patterns of infant–caregiver mutual regulation— a shape and feel of relationship that is formed by and that forms a certain kind of baby and a certain kind of parent. This much more complex view of how empathy is elicited, communicated, and received leaves contemporary relational therapists with new considerations about how to do their work. What does “authenticity” mean within this context of continual mutual influence? Is complete immersion in a client’s experience actually possible? Rather than trying to distill purer forms of authenticity or empathy, today’s relationalists embrace the idea of mutual influence. Aware of working in a complicated, bidirectional field, they pay close attention to the unique forms of connection that take shape with each of their clients. An objective understanding of the client’s need is no longer the point. The point is to explore, understand, and improve a mutual connection. In this systemic view of mutual attunement, the communication of empathy is more of a mystery to enter than a tool to master. “Able to communicate empathy” means able to persist in that mysterious dance, making connections happen around, through, and beyond inevitable misses and disconnections. Downloaded by [New York University] at 13:36 13 August 2016

Able to Know Who Is Who (and What Is What)

Empathy is a system of mutual cues and responses that regulate each participant’s experience of self and the other in the system. But at the same time, each participant is a separate person with a unique subjective reality. Empathy is a mutual activity, and yet the empathy that parents have for young children does not expect an equivalent empathy in return. Therapists, like parents, practice intentional, purposeful, and self-reflexive empathy. Beginning with the Basics 51 Therapists and parents focus on what a client or a child is experiencing. They suggest words and meanings for what’s happening. They are responsible to keep clear whose feelings are whose. They hold in mind the uniqueness of their own and the other’s experience. We might call this constructive empathy, an empathy that knows what it’s doing. This knowing may not be conscious or articulated, but it is present even between adult friends who know that when one is in trouble, the other provides a special kind of listening that doesn’t take over the other’s hurt or get lost in it. The Stone Center theorists argue that such mature, intentional empathy is the work that has fallen to women in our culture—and therefore it has not been honored as a gift or a special capacity. And so, while fully appreciating the interactive mutual nature of empathy, Judith Jordan also highlights the strengths embedded in the intentional practice of empathy: (1) a secure, well-differentiated sense of self, including the flexible self- boundaries that make it possible to step into—and out of—the other person’s shoes, feeling both sameness and difference; (2) the ability not only to feel-with but also to give meaning to that feeling with thought; and (3) the ability to use these feeling–thoughts to help the other understand his or her inner world better. The gift of such empathy allows people to learn that they can feel and think for themselves and also be connected to others. It shows them how to extend this kind of empathic understanding to others. In therapy, a client can also turn this fledgling capacity for empathy toward herself, allowing for the integration of feelings, memories, and self-representations that had been shut away by isolating shame.3

What Does This Empathy Do for Your Client?

How does this definition of empathy play in the therapy hour? First of all, what does it mean for your client that you have been in therapy yourself, facing your own fears and bearing your own most painful feelings? It Downloaded by [New York University] at 13:36 13 August 2016 means that you know what it’s like to be in her chair right now. You understand how ashamed she may be to tell her story, and how frightened she may be of her emotions. It means that your responses to her feel grounded and sure, and so she feels she can count on you for understanding that runs deeper than words. Your commitment to doing your own emotional work means that no matter how harrowing your client’s memories, how intense her fear or rage, or how bone-wearying her depression, you’re there for it all. If you start to feel drained, you take care of yourself. If you sense yourself pulling away, you get the help you need to be able to return to the relationship. You are 52 Beginning with the Basics especially careful to know about the feelings you have when she has strong feelings about you. What does it mean for your client that you communicate your empathy well to her? First of all, she will feel your empathy only if you can communicate it to her in some way. Secondly, your verbal and nonverbal attunement gives her the experience of being with a real person on whom she has a genuine impact. As your client sees you trying hard to understand her, and as she feels the care and attention in your effort, she may begin to feel more like a real person herself, with a story and feelings that actually matter. As a contemporary relational therapist, you will try to balance your authentic presence with giving your client the kind of response that seems most helpful in the moment. You know that you will never strike the perfect balance between genuine self-expression and meeting your client’s needs, for the two intentions exist in tension. You know, furthermore, that this is a creative tension and part of a complex picture in which empathy is a dance of separateness and connection all at once, as infant studies demonstrate. What does it mean for your client that you have listened to what some of those baby-watchers have said about the mutuality of empathy? It means that you attend to how the two of you keep co-constructing your ways of connection. At first this will be just part of your careful listening. Later, as appropriate, you may share with her what you notice about your mutual style of connection and invite her to do her own noticing. As the two of you pay attention to the kinds of responses that help or hinder her, to what scares her and what makes her feel safe, the therapy becomes slowly cleared for freer expressions of who she is and what she feels. What’s the overall effect of this kind of attention to the process of connecting with each other? After a while your client begins to realize that you aren’t sifting through her feelings in order to uncover the hidden truth about her, something she might never have guessed. On the contrary, she, her being, is what is real to you. Her immediate experience is what matters. Her experience matters even more than the stories she tells to explain her experience. From day to day and over time her stories may shift and change in feeling Downloaded by [New York University] at 13:36 13 August 2016 and emphasis. But the bottom-line “real” for her remains the reality of the connection between the two of you and the fact that you believe her. You know that your client’s story is as real as she is. She and her story are one bundle of meanings as she tells them to you. And yet even the telling puts those meanings into further motion. The meanings move between the two of you, and your client finds herself moving and changing along with them. Eventually, she might find herself enjoying the adventure of not knowing what she’ll say today, what will happen next, or what new meanings will turn up. What does it mean for your client that as her therapist you take responsibility for maintaining empathy for her without expecting empathy Beginning with the Basics 53 in return? She might find the situation awkward, for it’s not how social relationships work. Or she might find it unthinkable, having been trained by formative relationships to look after another’s well-being before her own. This training is most potent when it happens to children who must look after emotionally needy or fragile parents. If this was the case for your client, she may come to realize how diligently she looks after you whether you need it or not (she has to assume you do). At first it will disorient her whole operating system to think that maybe she doesn’t have to be “good” in therapy, the parentified child ever careful of a fragile mom or dad. Even- tually, though, she may be able to relax in the presence of a competent, emotionally sturdy adult whose chief concern is her well-being. What does it mean for your client that you can empathize with her and at the same time be clear that you aren’t her? Let’s put the question the other way around. What if, as she talked, your own emotions took over? What if you told her that she’s just like you, or that you know her feelings better than she does? This kind of emotional takeover is as disturbing for a client—for anyone!—as emotional abandonment. Emotional neglect and emotional intrusion are actually two sides of the same coin, and clients who have suffered both have good reasons to believe that they will never be understood. They are wise to protect themselves from connection. But here and now, if on the one hand you won’t disappear on them, and on the other hand you won’t take over their emotional space with your feelings, needs, and agendas, they may finally discover a space in which they can get to know who they really are through expressing what they actually think and feel. How can you show care not to take over your client’s feelings? You can respond in the form of “wondering.” You can use the word “maybe” a lot. You can indicate that you’re trying to get it; this is what you understand so far, but you’d like to get it better. Clients will begin to count on this respectful, open-ended curiosity, and then they will join in the shared process of “getting it.” In fact, the process of creating understanding will become more important to them than getting a perfect empathic response right off Downloaded by [New York University] at 13:36 13 August 2016 the bat from you. Why is this? Because what they need is not perfect empathy, but the experience of a relationship in which they are free to work out mutual understanding with a reliable partner. (Infants and young children don’t need perfect empathy, either; in fact, overattunement can be stifling and intrusive. On the other hand, they do badly need the experience of ongoing relationships in which misattunements and misunderstandings can be repaired and the relationship put back on track.4) Somewhere your client knows that neither she nor you can get out of your own skins, your own histories and life contexts. She knows it would be wrong for you to “know it all” or to tell her how she feels or what’s true 54 Beginning with the Basics for her. She might sometimes wish that you had a “God’s eye” view of her and all the answers that go along with that, but on the whole and in the end, she’ll be glad that you’re a fallible real person trying to understand her the best you can. Your understanding involves more than just emotional attunement; your empathy comes with thought. You think about the patterns in your client’s life, her recurring fears, expectations, and hopes, and how they play out. You ponder the experiences you share in therapy and wonder how they affect her feelings. What does it mean to your client that you think about her with empathy? Maybe for the first time in her life your client can sense that she exists over time as a real person who can be known in depth by someone else. In your thoughtful connection with her, your client learns not what is true for her—that’s hers to discover with your help—but how to wonder about herself. As her capacity to self-reflect expands, her sense of self grows stronger and more resilient. At the same time, it can be a great relief to your client not to have to be anxiously “overthinking” all the time. It’s nice for her to know that someone else is minding the store, keeping track of what’s going on. Sometimes, especially if your client always had to keep herself safe by thinking of everything, it can be quite wonderful for her to just let herself be, feel, talk, float, and know that someone she trusts is doing whatever thinking needs to happen. What does it mean for your client to begin to have empathy for herself? As you listen with care and respect to her story, she begins to realize that whatever is hurting her, it isn’t trivial, stupid, or a product of her own weakness. Then she might notice links between her feelings now and her feelings when she was growing up—and they weren’t her fault then, either. Another layer of empathy has become available to her: compassion for the child that she was, a child who made sense of what troubled her by deciding that something was wrong with her—she was the problem. Now the shame or disgust she has felt about that child can give way to sadness for what she lost, and to loving respect for how she did the best she could Downloaded by [New York University] at 13:36 13 August 2016 anyway. When there’s more room in your client’s imagination for the reality of her own struggles, she begins to see other people differently, too. We might say she has more empathy for them—or more knowing that life is not a simple process of doing things right or wrong, that almost everybody gets burdened by family legacies of shame or guilt, and that the secrets of being okay lie not in escaping trouble but in living through trouble with others, supported in mutual networks of care and understanding. These new thoughts and feelings will help her find a more grounded, balanced, and secure place in her own present life. Sometimes the people she will Beginning with the Basics 55 come to see differently are some of the people who once hurt her most: a frightening, rageful father tormented by the demons of his own depression, an unavailable mom silenced by her own self-doubts, a partner whose childhood pain got so entangled with hers that there was nothing to do but separate. What’s happening to your client? Because she is being understood, she can understand who she is, what she feels, and how she came to be the person she is today. She is coming into a stronger sense of self not because she’s gaining her independence, but because someone has shared connection with her. From that alive and resilient place of knowing “This is me!” she is reaching out for more connection, for relationships in which she both understands and is understood.

The Scope of Empathy Work

The power of empathy makes relational therapy a versatile way to work. For example, although relational therapy doesn’t emphasize insight, it often happens that as empathy draws your clients’ memories, beliefs, and feelings into the light, new insights emerge, allowing clients to feel less confused and “crazy.” Relational therapy isn’t intent on unearthing clients’ memories. It doesn’t go after their feelings in hopes of release or catharsis, nor does it try to change their faulty belief systems and negative thought patterns. Nevertheless, as empathy creates safe space for remembering, clients may well remember events they had forgotten, with feelings that were too much to bear alone. As empathy allows them to emerge from shame, they can explore what they actually believe and think. Relational therapy doesn’t push a client to make specific changes in his life unless that’s his agenda. Your empathy, however, might tune into a client’s restless, “stuck” unhappiness, giving him space to move. Your acceptance of a client’s self-doubt might, paradoxically, allow him to reclaim some confidence. If he’s entangled in difficult relationships, your under- Downloaded by [New York University] at 13:36 13 August 2016 standing can help some find what he needs to say to his parents in order finally to “leave home,” or discover his sense of entitlement with his boss, or figure out how to negotiate better ways of give and take with friends and lovers. When there’s somebody who really gets how tricky these issues are for him and who stands right behind him helping him find out what he wants, he doesn’t have to stay stuck. Relational therapy isn’t bereavement therapy, but when a client has suffered a loss, you will stay with his pain and sadness, his angry, lonely despair, and all of his memories and regrets for as long as he needs you to be there. Sooner or later most clients’ experience of relational therapy 56 Beginning with the Basics becomes, for a while at least, an experience of grieving—allowing the pain of the past to be real, and mourning failed hopes and broken dreams. And finally, although relational therapy wouldn’t characterize itself as a spiritual therapy, there’s something profoundly powerful about creating a quiet space in which to know oneself and be known. As the turmoil of their lives subsides, clients may return to this quiet space to meditate on the meanings of life, in all of its brokenness and beauty. Such is the breadth of a relational mode of therapy, and it’s a good foundation for more specific kinds of therapeutic expertise. For example, phobias, obsessions, compulsions, and intrusive post-traumatic symptoms often respond well to desensitization and relaxation techniques. A relational therapist will use these tools with his clients, but he will also remain mindful of the larger picture. Sudden trauma may produce intrusive symptoms, but it may also shake the victim’s entire sense of being safe in a predictable world, and this deeper fear may extend to the world of his relationships with others. Phobias and obsessive-compulsive patterns may be symptoms of deep anxieties about interpersonal safety, even though a client’s efforts to control the danger may focus on physical events and objects. Another way to make a frightening relational world feel safer is to become addicted to a mind-numbing activity or substance. If a client’s pre- senting problem is an addictive and disordered relationship to food, drugs, sex, gambling, or other repetitive activities, you may, as a relational therapist, refer him to a treatment center that specializes in getting the addiction under control, or if you have the training, you may do that work with him yourself. But after the behavior is under control, the real work starts. What is it that he hasn’t wanted to know about or feel? Now that he’s not numb, what’s it like for him to be in his own skin? Can he talk about the emptiness inside, the restlessness and the craving? As a relational therapist, you know that the anxious emptiness that drives his craving is a symptom of deep isolation. It’s what he’s left with when nobody sees him or knows who he is, and he’s felt like that forever. It’s a long road back, not just from his addiction but from his conviction Downloaded by [New York University] at 13:36 13 August 2016 that aloneness is his life. It may take you a long time to get in, to convince him that you’re really there and that he matters. But you’re in it for the long haul. If he’s ever going to get over it, not just the addiction but what drives him to it, this is the kind of long-term help he will need. People who have suffered childhood physical and sexual abuse also need long-term help. Therapists who work with abuse survivors have a special body of knowledge about the symptoms survivors suffer—dissociation, hypervigilance, crippling anxiety, flashbacks, and intense shame and self- hatred, regulated through self-harm. At the root of all these symptoms is a devastating betrayal of trust. Often the one person the child looked to for Beginning with the Basics 57 love and protection also abused him. And yet, to stay alive emotionally as well as physically, the child had to stay connected to the caregiver. If this is your client’s story, at the dark, silent center of all of his symptoms, that betrayal lives on, making him sick at heart. No one can be trusted. Love is a lie, a trick. If he doesn’t look out for himself, nobody else will. And chances are, no matter how well he watches out and is careful, he’s going to get hurt again. Why on earth would he trust a therapist, someone who offers care? As a relational therapist, you not only help manage and quiet the symptoms that follow such traumatic stress, you also invite your client into a relationship that feels, in essence, impossible. He can’t trust you, but he needs your help desperately. To accept this bleak reality is where an empathic process must begin. If the knot of betrayal is ever to loosen inside your client, it will be through a long, hard process of learning to trust you anyway—in spite of all he knows about what’s dangerous, and in spite of all the little ways you will fail him, scare him, and in those ways hurt him all over again. This book includes an entire chapter (Chapter 4) about the tri- als and tribulations of this sort of interpersonal journey. For now the point is simply that the deep, persistent empathy of relational therapy may be the most fitting therapeutic response to the relational devastation suffered by survivors of childhood abuse. In short, although in a general therapy practice special situations require special interventions, the therapist’s empathy is a crucial part of every treatment. Even when clients express themselves in sculpture, painting, dance, and music, or through dreams and psychodramas, they need someone to receive their expression, to feel into it and wonder aloud about its energies, feelings, and meanings. Some relational therapists bring these other modalities into their practice to broaden and deepen the possibilities for empathy between themselves and certain clients. And then there are all the possibilities of empathic relational work with more than one person at a time. As a relational therapist you can extend empathy freely and equally to all the members of a family or a group in a consulting room, even if their subjective truths all differ and they are all Downloaded by [New York University] at 13:36 13 August 2016 feeling misunderstood. You hope that the understanding you show each of them will calm the angry anxiety that prevents them from hearing one another. Even if they can’t talk to one another, they can see how feelings change as you put yourself in the shoes of each of them in turn. Without words you will be telling them, over and over, “This is what listening looks like. This is what being heard feels like. When there’s empathy in this room, everything gets safer, doesn’t it? Do you think you could try it?” In relational work with couples, you start by letting each of them know that their feelings matter to you. Long before hurt, angry partners are able to listen to each other with empathy, they hear how you listen. While one 58 Beginning with the Basics talks to you, the other hears about vulnerabilities that have been hidden behind walls of defense and blame. Slowly—how slowly depends on how badly hurt and betrayed each of them feels—you encourage them to talk with each other, and you coach them toward empathy, diplomacy, and negotiation. Couples take home from this process a lot of new information about each other. But none of what they learn matters as much to them as their newfound ability to put empathy to use in their everyday communication. A relational model of group therapy makes intuitive sense, too. A group set up so that members learn from their exchanges with one another offers wonderful chances to experiment with empathy. A group member can be heard and understood by a peer—not a therapist who’s been trained to do this “empathy thing.” Empathy can feel more trustworthy when it comes that way. A group member can reach out to others and find that his own empathy is just as powerful as what he has received. The experience of mutual, compassionate empathy is always rewarding, and for those who grew up with tight, cold silence or with disrespectful, careless chaos all around, the giving and receiving of meaningful empathy can be exhilarating. A relational group asks its members to practice being both open and boundaried, both separate and connected. Here a member can become acutely aware of what it feels like to influence and to be influenced, to be that self who is a self-in-relation. Probably the therapeutic scope of empathy is broader than I have been able to sketch here. On the other hand, maybe you’ve begun to wonder if there’s anything a relational therapist doesn’t take on. I should reiterate that special injuries and special symptoms may require specialized training. Yet all psychological difficulties require careful, caring understanding of the client’s experience of the problem, and relational therapists do that well. Often it turns out that this understanding is also very effective treatment. Why would this be? Not because empathy is a magic bullet, but because most psychological problems have origins in self-with-other problems, which happen when empathic connection between self and other has Downloaded by [New York University] at 13:36 13 August 2016 broken down. It makes sense, then, that bringing empathy back into the system will begin to knit up what has become unraveled through disconnection. The relational therapist tries to carry this repair process as far as it will go. That’s why, no matter what problems or symptoms a client brings to therapy, there can be a generic answer to the question, “What’s it like to get into relational psychotherapy?” It’s like stepping into empathy. But sometimes even relational therapy doesn’t work, and clients leave feeling they didn’t get the help they needed. When would a relational, empathic approach be likely to fail? Relational therapy runs aground when you and the client just don’t hit it off. The relationship hits a wall before it Beginning with the Basics 59 starts. We could call the situation a “personality clash,” but probably it’s fear that gets in the way. Maybe something about you stirs up the client’s fear of authority or his fear of being vulnerable. And then maybe his way of protecting himself sets off your own self-protective reactions, which don’t help the situation. Fear is what usually undermines the work of empathy. A client fears being belittled by someone with power; he fears being “boring” or becoming suddenly unwelcome or “in trouble.” He fears that assumptions will be made about the meanings of his gender, race, class, or sexual orientation. If you can hold back your reactions and help a client speak his fears, letting him know that they make sense to you, likely the therapy can be saved. In fact, the relationship grows stronger when its scary aspects are brought into the open. If such fears are strong but remain underground, the therapy probably won’t last long, and it won’t feel successful to anyone. Sometimes the fear that a client brings into therapy is an overall dread of interpersonal connection. Genuine connection is a powerful threat, for it makes him feel unbearably vulnerable. Often this client hardly knows he’s scared, because his life is built around living out his roles and taking care of business without feeling much at all. He expects you, as his therapist, to tell him why he has his symptoms of stress or depression; he wants to set goals and devise strategies for solving his problems. What he’d really like is a helpful book to read and a homework assignment. What he really doesn’t want is a relationship that’s alive and moving between himself and the therapist. (What a terrifying thought!) Surely, we might think, in this case relational therapy won’t work. And often it doesn’t. As therapist, you must respect whatever the client needs to do to keep himself safe. However, you will usually hang in with such a rigidly protected client for as long as the client wants to come. Why? Because you believe that underneath all that disconnection and terror, there’s a spark of longing to connect. Why else would he keep coming? Maybe somewhere he knows that what you offer is a chance at a better life, and maybe if you keep offering empathy instead of cure, one day that spark of longing might become a spark of relationship between the two of you. Downloaded by [New York University] at 13:36 13 August 2016 That would be only the beginning of a long journey of self-recovery for your client, but relational therapy is made for those long journeys. In other words, even when it looks like empathy isn’t going to work, it might just work after all. In fact, paradoxically, relational psychotherapy is best suited to just this kind of situation. I’ve been saying that empathy-work can address a broad range of specific problems clients bring to therapy, but relational psychotherapy does have its own central focus. It specializes in understanding the kind of pain that’s locked away in a client who can’t bear connection because he knows it will hurt. But at the same time, his self-protection is cutting him off 60 Beginning with the Basics from life. Fundamentally, his problem is a painful relational dilemma. Real relationship is impossible for him. This impossibility, however masked or expressed by various symptoms, is the situation that a relational therapist is more than willing to take on, believing that sustained empathic connection could make relationship possible for such a person again. The next chapter is about how situations of relational dilemma get to be that way. How do painful interpersonal experiences become s elf-protections that end up feeling like jail cells? Or as we therapists often hear the question put, “Why do I keep feeling so bad when I try so hard to feel better?”

Notes

1. Kohut, How Does Analysis Cure?, 82. 2. Rogers, On Becoming a Person, 184–185. 3. Jordan, “Empathy and Self Boundaries,” in Jordan et al., Women’s Growth in Connection, 67–80. 4. See Beatrice Beebe et al., “Systems Models in Development and Psychoanalysis: The Case of Vocal Rhythm Coordination and Attachment,” Infant Mental Health Journal 21, nos. 1–2 (2000): 99–122. Downloaded by [New York University] at 13:36 13 August 2016 3 Assessment: What’s Wrong When Your Client Feels Bad?

A Certain Kind of Bad Feeling

Some clients come to us for help with a particular problem in their lives. Others come with something less specific, and as they try to tell us what’s wrong, they search for words they think we’ll understand: “I think maybe I’m depressed. I feel a lot of anxiety. I have low self-esteem.” Or else they just tell us how they feel—all strung out, dreading another day, worthless, lost, worried all the time. This is the kind of “feeling bad” this chapter explores. For such clients, the distress they feel isn’t an emotional reaction to a life crisis such as divorce, a business failure, or the death of a loved one. They are able to feel sad and angry in response to loss, and they can manage the ordinary stress in their lives, the demands of family, work, and mortgages. They also know that something else is wrong, a “feeling bad” that doesn’t go away even when life runs smoothly. This kind of feeling bad has been part of their lives, part of their self-experience, for a very long time, and often they think it will never be any better. At times of loss or stress, however, the bad feeling can suddenly get worse. That’s often when such a client comes for help. In empathic alliance with her, you will feel the punch the crisis packs, the meanings it holds. Downloaded by [New York University] at 13:36 13 August 2016 In your presence she will find strength to cope with what she faces. But as the crisis eases, you find out that you and your client have dealt with only the tip of an iceberg. Much lies below the surface, “bad feelings” that have been lurking for a long time. Now she decides that it’s time to face those deeper issues. When your client looks for a word to capture what she feels now, “dissatisfied” comes up. Life isn’t what she thinks it could be. For a long time she thought that if she got a degree or made enough money or met the right person, she’d be happy. But she has a career now and her relationship is okay … so what’s missing? Sometimes she thinks maybe a better job, a new 62 Assessment city, a long vacation. Maybe having a baby. But that thought scares her. By now she knows that she can’t blame her chronic malaise on circumstances. Would it even be fair to bring a child into this life? Another word for her dissatisfaction might be “dissonance.” Her hopes aren’t matching up with what she’s getting out of life, and it’s nothing that achievements and possessions can resolve. It’s not a situational dissonance; it’s psychological. In fact, as relational psychotherapy understands, it’s relational dissonance—longstanding relational dilemmas and impossibilities that she has never been able to resolve. They’ve become so much a part of her experience that she hardly notices them. But she notices their effects. This is one more way to say that psychological problems can often be traced to self-with-other problems. The psychological problems aren’t caused by circumstantial problems, but they aren’t coming just from inside your client, either.1 Where do your client’s psychological “bad feelings” come from, then? This chapter proposes that these bad feelings are very often produced by something that’s happening, in one way or another, between your client and other people. She’s not a closed system, creating her emotional weather all by herself.

Systems Make a “Self”

In fact, a person’s psychology, or sense of self, is produced by at least three different kinds of systems interacting at the same time. First, there’s what’s happening right now between that person and another person. Second, each person brings self-experience to the interaction—his sense of power in the relationship, his memories of previous contact, his desires, fears, and feelings of the moment. These systems of perception, memory, belief and feeling that make up a person’s experience at any given moment can be called “self-states.” Changes in emotional “weather” often signal changes in self-states—from cheerful confidence to shamefaced anxiety, for example. Downloaded by [New York University] at 13:36 13 August 2016 Let’s put these first two systems, the interpersonal system and the self- state system, into play. Let’s say a client of yours called Ben goes out for a beer after work with a friend, Jim, and Ben decides to talk about an idea he has for a new little business. He launches in happily and Jim listens, but without enthusiasm. Suddenly, instead of feeling excited about his idea, Ben feels deflated and almost ashamed of having brought it up. His self- state has changed drastically. If he did a self-state review, he’d find that not only have his feelings changed; he’s also wondering if his idea is stupid, he’s thinking he probably can’t make it happen, and he’s lost his energy even to talk about it. Assessment 63 Of course, happy excitement and self-doubting shame are two self-state possibilities for Ben that predate his exchange with Jim. Jim’s response didn’t create what a deflated state feels like for Ben, or how quickly Ben can fall into it. On the other hand, if there were a video recording of their conversation, an observer could point out exactly where Jim missed the cues that invited his positive response, where his non-response deflated Ben’s energy. Jim’s self-state wasn’t what Ben had expected. Afterward he wished he had asked Jim more questions before he launched into his own idea. Had Jim had a fight with his wife? Maybe, Ben thinks, he was annoyed with me about something. Or maybe he had a headache. Or maybe I reminded him of a business idea that went bad on him once. Ben doesn’t know how his words affected Jim. But they did, and at the same time, Jim’s response affected Ben. Two selves, or “organized worlds of subjective experience,” met in the pub, and another small, systemic world was created in the moments of their interaction.2 That two-person system affected both of the self-state systems present there, to different degrees and in different ways. So it goes in human interaction.

A System That Makes Sense of Interpersonal Process

The plot thickens. In addition to the self-state systems each man brought into the interaction, and in addition to the interactive system created during their conversation, there was a third kind of system at work to produce Ben’s sense of self in the pub. We could call that system his interpersonal process memory. It’s made up not of specific memories of interactions between Ben and others, but of generalizations of how many similar interactions have gone before and of how, therefore, they are likely to go again. If his system didn’t streamline his event memory into generalized process memory, Ben would have to work his way through every action and interaction as if it were his first. Daniel Stern says that infants begin streamlining their interpersonal learning very early, developing what he calls representations of interactions Downloaded by [New York University] at 13:36 13 August 2016 which have been generalized (RIGs).3 For example, when Ben was a baby, he probably developed a RIG around the sequence of crying, hearing footsteps, and being picked up and comforted. Not only did that RIG contain action sequences, it was also full of affect exchanged between him and his caregiver, and so it also contained a tone or feeling of “self” for him. So almost from the very beginning, even before he had a toddler’s awareness of a “me,” his affectively toned self-feelings were bound up in repetitive self-with-other interactions. Making these RIGs was just the way his system automatically made sense of many bits of experience—after those bits had been repeated in similar sequences many times. 64 Assessment As an adult, he doesn’t have to be aware of his RIGs, either. They are still just the way the world works and how he gets along in it. But we might hypothesize certain RIGs at work for Ben in the pub this afternoon. He was enacting a certain RIG as he entered with excitement, expecting some enthusiasm in return. He expected a particular kind of interaction, with the positive self-feelings that go with it. But it turned into a different kind of interaction, and a different RIG slipped in, one in which his energy meets nonresponse. The deflation that followed led to Ben’s self-feeling of shame. Both the expectant and the deflated RIGs were readily available to Ben as components of his process memory. Thus process memory is an active system, too, not a closed book. It’s constantly making sense of data, and to a certain extent creating much of the reality a person experiences. Perhaps a better term for process memory is “organizing principles.”4 The work of organizing experience into recognizable patterns is never finished. Organizing principles can be as small as one little RIG and as large as the networks of RIGs that make up a worldview. Later in this chapter we’ll look at organizing principles more closely. For now it’s important just to identify them as the third system that was interacting with Ben’s self-state and also with whatever was happening between Ben and Jim. The question of this chapter is, “What’s wrong when your client is feeling bad?” So far I’ve said that the “feeling bad” I’m talking about isn’t just an expectable reaction to crisis or stress. It feels more like chronic dissatisfaction. It’s a kind of psychological dissonance that has its origins in relational dissonance. Now that I have sketched out the three kinds of systems that are involved in any relational interactions, I can explain that relational dissonance—that feeling of being jarred by people or disconnected from them—can originate in any of the three systems. When, for example, Ben’s self-state is under the influence of financial worries or a nasty cold, it can be difficult for him to enjoy any interactions. When there’s something off about an interaction, as there was with Jim, the interaction itself can disturb both participants. But the kind of relational Downloaded by [New York University] at 13:36 13 August 2016 dissonance that has the most power to produce chronic dissatisfaction and psychological dissonance is the kind that originates with organizing principles. Let’s go back to Ben in the pub. What happened made him feel bad. But his bad feelings don’t count as the kind of psychological trouble we’re trying to understand unless he can’t shake them off. The relational dissonance he experienced doesn’t grow into psychological dissonance until what’s wrong begins to feel like it’s something wrong about him; it doesn’t become chronic dissatisfaction until the wrongness stays with him as an uncomfortable, dissatisfied, troubled feeling about himself. Assessment 65 As it happened, some of that psychological trouble did set in for Ben. He was deflated by Jim’s flat response, and then he started to feel stupid about having been excited. Rather than protest to Jim, “Hey! What’s up? You’re pretty flat today!” Ben went quiet and began to feel shame. It’s a feeling Ben knows all too well, he tells you in therapy. Once it happens, it’s hard to shake off. Let’s explore Ben’s situation further.

“Something Is Wrong with Me!”

Ben knows Jim didn’t mean to make him feel stupid or ashamed. But suddenly his feelings of disconnection and deflation meant that something wrong with him. The first word that came to his mind was “stupid,” and it stuck. Ben tells you that “stupid” is the word that usually comes to mind when he’s feeling bad, and now that he thinks about it, he knows that he often worries about doing dumb things. Sometimes when he’s feeling anxious and out of sorts, he has intrusive flashbacks of stupid moments from his past. Ben has developed a story about the psychological dissonance he suffers, and the story says it’s all about feeling stupid. If only he could stop feeling stupid, he would feel better. But Ben has never been able to talk himself out of the problem. Ben can’t talk himself out of the problem because it isn’t really about feeling stupid; it’s about feeling shame. When something feels off between Ben and someone else, his system organizes that information to mean that there’s something wrong with him. The name of this basic feeling is shame, and shame spawns many different kinds of stories, defeated stories like “I’m stupid and worthless,” defensive stories like “Nobody understands me,” and counterattack stories like “I don’t get mad, I get even.” Shame is just one of Ben’s self-states. In other states, he keeps connected with others in the world, needing to interact in order to feel productive and valued. In fact, Ben does the very best he can, wanting to contribute Downloaded by [New York University] at 13:36 13 August 2016 and to experience life as meaningful and good. Sometimes his interactions are less than perfect. That’s just how life goes. The real problem for Ben is that each of those imperfections or “misses” leaves him feeling that there’s something wrong with him. How does it happen that some people experience interpersonal difficulties as problems to solve or to ignore while other people experience them as their own defectiveness? It’s a matter of different organizing principles. These principles are automatic generalizations that have their origins in interpersonal interactions. So it makes no sense for Ben to blame himself for failing to change his feelings by thinking better thoughts. 66 Assessment As a therapist, you can tell Ben, “I don’t think the problem you have with feeling stupid is just inside you. I think it comes up when things happen. When things happen between you and other people, you worry whether they think you’ve done something wrong, whether they like you or understand you. I think that’s what’s getting you down. Things keep happening, they lead to the same old bad feelings, and then you think there’s something really wrong with you.”

Where Inside and Outside Meet and Mingle

Implicit in what you’ve suggested to Ben is an important point: Psychologi- cal problems don’t come from either inside or outside of him. Instead, they come from the space where data from the outside world meet his capacities to make sense. He can’t get outside of his mind to what’s “really” out there, nor does his mind have anything to register apart from what comes in. Think of Ben’s early RIG of “crying … footsteps … being picked up … feeling comforted.” It has meaning more substantial than a sequence of events. We could say that the RIG exists in Ben’s mind; however, it doesn’t get activated until the sequence starts to happen. Furthermore, even for an infant, many representations of interactions are developing at the same time; there’s a lot to sort out in this inside/outside place of making sense of interactions. For example, what if something else happens to young Ben sometimes, say, “crying … footsteps … an angry voice … feeling overwhelmed”? Then another RIG will have to develop along with the first, and Ben’s mind will have to organize a world that holds both RIGs, both of them “true” but both also a construction of reality. Ben might be able to hold both RIGs by knowing his mother as mostly responsive but sometimes moody and stressed. Or he might make sense of the “overwhelmed” RIG by deciding he’s bad when the unpleasant interaction happens. The he can keep the bad away by doing whatever it takes not to make his mom angry. But although the RIG is kept away, it doesn’t

Downloaded by [New York University] at 13:36 13 August 2016 disappear. It can organize other unpleasant interactions into an “I’m bad” feeling. Ben’s current propensity to feel shame may have links to organizing principles that began to form that long ago. Infants and young children make sense of their relational worlds as best they can, and especially when it organizes danger, that “sense” persists. That’s why some adults solve or ignore interpersonal problems while others experience them as their own defectiveness. Some children are helped to integrate good and bad experiences with other people, their positive and negative RIGs. Other children, left on their own with interpersonal trouble, try to protect good experience from bad by keeping the bad away Assessment 67 and storing it as shame. We’ll return to this idea in the Chapter 4, when we discuss relational trauma. The point here is that this pattern of feeling bad gets put into motion by a process of “inside” organization meeting “outside” data. This place or activity where outside meets inside is where an infant sense of self comes into being and where an adult sense of self is held in being. Here the three systems I’ve described—self-state systems, systems of current interaction, and systems of organizing principles—are constantly busy, making and exchanging the information that gets turned into personal meaning and feeling. If we keep in mind that all this is happening, we can look at how both outside and inside contribute to psychological dissonance without having to choose either location as the cause of the trouble. We’ll begin with what comes at your clients from the outside.

Problems That Start from the Outside

Feminists have been saying for a long time, at least since the publication of Phyllis Chesler’s Women and Madness in 1972,5 that women’s psychological problems are not in women’s heads; the problems come from outside. The story goes something like this: June Cleaver, Beaver’s mom, may look fine on camera, but when nobody’s looking, her sparkle dies. She drinks secretly to numb her anxiety, and sometimes she feels that it’s not safe to leave the house. Why? Because she can’t remember who she is or what she’s worth. Her value lies in what she does for others. She’s bored with repetitive, undervalued housework, she’s isolated from other women, she’s starved for adult company (Ward is a good man, but he doesn’t talk much), and she feels empty nest coming on. Actually, she’s really quite angry that her life has come to this. But everything around her tells her it’s a wonderful life; she has absolutely no reason to be angry. So she stifles her anger—all of her feelings, in fact—and she gets depressed instead. She sees a psychiatrist who prescribes Valium for her nervous problems. Mixed with a little alco-

Downloaded by [New York University] at 13:36 13 August 2016 hol, the pills do take the edge off, and they leave her with enough energy to vacuum, mop, dust, and get meals on the table. On she goes, a woman with her psychological problems under control for now. Second-wave feminists took a good look at June Cleaver and said: She’s not sick! The problem isn’t inside her. Her assigned role is a form of oppression, and she’s being kept in her place for a reason. Ward and the boys get more from her life than she does, but they assume that’s just how it should be. And in fact a whole patriarchal establishment, including psychiatry, is making that same assumption: that a white, middle-class woman should be happy with her place in the home, with her role as provider of physical and 68 Assessment emotional care. What can June do but agree?—unless she finds the support of a group of women who understand what’s being forced on them from the outside and who respond, “We’re not crazy, we’re angry!” In other words, what looks like mental illness is actually a healthy response to a sick system. More recently, third-wave feminists like Laura Brown expand on the idea that oppressive systems produce mental illness. If you are a woman, they say, but especially if you are also a woman of color, a lesbian, a disabled woman, a single mother, or a poor woman, the social system that privileges able-bodied, heterosexual, affluent white males will make your life even harder. The way privilege works in our society, you don’t just feel oppressed and devalued, it’s happening to you in many material ways. The pressures on you to feel not good enough, second-rate, and defective are powerful. They can push you into shame, but the problem is not inside you; it’s coming at you from out there. Relational psychotherapy takes this reality seriously. When clients come into therapy having absorbed a message that they are second-class citizens, they need help noticing the message and what it does to them. Often these clients notice just their own bad feelings about themselves. The self-with- other context of their feelings has become invisible. They won’t think to trace these bad feelings back to the everyday interactions they come from. I’m thinking of a lesbian client, “Sue,” who told me she had a seasonal depression that settled on her every December. “Just a bad funk,” she said. “By February it’s gone. Maybe it’s the lack of daylight.” I asked her what December was like for her. “Parties,” she said, ticking them off on her fingers: office parties, cocktail parties with acquaintances, and festive meals and celebrations with family. Luckily, she was an extrovert who liked socializing. “It’s my antidote to depression,” she laughed. She also told me that she’d been out for six years and was comfortable with her orientation. Sue and her partner “Lyn” had been together for three years, and were out to their families. Sue wasn’t out at work, she said, because that didn’t feel entirely safe. But most of her old friends knew about her new life. As we moved into December, we paid close attention to Sue’s everyday Downloaded by [New York University] at 13:36 13 August 2016 experience. She noticed that at the office party she couldn’t talk about her holiday plans with Lyn. So in spite of all the banter she exchanged with work- mates, she felt like a stranger to them. “Not a good feeling!” Sue said. At the cocktail party reunions, she did mention Lyn and their new home—three times!—and each time someone changed the subject. Her old friends were happy to see her, but they didn’t want to know about her new life. “That feels bad, too,” Sue said. “It’s like there’s something too weird about being queer—but they would never ever say so.” As Christmas approached, Sue began to talk about her upcoming visit home and about her father, who had always been her mentor and Assessment 69 confidante. “He’ll treat Lyn like a buddy, too,” she said. “Like a buddy of mine, like we’re college roommates, not adult women who’ve chosen each other to be a couple. He’ll put his arm around me like always, and say I’m still his girl. Like it’s a joke.” Sue didn’t want to think about how the joke would make her feel. But she sat still for a moment and then she said, “It’s like if only he could keep me little, then maybe I’d grow up right—grow up and marry somebody just like him!” That December Sue noticed the homophobia that was just an ordinary part of her life, a subtle oppression that intensified as her social life intensified. She’d say, “It’s not about me; they don’t mean it,” or “It doesn’t matter. I’m used to it.” But we found that she felt especially worthless, flat, and depressed after those events that “didn’t matter.” Every time we let it matter, her funk dissipated. Her inner ailment turned out to be an expectable response to messages that subtly told her she was second-rate. Subtle, systemic oppression isn’t just outside of therapy; it comes right into the room if you fail to acknowledge the social power you have—by being straight in relation to your client’s queerness, for example, or white in relation to her color, affluent in relation to her poverty, or able-bodied in relation to her disability. If you ignore the differences in social location and power that are in the room, you collude with a system that makes itself invisible while it continues to oppress. So if you work with clients who come from different social worlds than you do, you need to be honest with yourself about your privilege—or theirs—and be ready to talk about it when they are. As you hear them, and as you don’t deny or try to fix what’s wrong for them, it can become tolerable to have these differences between you. In fact, honest work around real, painful difference can build your clients’ confidence in the potential of the therapy. There’s no better way to let them know that you see the wrong that comes at them from the outside—even from you, as a participant in an unjust system.

Disconnection in Society and Family Downloaded by [New York University] at 13:36 13 August 2016 Stone Center feminists add another dimension to the idea that bad feelings are responses to what comes at clients from the outside. They believe that interpersonal disconnection is what causes psychological dissonance. Inter- personal disconnection happens especially when people with more power devalue and disrespect those with less power. Disconnection characterizes a patriarchal society that values autonomy, power-over, and winning more than the feminine values of empathy, connection, and cooperation. Hope lies, Stone Center theorists say, in relationships of mutuality that can heal disconnection. Relational connection can mend societal 70 Assessment brokenness, and it is also the key to emotional health for both women and men. Stone Center theorists highlight the emotional work women do to make connection happen in families, and they also explore what happens when connection fails in families. They show how family systems of disconnection have incredible power to create psychological dissonance for family members. Jean Baker Miller and Irene Stiver identify particular destructive patterns of disconnection in families.6 Some families erase unacceptable reality with a conspiracy of silence. An extreme example is the secret of sexual abuse in the family, but families keep silent about many other kinds of skeletons in the closet, too, such as abortion, suicide, mental illness, and babies born out of wedlock. In a second pattern, parents are emotionally inaccessible to their children. Alcoholic parents, for example, are absent when intoxicated, and even when sober they often lack the emotional skills to make contact. Parents who have been traumatized by war, death camps, or childhood family violence want to put those memories behind them and spare their children knowledge of such horror. But in blanking out their own histories, they make themselves strangers to those closest to them. Miller and Stiver also identify a third pattern of disconnection, the parentification of a child. In families stressed by poverty, divorce, parental illness, or parental emotional fragility, children may take on responsibilities beyond their years. Many children manage these challenges well, and working alongside their parents to help the family gives them confidence and self-esteem. But sometimes a child is covering for a parent who can’t manage adult relational responsibility. To keep herself and the family in balance, the child becomes, if only subtly and unconsciously, a parent to the parent. Acutely sensitive to her parent’s emotions, she can find no place to be just a child with a child’s anxieties, confusions, and needs. Her performance of competence requires radical disconnection from her own frightened, needy, vulnerable self. This, you might remember, was the case for Jane, whom we followed through different modes of therapy in Chapter 1. Downloaded by [New York University] at 13:36 13 August 2016 Disconnection happens in different ways in different families, but it leads to the same kind of dissonance: relational longings squashed by the conviction that disconnection is necessary. A client who has grown up disconnected wants to be known and loved as herself; she also “knows” that relationships mean hiding who she is and what she feels. It may not be clear to her why bringing her whole self to relationship would be so risky, but fear learned early is very hard to shake. Living within a semblance of relationship helps clients manage social disconnection, too. When social systems oppress and injure clients by failing to see them and to respect who they are, they put up relational barriers Assessment 71 to protect themselves from further hurt. They carry on with life seeming to belong, but they keep themselves basically hidden and apart. For them, as for clients from disconnected families, this semblance of connection can all too easily turn into feelings of isolation and worthlessness, a deeply dis- sonant sense of being at odds with others and with themselves. And then they begin to feel that the “wrong” is inside them.

The Bedtime Story Clients Tell Themselves

How does being disconnected from others turn into feeling wrong inside? Social constructionist and feminist therapies take the illness out of mental illness and locate it in social systems of oppression. But they also acknowledge that this outer conflict becomes an inner tension, self divided against self. How do social construction therapies explain this inner tension without capitulating to the idea of individual psychopathology—to the idea that something is wrong inside a person? These therapies use the idea of narrative. They note that in systems of oppression, people in power “own” the stories about how the world works. In these stories, the losers in the system deserve to lose because they are lazy, inferior, weak, or prone to making bad choices. The stories are woven into the fabric of everyday life, popular culture, and mainstream media and politics. If a client lives on the “loser” side of social difference, and if she doesn’t have a strong community and family speaking a stronger story to her, she will start to believe the loser stories. There’s nothing else available. And it’s not like she can escape living out a story of her life. That’s what human beings do, narrative theorists say.7 Your client can’t escape living a story, but she can pay attention to what it is. She can listen in on what Laura Brown calls the bedtime story she tells herself.8 She might hear herself saying things that “they” say about her, those who live on the “winner” side of social differences. When she sees herself through their eyes, she values herself by their standards. Their Downloaded by [New York University] at 13:36 13 August 2016 benchmarks tell her she has failed, and she hopes for no more than their story allows her. Every morning she goes out to live another day of this particular story—because it’s not just their story; it’s hers now. This is how narrative therapy explains “internalized oppression.” The story keeps coming at your client from the outside, but there’s no alternative story for her to live. There’s no escape from some stories of oppression. In the history of human power relations, many of the losers—serfs, slaves, untouchables, prisoners, women, and children—had no chance of a different story. Many still don’t, and their struggle is for survival. Psychological dissonance 72 Assessment increases as a different story becomes possible. If a client can afford to notice the bedtime story she tells herself, she has some inkling that maybe something could be different. She’s feeling tension between the story she’s been given and something else she wants. This uncomfortable psychological dissonance is the first step toward change; it’s what gets her to therapy, for example. The next step in assessing trouble from a narrative perspective is for your client to understand the power of the narrative she has been given. The longer she listens in on the bedtime story she tells herself, the more she feels what it does to her. It helps when someone helps her put the real names to her experiences: “abuse,” “sexual harassment,” “racism,” “incest,” or “homophobia.” Therapy helps her face and bear the pain of what the story does to her, while letting her know that another story is possible. A new story won’t burst upon her. It won’t be easy for her to find her own real experience or her own voice for speaking. But when she does, she will be pushing back at the wrong that makes her feel bad.

Relational Strategies and Relational Images

As we’ve seen, Stone Center theorists agree that psychological problems aren’t internal individual problems; they are self-in-relation problems, they say. In families where important things can’t be spoken, where parents are emotionally unavailable, and where children have to grow themselves up, self-in-relation isn’t possible. Children learn to keep vulnerable parts of their experience out of sight and out of mind. They may create complex inner worlds of safety. They may soothe themselves with addictive behaviors or substances. They may sink into depression, self-loathing and despair. These are all symptoms of their isolation—no longer imposed from the outside, but now a habit of being. How do Stone Center theorists explain how disconnection from others becomes a habitual state of being? They clarify the relationship between

Downloaded by [New York University] at 13:36 13 August 2016 such “outside” experience and “inside” psychological patterning with reference to clients’ strategies for maintaining disconnected kinds of connection, and to the relational images that construct their clients’ self-images. A client’s best strategies for remaining connected with others may be, paradoxically, self-isolating behaviors. To negotiate both inner needs and outer realities, a client maintains a subtle but powerful disconnection within a semblance of connection. Experience has taught him how to share only those parts of himself that others will like and can use. In a relationally nonresponsive or abusive environment, this knowledge once served him well. It also helped him become a responsible colleague and a Assessment 73 dutiful husband. His disconnecting strategies for connection still protect him, but as adulthood wears on, they also leave him isolated, unknown, and unhappy. In describing his situation in this way, self-in-relation theorists avoid locating illness or defect inside him, while they also acknowledge that he keeps enacting painful patterns of early experience in his current life. Meaningful moments that meld internal and external experience are captured by what Stone Center theory calls “relational images.” Sometimes relational images appear as vignettes of childhood memory. One client stands alone on the playground, left out of the game. Another is huddling at a locked door in the winter, her house key lost—again! A third has just been caught cheating on a grade five math test. For each client, the image has come to mean some kind of personal failure. As they tell these stories in therapy, however, your clients begin to see these images in context. Your first client was left out because his family moved a lot and he was always the new kid. Your second client was only eight when she lost her key. She was scared and her hands and feet ached with cold, but when her mom finally hurried up the walk, she saw only anger in her mom’s eyes. For your third client, getting high marks was the only thing she was good at. This made it so very hard not to peek when she didn’t know an answer. As you and your clients live with these images, your clients begin to understand that their relational contexts give them meaning. Feelings of being unlikable come because you’re ignored on the playground. Angry eyes make you feel small and stupid about a mistake, especially when you’re scared. Some punishments make you feel like bad is all you are and ever will be. Such relational images keep taking a toll on personal well-being even when the memories are stored safely out of daily awareness. A self-in-relation therapist expects that when people come for help, suffering from dissatisfaction and dissonance, anxiety and depression, it’s because their strategies for disconnected, “safe” kinds of connection have isolated them in ways that are becoming unbearable, and also because their Downloaded by [New York University] at 13:36 13 August 2016 relational images keep telling them mostly bad things about themselves. That’s what’s wrong for clients when they feel bad—not something pathological inside them, but the pain caused by their everyday self-protections and their everyday memories.

What’s Wrong? A Brief Detour through Object Relations Theory

Relational psychoanalysis has its own way of explaining what’s wrong when your client feels bad. But to understand both the Interpersonal/Relational 74 Assessment and the self psychological positions, we need to look first at object relations theory. Behind much of relational theory, there’s a long history of psychoanalytic theory. Within that general history, it was object relations theory that began a movement away from Freud and toward more relational understandings of psychological processes and “pathology.” In a classically Freudian scheme, a patient’s bad feelings—guilt, anxiety, depression, and other symptoms of neurosis—come from aggressive and sexual drives that are entangled in unconscious fantasies. Hidden conflict between instinctual drives (id) and a punishing, silencing containment of those drives (superego) expresses itself as symptoms. After Freud’s death, many psychoanalytic theorists began to suspect that not all adult psychological conflicts originate from the child’s Oedi- pal struggle to find his or her appropriate sexual self-definition in relation to both parents. They proposed that many significant conflicts originate in earlier childhood and even in infancy. They located these conflicts inside the child, and mapped them out as the child’s internal relationships to internal images of his parents or his “internal objects.” Their adult clients, they reasoned, were suffering from still-unresolved problems in their internal “object relations.” In object relations theory, bad feelings are still coming from conflicted, blocked, and tangled-up drives. But the field of conflict has become more complicated. More attention is given to the existence of others— internalized as “objects”—and questions are asked about the relationships between the adult patient and those internal others. The conflict going on in these internal relationships is more complex than a struggle and standoff between id and superego. Drives themselves are more complex than innate sexual and aggressive instincts; they also involve a child’s need to attach and a child’s innate psychological energies that can be turned to adaptive, developmental tasks. We can illustrate this shift in terms of two RIGs, one that links crying to feeling comforted and the other that links crying to shamed iso- Downloaded by [New York University] at 13:36 13 August 2016 lation. For object relations theorists, more is going on in these scenarios than a child’s pleasure-seeking instincts being either gratified or frustrated (arousing her aggression). The child is also busy making an internal map of what’s happening, and the components of the map are her drives (love and hate entangled with attachment longings), the internal images of the others who respond to her drives, and internal images of self that correspond to internal others. So, for example, the child dealing with the problem of the two RIGs has an internalized comforting Good Mother and an internalized frightening Bad Mother, with corresponding images of Good Self and Bad Self. Assessment 75 In healthy development, the intense feelings bound up in the Bad Mother– Bad Self relation are neutralized as the good and bad images coalesce into the image of a consistently good enough mother, in whose presence the child can enjoy a free range of self-expression and be good enough, too. On the other hand, the child’s internal objects may remain fragmentary, the bad ones bound up with intense psychic energy and also wrapped tightly within strong defense mechanisms such as denial and repression. Then these unresolved early childhood object relations sink out of sight, into the unconscious. But they reappear in a patient’s adult life as projections—as seeing those bad images in the faces and actions of the patient’s significant others. As object relations theory describes this situation, the adult patient who suffers these pervasive experiences of Bad Other and Bad Self has no idea about their origins. He knows and feels only the anxiety, despair and hate they stir up in him. His therapist expects that as he becomes a significant attachment object to her client, his projections will surely come at her, too. As his intense transference feelings rise into his consciousness, she helps him allow into his awareness the internal dramas of Other and Self that generate the feelings. At last he is able to visit the internal scene where his early conflicts were laid down; he can begin to understand what’s wrong when he feels bad. His therapy will help him knit up fragmented images of Good/Bad Self and Other into a much healthier picture of a good enough other in relation to a self of many aspects, both “good” and “bad.” Through this process, and through taking back his projections of internal conflicts, he will find his way to more comfortable, autonomous relationships with real others in the world, relationships far less troubled by the past he has carried around internally all this time. In object relations theory, once, long ago, bad feelings were this client’s response to what came at him from the outside, but they very soon became an “inside” problem that then began to wreak havoc on his “outside” world. When he talks about what he has learned in therapy, he might put it like this: “It’s not my actual, present-day Father who’s the problem; he’s just an older guy living his own life on the other side of town. The problem is the Father I carry inside from when I was a kid. And then I project that Downloaded by [New York University] at 13:36 13 August 2016 problem—so that the all the powerful men I know turn into that Father!” Object relations theory focuses on what happens inside clients, and then it helps them clear up confusion between inside and outside. And yet, far more than the classic Freudian scheme does, it does pay attention to interpersonal relationships. In object relations theory, “self” or “ego” comes into being not where drives are recognized and tamed, but in the ongoing interface between “outside” and “inside”—even though that interface is internalized. It is this strong movement toward relational reality that makes object relations theory useful to “relational psychoanalysis” and also a bridge to self psychology. 76 Assessment Interpersonal/Relational Psychoanalysis and Object Relations Theory about “What’s Wrong”

Many relational analysts from the interpersonalist tradition use object relations theory to understand what’s wrong for their clients. Sullivan himself set the stage for this when he included the concepts “good mother,” “good me,” “bad mother,” and “bad me” within his transactional, interpersonal practice of psychiatry.9 Contemporary practitioners of interpersonal/relational psychoanalysis, less opposed than Sullivan was to “the unconscious” and “transference,” include ideas about trauma-induced splitting and about the unconscious projection of a client’s powerful dissociated feelings onto the therapist. They try to engage with many split-off parts of a client’s self, not just “good” and “bad,” in hopes of fostering healthy re-integration.10 Incorporating object relations theory into an interpersonalist mode of therapy allows a psychoanalyst to move back and forth between the intrapsychic and the intersubjective, between inside and outside, always keeping an eye on how each “side” gives form and substance to the other. To keep this movement going, the Interpersonal/Relational psychoanalyst constantly invites the client’s troubled psyche to engage directly with her: “Talk to me; connect with me; push me away; tell me what you’re thinking just now; tell me how you feel about me right now; want something from me; hate something about me—do all this with me—and then together we will be able to sort out what the ‘inside’ trouble is.” Whether such words are spoken or not, this is how a client’s intrapsychic Self–Other conflicts become interpersonal dynamics. First they are lived out, and then they are deconstructed and understood in the therapy. Intrapsychic splits are healed as the analyst draws dissociated parts of the client’s inner experience into interpersonal contact on the “outside.” In this safe relational context the client can experience as safe his own bad feelings and the most painful parts of his internalized history. In Interpersonal/ Relational psychoanalysis the object relations script of what’s internally wrong with a client becomes live theatre. Playing out the wrong vividly and

Downloaded by [New York University] at 13:36 13 August 2016 consciously allows for integration, and playing it out in a new relationship changes possibilities going forward: the longstanding wrong can itself be transformed.

Between “Inside” and “Outside” in Self Psychology

Self psychology doesn’t use object relations theory; it transforms object relations theory into more radically relational theory.11 At the same time it proposes a new locus for therapeutic discovery and change, the space of Assessment 77 empathy. Over the years, self psychology has come to understand this therapeutic space as fundamentally intersubjective. The client’s and the therapist’s self-systems, conscious and unconscious, are present in the space of empathic understanding, and so this is a space in which several kinds of “inside” and “outside” meet and mingle. Instead of moving between an interpersonal “outside” and an “inside” of object relations, self psychologists try to stay in this empathic, in-between space. Self psychology understands that the bad feelings clients bring to therapy also originate in intersubjective space, and it explains what has gone wrong in terms of childhood development. The key developmental concept, which transforms previous theory about internal object relations, is the concept of selfobject. As we’ve seen, in the history of psychoanalysis “object” has come to mean a person’s internal experience of another person. Our object relationships are our relationships to internal images of important other people in our lives. In self psychology theory, a selfobject is the internalized presence of another person when the presence of that person is necessary for a positive experience of self. The other’s presence provides the self with experiences of identity, agency, and value: “This is me; I can do it; I matter!” These feelings may seem to belong just to the self in question, but in fact, they couldn’t exist without the presence of the other, both actual and internalized. Selfobject theory also explains the negative parts of self-experience. When another’s presence fails to support a self’s cohesion, power, and goodness, the self feels weak, fragmented, depleted, or flawed. With this vision of where crucial psychological dissonance originates, early self psychology added a whole new arena of bad feelings to the psychoanalytic picture. “Feeling bad” can stem not just from internal conflict but also from deficits originating in faulty self-with-other experience. If that’s the case, then what’s wrong for your clients comes not just from bad things that happened to them, but also from good things that didn’t happen for them. Their senses of self are not as coherent, resilient, cohe- Downloaded by [New York University] at 13:36 13 August 2016 sive, or sturdy as they might be. This kind of “what’s wrong” often means that clients are especially susceptible to disturbing episodes of shame that fragment a shaky sense of self. That’s self psychological language for what happened to Ben when he shared his excitement with Jim and found himself deflated. Self psychology not only recognizes clients’ vulnerabilities in this regard, it traces these vulnerabilities to caretakers’ failures to provide the supportive, empathic selfobject experiences clients needed when they were young. Self psychology also holds therapists responsible for providing the kind of understanding that will help clients feel more cohesive, safer, 78 Assessment and stronger, not more shamed and fragmented. The self psychological therapist becomes the selfobject (or more accurately put, the provider of selfobject experience) that a client needs in order to repair deficits in his self-structure. This repair comes partly by way of his new, good experience of his therapist’s in-depth empathy for him. It also comes partly through the strength he gains when the therapist’s empathy is not quite right, and client and therapist have a chance to find out together what went wrong and to repair the “miss.” In other words, self psychology makes the therapy relationship a crucial scene for the reworking of a client’s principles that organize his relational experience. Thus self psychology also takes in stride the fact that as a therapist you will fail your clients sometimes, and that then their bad feelings will be coming directly from the therapy. Their experience of being misunderstood, criticized, belittled, or abandoned by you will set off that powerful psychological dissonance called shame, an experience of self as weak, crumbled, or severely flawed. When this kind of shame overwhelms and silences a client in therapy, it’s essential to look for the origins of the shame in moments of misunderstanding between the two of you. When together you are able to understand where exactly the break in empathy occurred, your client’s feelings of falling apart or becoming worthless will quickly diminish. At this point we might ask: When both shame and repair happen in the here and now, where are the bad feelings really coming from—from old RIGs that turned present disappointment and hurt into “There’s something wrong with me”? Or from the current misunderstanding between client and therapist? It seems our answer must encompass both possibilities. So perhaps we need to ask different questions, such as: What was going on between “outside” and “inside” when the troubling organizing principle was formed? What’s going on between “outside” and “inside” now? How are those two times related? With these questions we approach a more radically relational version of self psychology. These questions were made possible with the arrival of intersubjectiv- Downloaded by [New York University] at 13:36 13 August 2016 ity theory, including studies of mutual regulation between mothers and infants, on the self psychology scene. A new paradigm made a new way of understanding possible. Early self psychology saw a self as a substantial, structured entity that could be firm or shaky, solid or riddled with deficit. In the new paradigm, a self is understood to be a subjective world of experience continually coming into being and held in being in intersubjective networks. This is the case, first of all, for the selves of infants and their caretakers. The overall feeling quality of their interactions indicates when things are going well or poorly between them. Repeated intrusive or disconnected Assessment 79 interactions create dissonance in the infant’s system. The problem shows up in the infant’s distressed responses to feeling abandoned or overwhelmed and also in the infant’s attempts to regain equilibrium through clinging, avoiding, or self-distracting behaviors. When the caretaker’s behaviors change, so do the infant’s reactions, and what’s wrong can be repaired. Of course, as Stern points out, when interactions are repeated, they become generalized. Repeated interactions begin turning into “principles” that organize experience in predictable patterns. A client’s adult relationships are also held within intersubjective networks. An adult’s sense of self can be just as profoundly affected by affectively loaded interactions between self-systems. Self-systems can threaten one another with annihilating shame or they can be a source of shared comfort and sanity. Or in territory between those extremes, a client’s interactions with others may often leave him feeling disorganized, unhappy, or out of sorts. If that’s the case for a client of yours, he’ll need to notice connections between real interactions that happened yesterday and how he felt afterward. It may help him to notice a connection between yesterday’s interactions and how he felt over and over in his childhood. It’s most useful when he notices that same bad thing happening in an interaction with you. The two of you notice, for example, that he clams up when you offer “helpful’ advice. He realizes he feels angry at first, and then depressed about himself. You notice that you offer advice when you’re feeling anxious about him. Together you wonder about an organizing principle that tells him that to maintain his emotional balance he must keep other people’s anxieties and agendas out of his personal space. He knows this causes a problem for his wife. She feels like he’s always disappearing, even though she tries hard not to intrude. Your client also knows he visits his parents rarely and keeps his mother’s phone calls short. None of you will see a video clip of your client as a baby, of how he had to turn his face away from a spoon and his mother’s insistence that he look at her, her intrusive anxiety that he eat. But that’s how early this pattern began, this interpersonal “wrong” in which he feels bad. Downloaded by [New York University] at 13:36 13 August 2016

Organizing Principles and a Worst-Case Scenario

Your client’s organizing principles, his tried-and-true ways of making sense, are telling him that for his own well-being he must keep his wife out of his personal psychological space. He “knows” that if he doesn’t, something bad will happen. But these organizing principles, like all his experiences of self, aren’t a closed system. They might perhaps change with further experience, especially now that he understands better what’s going on. 80 Assessment Your client’s wife loves him and wants to be closer to him. He decides to share with her what he’s learning about himself in therapy, and then she proposes a deal: She promises not to worry out loud or meddle if he will share with her his thoughts and feelings about a project that’s important to him. With some trepidation he does so, and he finds, to his great surprise, that her interest doesn’t feel like a threat after all. In fact, when he feels she understands his hopes and fears, he also feels a burst of energy for his project. A loneliness he hadn’t even noticed is quietly eased. He looks forward to inviting her in more. In this scenario, your client’s organizing principles prove to be open to new information. It’s not impossible to revise and expand them. But it could also be the case that he is organized more tightly against a threat that feels annihilating: Intrusion will wipe him out. He can barely risk negotiating the deal his wife wants. When he dares to open up to her, her anxiety to respond “just right” feels horrible to him, bringing on a new guilt-laden obligation. Your client retreats and shuts down. That doesn’t mean that his system is locked up forever, just that it quickly organizes information as suspicious. Slowing down this automatic reaction will take lots of exploration of what happens when his wife’s anxiety (or yours) sets off his experience that he’s not safe. It will also take many instances of finding out that in spite of his fears, sharing himself turns out to be safe after all. This second scenario illustrates that some kinds of feeling bad remain very resistant to being changed by new input from the outside, for they involve very strong organizing principles. Donna Orange, an in tersubjectivist self psychologist, calls these strong organizers “convictions”—emotional convictions rooted in powerful emotional memory.12 Emotional convictions that other people are dangerous can turn any interpersonal experience into bad experience. When a client carries strong negative emotional convictions, he must avoid real connection in order to avoid the inevitable humiliation or violation he anticipates. When invitations to connect come his way, he’s hamstrung by how he makes sense of them. When a person who suffers in this way comes to therapy, your central work Downloaded by [New York University] at 13:36 13 August 2016 as a therapist will be patient, persistent, gentle efforts to engage him in a relationship that slowly begins to feel safe to him. In a worst-case scenario, even therapy never feels safe. For such a client, organizing principles have set like cement in a pattern Bernard Brandchaft would call “pathological accommodation.” The substance and dynamics of the client’s own self-system have been swallowed up by the self-system of someone far more powerful than she, often a needy, abusive, intrusive parent. This client had to submit to this takeover of her core emotional self or be psychologically abandoned or destroyed. As a child, wholesale accommodation was the only way to keep the connection she needed in order to survive.13 Assessment 81 The problem for her, then, is far worse than inauthenticity. She’s not “there” enough to hide who she really is. Who she is has been denied and obscured. The only self she knows is a mirror of someone else’s need. Beneath this ostensible self, there is the dissociated, scrambled chaos of her own feelings. Her self-system will expend masses of psychological energy to get rid of her own experience in order to ensure her survival. Her organizing principles are especially rigid because they hold in place a system in which there is little margin for error. But then she finds herself in another, later life. The Powerful Other in question is no longer physically present. She is free now—but she isn’t. This is when psychological dissonance becomes acute for her. She longs to be free from anxiety, free to want things, free to love. But the accommodating pattern still owns her; it’s still terribly dangerous to have a self of her own. Yet even in this worst-case scenario, there’s a chance that your client’s system may still be open to influence, open to being altered if ever so slowly and slightly, by having different experiences in a therapy that finally does prove itself safe enough to try. The power of these experiences is enhanced when you and your client notice them together in therapy. You’ll have to notice small good changes over and over, and you’ll also have to pay careful attention to how the old principles keep trying to kill off small changes for the better, for the sake of “safety.” This will be the central work of her psychotherapy, and it’s very hard work. The good news is that it’s possible— even when so much is wrong and a client feels this bad.

What’s Wrong When Your Client Is Feeling Bad? A Summary

Each of the relational theories we’ve visited has a useful angle on what’s wrong when your client is feeling bad. These views also converge in important ways. Each maintains that psychological problems—different kinds of feeling bad—don’t arise from inside your client or begin with her. Rather, Downloaded by [New York University] at 13:36 13 August 2016 they are expectable reactions and responses to what has come at her in life. In other words, what’s wrong exists at the interface of outside forces and inside effects and responses, whatever that interface is called. As we have seen, the interface between outside forces and inside responses may be identified as oppression and resistance, as disconnection and strategies for safe connection, as the place where symbolic relational images and self- defining narratives exist, or as the space of empathy. What happens at that interface we may call empathic failure, fragmentation, and repair, or the creation of organizing principles, or accommodations to the other that both protect and destroy self. 82 Assessment Each of these explanations of an outside–inside interface has a distinct flavor. Some keep “what’s wrong” mostly outside of the client, while others allow it to be staged more internally. But for all of them, the “feeling bad” that a client suffers is a systemic phenomenon, something that happens in social or interpersonal interaction. What’s wrong isn’t something finished; it’s something that will keep on happening unless it is interrupted. Change can begin only when the ongoing interactions of the system begin to change. In other words, both what’s wrong and what can be changed are performative. As any therapist does, you will have reasons of personal history, worldview, and politics to prefer one or another of these relational explanations of what’s wrong when your client feels bad. Clients, too, come from many walks of life and thought. Some come with a well-developed political analysis and a vision for personal and social emancipation. Some have family of origin concerns and are seeking more rewarding relational lives. Some come shame-ridden, needing someone’s compassionate presence to shore up a shaky self. Others bring with them a bundle of symptoms tucked with them into a narrow, dark prison of self-loathing that it seems no kindness can reach. Certain kinds of theory might be more helpful than others for work with certain kinds of clients. But for all relational therapists and their clients, therapy is a process of self-with-other performative change. It’s about learning how to do and to experience life differently—with others. That’s the only lasting antidote for what’s wrong when clients are feeling this kind of bad. Because what’s wrong isn’t some kind of failure or poison inside your clients. What’s wrong is what they have learned to do in order to make the best of the relational experiences life has dealt them so far.

Notes

1. Some psychological problems do come from “inside.” Organic and genetic factors are implicated in the development of schizophrenic illness. Hormonal imbalances can precipitate postpartum and Downloaded by [New York University] at 13:36 13 August 2016 menopausal depression. The “chemical imbalance in the brain” of manic-depressive disorder can be effectively balanced with lithium. But these remain relatively rare conditions in the context of the millions of North Americans treated for anxiety and depression every year. Most of them are also treated with chemicals, treatment that seems to change something “inside.” Does this mean, then, that what was wrong began “inside”? Perhaps. But it can also be argued that the pathology of brain chemistry in people who are chronically anxious and depressed is an effect, not a cause, of “feeling bad,” and that the primary causes (and best ameliorations) of feeling bad are still to be found in interactions between self and social environment. 2. Intersubjectivity theory proposes that we think of “self” as a world of subjective experience; see for example, Stolorow and Atwood, Contexts of Being, 2–4. 3. Stern, The Interpersonal World of the Infant, 97–99. Assessment 83

4. The term organizing principles comes from intersubjectivity theory; see George Atwood and R obert Stolorow, Structures of Subjectivity: Explorations in Psychoanalytic Phenomenology (Hillsdale, NJ: Analytic Press, 1984). The Boston Change Process Study Group describes how interactional processes from birth onward give rise to “procedural knowledge.” They call this knowledge, which gives unconceptualized form and meaning to all of a person’s further relationships, “implicit relational knowing.” See Karlen Lyons-Ruth, “Implicit Relational Knowing: Its Role in Development and Psychoanalytic Treatment,” Infant Mental Health Journal 19, no. 3 (1998): 282–289 I use the term organizing principles to mean the (mostly unconscious) articulations of this general procedural knowledge or implicit relational knowing. 5. Phyllis Chesler, Women and Madness (New York: Doubleday, 1972). 6. Jean Baker Miller and Irene Stiver, The Healing Connection: How Women Form Relationships in Therapy and in Life (Boston: Beacon, 1997). 7. For a clear, concise explanation and example of a narrative approach, see David Epston, Michael White, and Kevin Murray, “A Proposal for Re-authoring Therapy: Rose’s Revisioning of Her Life and a Commentary,” in Sheila McNamee and Kenneth Gergen, eds., Therapy as Social Construction (Newberry Park, CA: Sage Publications, 1992), 96–115. 8. Brown, Subversive Dialogues, 117. 9. Harry Stack Sullivan, The Interpersonal Theory of Psychiatry (New York: Norton, 1953). 10. See, for example, Darlene Ehrenberg, The Intimate Edge: Extending the Reach of Psychoanalytic Interaction (New York: Norton, 1992); Jody Davies and Mary Frawley, Treating the Adult Survivor of Childhood Sexual Abuse: A Psychoanalytic Perspective (New York: Basic Books, 1994); and Philip Bromberg, Standing in the Spaces: Clinical Process, Trauma and Dissociation (Hillsdale, NJ: Analytic Press, 1998). 11. For an in-depth account of the development object relations theory and its transformation into self psychological theory, see Howard Bacal and Kenneth Newman, Theories of Object Relations: Bridges to Self Psychology (New York: Columbia University Press, 1990). 12. Orange, Emotional Understanding, 113–124. 13. Since his seminal 1993 paper, “To Free the Spirit from Its Cell,” reprinted in Robert Stolorow, George Atwood, and Bernard Brandchaft, eds., The Intersubjective Perspective (Northvale, NJ: Jason Aronson, 1994), Bernard Brandchaft has been developing the idea of pathological accommodation and clinical approaches to the problem. Downloaded by [New York University] at 13:36 13 August 2016 4 Relational Trauma: Past and Present, Memory and Now

From a relational perspective, a client’s psychology is a process that happens where inner and outer meet, where a client’s mental organizing systems make sense of what happens to him in relation to others. Past and present meet here, too, because a client’s interpersonal process memory is a powerful organizer of the meanings and feelings moving through his present-day interactions. A client’s past self-with-other systems tell him how to “do” present systems, and that doing shapes his relational and emotional life. This is how past is present, according to a performative relational model of therapy. Popular conceptions of therapy link past and present, too, often with the assumption that therapy is about remembering traumatic events that clients have repressed. Sometimes it’s assumed that the strong feelings involved in recovering memories will purge the poison of trauma from a survivor’s system. Or cure is thought to be like putting together a puzzle, linking specific past experiences with specific fears and behaviors in the present. I don’t disagree with this basic idea: that therapy is about dealing with the effects of the past as they live on in the present. But relational therapy has its own approach to past trauma; to understand it, we first need to understand a relational definition of trauma and its effects. Downloaded by [New York University] at 13:36 13 August 2016

What Is Trauma?

Trauma comes from a Greek word meaning “wound.” In the world of psychology, trauma means shocking, wounding experience that has lasting psychological effects. Certain psychologists, psychiatrists, and psychotherapists specialize in understanding the psychological processes that follow the shocks and violations trauma survivors have suffered. Judith Lewis Herman is one of these. She writes from a feminist, relational perspective Relational Trauma 85 about the psychological aftermath of having suffered war, political impris- onment, torture, camp incarceration, kidnapping, rape, domestic violence, or childhood physical and sexual abuse.1 Along with many others in the field, she proposes the name complex post-traumatic stress disorder (PTSD) for the after-effects of prolonged subjection to violation and domination. Long after escaping the scene of the trauma, a survivor continues to suffer the past as if it were present. Nightmares and daytime flashbacks bring back sights, sounds, smells, and other body sensations. These fragments of traumatic memory remain frozen in time, frozen by an old terror that may still flood the survivor when memories break through. In this daily atmosphere of retraumatization, a survivor fears real and present danger around every corner. Insomnia, constant irritable anxiety, and repeated surges of fight or flight adrenalin wear down a survivor’s physical resilience and bring on physical symptoms of long-term stress such as hypertension, irritable bowel syndrome, and chronic pain and fatigue. When severe trauma is inflicted again and again, many survivors learn to dissociate from what’s happening to them, sometimes through powerful trance states. Likewise, when the trauma has become history, a survivor learns to minimize its intrusive aftereffects by disengaging from the risks of daily life. In a safe, repetitive daily routine, there will be less chance of feeling the kind of momentary scare that might set off a flashback. If a survivor avoids new people and new situations, she doesn’t have to be so hypervigilant. If she numbs out most of her daily feelings, she can also manage to keep out of her awareness the painful feelings still entangled with her traumatic past. But although various kinds of dissociation allow the survivor to keep painful feelings out of her awareness, the feelings still generate pervasive anxiety and physical symptoms of stress, and they keep breaking through in fragmented, unintegrated bits of memory. Numbing her feelings eases some of her pain, but rather than solving her problem, numbing keeps her problem in suspension, out of the reach of help. Constricting her interactions may also leave her isolated, depressed, and despairing of any meaningful future. Downloaded by [New York University] at 13:36 13 August 2016 This oscillation between feeling overwhelmed by intrusive symptoms and diminishing the symptoms by diminishing her life is only a small part of what an abuse survivor suffers. Far worse is the emotional anguish of having suffered relational violation and betrayal. Especially in the case of childhood physical, sexual, and emotional abuse at the hands of a caretaker whom the child should have been able to trust, such betrayal crushes a child’s sense of self. The survivor of such betrayal may carry a deeply wounded, terribly damaged sense of self for a lifetime. A secure self develops in response to secure connection with caretakers who use their power benignly, with respect for a child’s emotions. When 86 Relational Trauma parental power is used to control and coerce a child with no thought for the child’s experience, the child feels powerless and obliterated by shame. Her ability to explore and to assert herself fades as she worries about keeping safe by being good. In trying to make a tolerable world for herself, she decides that the bad things that happen to her are her fault (as she may have been told). It’s better to be a bad child in a universe that makes sense than a good child in a universe that’s randomly cruel. For an adult survivor of severe childhood abuse, a deep, helpless sense of “what’s the use” takes root, along with pervasive self-blame, shame, and guilt for whatever bad happens to her. With personal dignity shattered, she carries feelings of being defiled and stigmatized, of being profoundly different from others. Having had to make sense of her childhood experience all by herself, she feels deeply and utterly alone, with no hope of being understood. Thoughts of her abuser bring rage and desire for revenge, but in her mind her abuser remains bigger than life with supernatural power over her. Though she hates what has been done to her, often she still sees herself and the world through the abuser’s eyes, the only view she was allowed to have under duress. When she sees the world through her own eyes, she finds it difficult to see any purpose or meaning in it at all. In her adult life, an abuse survivor’s relationships are confusing and disturbing. Having known betrayal intimately, she distrusts professions of love. Since as a child she trusted those who hurt her, she also deeply distrusts her own ability to tell “good people” from “bad people” and thus keep herself safe. So sometimes she just takes thoughtless risks, and other times she withdraws into isolation. Somewhere she keeps on hoping that someone will rescue her, even while she turns angrily away from a world of dangerous people. In intimate relationships, she fears abandonment, but at the same time she walls herself off against invasion and emotional takeover. Interpersonal conflict throws her into intolerable anxiety, for asserting herself means she will elicit the other’s rage. Her only options are to rage back or to submit, and either way leads to annihilation. Downloaded by [New York University] at 13:36 13 August 2016 A Continuum of Relational Trauma

This is but a brief sketch of the stress and trouble a trauma survivor copes with every day. Certain clients fit this picture exactly, and it’s clear that they are survivors of sustained childhood abuse. For other clients from difficult childhoods the pain is not so physically or psychologically overwhelming. They have confidence and initiative enough to make decent lives for themselves, including a sense of belonging to family and community. They can trust others well enough to be in intimate relationships, Relational Trauma 87 and they can learn to manage interpersonal conflict constructively. They also struggle, however, with pervasive anxiety and depression and with deep doubts about their worth and connection to others. Is it helpful to think of their childhood pain as trauma, too, and to understand them as trauma survivors? In my clinical work, both with survivors of atrocious childhood abuse and with clients whose childhood suffering was subtly inflicted and mostly invisible, I have wondered for a long time whether there is more continuity or difference in their two kinds of experience. As I have become more aware of the relational trauma at the heart of a history of abuse, I have come to see far more continuity than difference, and I find myself placing many clients on a single continuum of relational trauma. This does not trivialize the atrocities done to those whose experience exists at the severe end of the continuum, and it includes their suffering in a larger picture of human experience. A unifying relational definition of trauma also validates those whose suffering has been more psychological than physical but no less real. They’re not sure whether they can call what happened to them abusive. If it’s not abuse, does their experience really matter? Is their pervasive psychological pain fraudulent, self-induced? Understood as relational trauma, their experience does matter profoundly, and their pain makes sense. There are also clients who can’t remember much of what happened to them. Can they heal if they can’t remember? A continuum of trauma based on traumatic relationship rather than on traumatic events takes the urgency out of such questions. Clients usually do remember the powerful relationships that hurt them, even if they haven’t fully recognized the hurt and don’t remember many of the details of how that hurt was inflicted. Clients may feel dismayed at the hard work of making contact with the fear and pain of their childhood relationships, but they aren’t usually surprised by it. What clients don’t anticipate, as they allow their deep conflicts about trust and connection to rise to the surface, are the relational ruptures Downloaded by [New York University] at 13:36 13 August 2016 that start to happen with important people in their lives and especially with you, their therapist. Working their way through these impasses is the most frightening and exhausting part of their trauma work inside and outside of therapy. A relational perspective on trauma reassures them that these aren’t side issues; these here-and-now relational places are exactly where the old pain shows up, and so it’s also where they have a chance to work through it toward new freedom and ease. Some clients can tell you detailed abuse narratives early in therapy, while they also tell you that remembering hasn’t helped. They wonder if they need some other kind of help. You notice that their story is about 88 Relational Trauma brutal events but not about brutal relationships, and you wonder whether their previous therapy work was able to touch the core of what happened to them: the relational betrayal at the core of violent acts and threats. Until these clients are able to face and work through the deep relational pain that the trauma caused, they can’t get to the heart of what happened to them. They do, indeed, need more help. Then there are the clients who can’t remember what happened to them, and the ones who are quite sure there was little overt violence or coercion in their families of origin. Yet in their daily lives with others, they feel frightened, isolated, angry, trapped, and worthless—all evidence that something relationally damaging did happen. You and they would be wise to wonder whether the quality of their early connections to caregivers left them with deep relational wounds, even though the original wounds may be well hidden. I’m suggesting that for clients in any of these situations, their experiences can be situated on a continuum of relational trauma. From one end of that continuum to the other, certain things hold true: (1) The injuries underlying clients’ psychological pain are at their core relational injuries: trust has been betrayed; legitimate interpersonal needs have been denied; a child’s personhood has been ignored or demeaned. Particular events have become traumatic because they were embedded in an ongoing traumatic relationship, one in which caretakers did not notice the child’s distress or help the child recover. (2) Clients wounded in early relationships protect themselves from remembering and from further hurt with a wide range of dissociative strategies and behaviors—from “spacing out,” to sever- ing themselves from their emotions, to medicating themselves with substances, to losing themselves in fantasy, to forgetting themselves in hectic cycles of responsibility. (3) The traumas of the past continue in the present not only in self-protective strategies but also in troubled relationships. For clients all along the continuum of relational trauma, interpersonal trust is riddled with doubt and fear, though when less severe those feelings can be masked. Still, their expectation of being ignored or humiliated is never far Downloaded by [New York University] at 13:36 13 August 2016 away. Holding one’s own in self-assertive projects remains problematic for someone who has suffered relational trauma, and situations of conflict can induce panicked flight or paralysis. A client may not recognize himself as a survivor of overt, severe abuse, but he may definitely find himself on this continuum of relational trauma. He needs to hear that with or without experiences of severe physical or sexual abuse, relational violations and betrayals count as trauma. His pain is not fraudulent. He can be sure that he isn’t doing it to himself. He also needs to know more about how this trauma happened and how it keeps on affecting him in his present life. Relational Trauma 89 Factors Contributing to Relational Trauma

Psychological trauma is emotional experience that’s more than a person’s psychological system can handle. Prisoners of war and torture victims are psychologically broken by assaults intended to overwhelm them with terror and helplessness. Battered wives become prisoners in their own homes, their psychological resources depleted as their abuser eliminates all outside contact and support. For a small child, terror and helplessness can be inflicted much more carelessly: there’s a sudden explosion of rage when he has made a mistake; he’s left alone with his badness in a dark room; he hears abusive, hateful exchanges between his parents; he lives with a constant threat of violence that keeps him anxiously watchful; he witnesses violent acts inflicted on his mother or siblings. A client may have specific memories of such overwhelming moments. He might also guess, based on how he saw siblings treated, that there were similar moments in his infancy. His crying might have been ignored so that he wouldn’t be spoiled—until he wore himself out with helpless wail- ing, and slept. Caretakers might have spanked or shaken him to make him be quiet and “good”—until his system learned the value of acquiescing. Mealtimes and toilet times may have been experiences of being invaded and controlled, of losing his bodily agency and integrity. Such injuries are inflicted by caretakers, and this is what makes them so traumatic. In such situations, the child is truly helpless. When the actions and emotions of his parents scare him, there is nowhere to turn. The child is literally at their mercy, as captive as a political prisoner or a battered wife, but he doesn’t even know he is captive, for this is the only world he knows. If instead, your client had lived in a safe interpersonal world as a child, even frightfully abusive acts by strangers would have had fewer lasting traumatic effects on him. Such abuse would have been a violent intrusion on his safe world, but it wouldn’t have constructed a world of terror in which he was trapped. In a safe world, if a child were hurt, his parents would care

Downloaded by [New York University] at 13:36 13 August 2016 about what happened to him. They would help him talk about his scary bad feelings so that he could get to feeling safer and stronger again. But this is precisely where a careless traumatizing parent fails. Not only does he or she shock, frighten, coerce, or humiliate a child, the parent doesn’t even notice what the child suffers. It’s not that the parent doesn’t know what happened; in fact, he or she does know, but it just doesn’t matter. It’s nothing. That’s what the child is left to believe. The child’s terror doesn’t matter because the truth (he’s told) is this: His father is right to be so terribly angry. Someone made him angry. Or it’s the child’s own disgusting behavior that has gotten him banished to his 90 Relational Trauma room, and he deserves his mother’s cold silence for the rest of the day. The neglectful chaos that swirls through his family is just how it is. If his father needs a helping hand in the shop and he’s slow and makes mistakes, it’s his stupidity. If he has a hard time at school, if he’s an unathletic geek or over- weight or effeminate, his parents are right to shame or scorn his weakness. Children can be helped to deal with many kinds of interpersonal hurt. They can even tolerate and integrate their parents’ failures, flaws, and emotions when their parents notice the effects of what they’ve done, take responsibility for making changes, and help their children talk about how they feel “when Mommy gets mad,” for example. The painful events we’ve been talking about are burned into your clients’ experience as trauma partly because they’re scary and came at them from people they needed to trust but mostly because those very people didn’t help them manage the painful, scary events. When a child survives a flood of overwhelming feelings and has to make his own sense of what happened, he can make sense in only simple, childlike ways. If he has been shamed, he is shameful. Believing that he’s the bad one in the relationship, he tries hard to be good. The more at risk he feels, the more tightly his perception of the world has to match his caregiver’s perception, a loss of self we’ve seen described as “pathological accommodation.” Some children who believe that they’re bad decide to live their badness in a big way. But for all their rebellion, they are no less tied than their “good” siblings to their ongoing trauma-management. Above all, a child who survives repeated trauma tries not to think about the bad times. There’s no way out except to wait for it to be over. So although the child is ever watchful for the signs of a new eruption, when a bad time has passed, he puts his feelings as far away as he can. Because no one acknowledges what has happened, he, too, has to turn that experience into something that hasn’t really happened. It’s “nothing,” and nothing he can make sense of, so he makes it his own kind of nothing. But through this act of disconnection, the “nothing” is put where it takes on a powerful life of its own. Downloaded by [New York University] at 13:36 13 August 2016 The Disconnecting Effects of Relational Trauma

The technical term for putting traumatic experience in a nothing place— where it takes on a life of its own—is dissociation. Giving it a life of its own is an ironic paradox, since for the trauma victim the whole point of dissociation is to get rid of painful feelings for good and forever. But in fact, dissociation just puts painful feelings where they can’t be integrated into a coherent narrative of a client’s history. From there they will keep causing trouble, and the client won’t be able to tell where the trouble is coming from. Relational Trauma 91 Strong, quick acts of dissociation, the kind a child can learn to perform very early, keep trauma out of narrative memory. So it’s not even the case that there’s a whole story of what happened to your client pushed down somewhere, waiting to be recovered. The picture is more like scattered fragments of radioactive memory—body memory, event memory, emotional memory, and/or interpersonal process memory. These fragments lie strewn across your client’s internal landscape, disconnected from one another and from your client’s awareness, but still emitting powerful, disturbing signals. During and after severe abuse, dissociation may be physiological as well as psychological. Many victims learn to get through traumatic events by using self-hypnosis to detach from their own consciousness. After an intense terrifying experience, what a victim has sensed, felt, smelled, seen, and heard will be encoded in only a part of the brain that doesn’t link into narrative memory. These fragments of memory will remain there unal- tered, the source of nightmares or flashbacks but never the victim’s own story. Therapy has to include the painstaking process of gathering up these fragments and holding them until they fall into the coherent patterns and meanings of narrative memory. If a particular client’s trauma is more psychological than physical, other kinds of dissociation will put relational trauma out of her awareness. She may remember disturbing events, but with no felt sense of what was going on between herself and her caretakers. Of course those things happened, she may say, but they don’t matter anymore. She may have put together a story for herself of a happy childhood. Nowhere in her story are the feelings that belong to a relationship in which fragile, angry parents fail to understand the needs and fears of a vulnerable child. These are the radioactive memories that lie scattered away from this client, unintegrated and therefore still meaningless. There are also many ways for a client to block the signals coming from those fragments: emotional numbness, self-medication, overwork, addictions, or psychosomatic illness. These strategies for disconnection (to use Downloaded by [New York University] at 13:36 13 August 2016 Stone Center language) keep her from being present to herself. She can’t be very present to anyone else, then; these strategies keep her out of relationship, too. As we saw in Chapter 3, behind a client’s everyday strategies for emotional disengagement and safe disconnection lie her interpersonal process memory and the principles it has produced to organize all the bits of her daily interpersonal experience. This is how the self-with-other system of her childhood gets replicated in her interpersonal systems today. This is what tells her, for example, that she must please her partner or she will be abandoned, that disagreement between friends is terribly dangerous, or that isolation is the most trustworthy kind of safety. 92 Relational Trauma If any one kind of everyday experience runs through relational trauma and its fragmenting, disconnecting aftereffects, it’s the experience of shame. For survivors of relational trauma, shame turns up in many forms. To be shamed is to become a pariah, cut off from human connection, and the reverse is also true: isolation is itself shaming. To be cut off abruptly or ignored deliberately can induce shame reactions even in very young children. When one is left alone, feeling bad, those bad feelings quickly become feelings about a bad self, for the feeling of shame carries with it the sense of being defective. As we noted in Chapter 3, when a child can’t make sense of bad feelings, one explanation is always available: “There’s something wrong with me.” Dissociation and disconnection riddle your client’s adult life with shame. Since he can’t know his feelings and motivations from the inside out, he can’t feel whole and strong. He’s ashamed of the disorganized anxiety he carries around, and he’s ashamed of the obsessions and habits that keep his anxiety under control. Nobody knows how hard he works to present a coherent, “together” front to the world. Chronic disconnection from others robs him of the support he needs to feel good about himself; here, too, isolation breeds powerful shame. His organizing principles quickly turn any interpersonal trouble into something he should be ashamed of. To live life in the long shadow of relational trauma is to live haunted and constricted by shame in all its guises.

How Does Remembering Help?

Relational therapy insists that only remembering-with will help a person whose life is constricted by relational trauma. Unless a traumatized client has someone to help her make reconnections, she won’t be able to shift out of her usual disconnected ways of being with herself and others. Her commitment to putting difficult experience out of sight and out of mind has been profound. When she was a child she couldn’t bear to feel her over-

Downloaded by [New York University] at 13:36 13 August 2016 whelmed, shamed confusion. Now she knows in her bones that there are very good reasons not to “go back” and feel any of that. Yet there is also a very good reason to let herself feel how it was: Putting those experiences out of sight has not really put them out of her life. She struggles with physical and psychological symptoms that don’t make sense. Something keeps sapping her energy and self-confidence. Though she can’t make the connections, she suspects it’s “old stuff,” and so she has looked for a therapist whom she feels she can trust. She’s absolutely right that trust is crucial. Once she pushed all the bad stuff out of sight because no one saw or cared, and that’s what made the trauma was so deeply disorganizing and Relational Trauma 93 shaming for her. To begin to speak to you about that shamed place will be a major emotional risk. Her risk starts to pay off, though, as your empathy for her experience eases her fear of being shamed again. She finds she can bring her jumble of hurt and angry feelings, and you help her sort them out, bit by bit. This time her feelings really do matter. This time someone is saying, “Yes, what happened really hurt you!” As you listen and respond, you reassure her that it’s okay if she can’t be sure of the details. What matters is that someone is here, now, to witness and validate the truth of what she feels. In time she will find herself not just speaking about her shamed confusion, but speaking directly from those shamed places in herself, in the shaky but growing hope that your empathic understanding will keep on welcoming her back into connection. In the next section of this chapter, we’ll look more closely at how this remembering takes place in therapy. Clearly it’s not an investigative search for the details of the story. In relational trauma, the hurt comes less from particular circumstances and events than from the ongoing attitudes and feelings important people had toward your client. Things that happened showed her how other people felt toward her. What she needs to remember is how it felt to be with those people. The legacy of that memory is imprinted on all the ways she protects herself from being hurt again by people close to her. This work of remembering-with is also not revisiting scenes of trauma in hopes of cathartic expressions of emotion. That kind of remembering just activates fragments of self-with-other pain. If what happened between your client and an abusive parent left her flooded by helpless rage, it’s no help for her to find herself back in that state, even if this time she can kick and scream about it. The help she needs now is the same kind of help she needed then: someone to see what was happening, someone to care about her hurt and to support an angry protest, someone to help her name cruelty as real, and a real part of her own story. This kind of remembering helps her because it adds up slowly to new, Downloaded by [New York University] at 13:36 13 August 2016 important knowledge: “This is who I am. These are the kinds of things I had to live through. This is how I made myself strong enough to survive, and these are the vulnerable feelings I had to hide away. This is how I came to be who I am today.” As this knowing falls slowly into place, she may feel as if she’s finding a lost self or as if she’s beginning to exist at the center of her own being. Now, because she is no longer a child, no longer alone and overwhelmed, she can say, “It’s better to feel the pain. At least I’m here!” Remembering-with is what makes the pain of remembering bearable and meaningful for your client. The presence of someone who witnesses, 94 Relational Trauma understands, and cares allows her pain to be transformed into grief. While dissociation is the psychological process most responsible for keeping trauma active and destructive, grief is the opposite process. A time of grieving is a time of integrating past and present meanings and feelings. Grief is the psychological process through which trauma can be laid to rest. Only grief can begin to heal the pain of loss, but since grief itself is acutely painful, people who have suffered loss need the close presence of others to help them grieve. Many human communities build this wisdom into burial and mourning rituals. As your client’s therapist, you bring this wisdom with you as you attend her grieving process. She may mourn for the broken spirit of her young self; for the confident, optimistic young adult she wishes she could have been; for the loving intimacy she avoided for too long; for so much of her potential wasted; for how very hard she has worked just to keep herself together; for the tenor of her everyday life, far too anxious and sad; and for the understanding, affirming mother and father she always longed for but never had—and never will have. Grieving brings past and present together into coherent meanings, dense and rich with feeling. From the crucible of mourning relational losses, a once-fragmented self emerges as a self of integrity. In the words of Judith Lewis Herman, “Integrity is the capacity to affirm the value of life in the face of death, to be reconciled with the finite limits of one’s own life and the tragic limitations of the human condition, and to accept these realities without despair.”2 And though grief may always haunt some of your client’s thoughts and memories, when it has done its work, it passes. The integrating work of grief not only recovers a self for her, eventually it sets that self free to look forward and to go on. As your client recovers herself and moves on, it’s just as important that she not be alone. During the long process of remembering, you were present to her suffering and grief. Now you are the one in whose presence she is no longer fragmented. Just as the grip of shame is intensely interpersonal, so the release from shame can be best known in the presence of Downloaded by [New York University] at 13:36 13 August 2016 another person. Release can be exhilarating, setting free blocked energies and desires. When your client has someone to respond to this new energy, it doesn’t overwhelm her. She is able not only to dream new dreams but also to make new plans and to take new actions. It was in hope of this outcome that she went to the trouble of finding out how to remember who she was. The point of remembering was to stop the mindless repetition of dissonance, anxiety, and emotional pain that plagued her subjective world. Mindful remembering-with brought her into the presence of what hurt her. But it also gave her the gift of grief, her integrity, and her freedom. Relational Trauma 95 How Is Therapeutic Remembering Done?

If remembering-with matters so much in work with survivors of relational trauma, we should be clear about how it’s done. The word “remembering” conjures up an image of a therapist taking a history and of a client answer- ing questions about whatever he can recall. But as you know from earlier chapters, that’s not how relational therapy goes.

Memory Is Now and Now Is Memory

In fact, a lot of what I’m calling “remembering” doesn’t look the least bit like a trip down memory lane. Relational therapy centers on remembering understood in a particular sense: making emotional contact with something that’s present and past at the same time. Remembering is a mental event constructed in the here and now, and this very here-and-now is constantly being formed by the sum total of all that we remember. In other words, every day and in every way, we live our lives through our memories. And when we remember a specific event, all of our other memories and all of our feelings right now shape and color what we think is coming straight from the past. That doesn’t mean our memories aren’t true. But it does mean that we have to think carefully about our definition of truth. Perhaps we would be wiser, at least in therapy, to talk about meaning instead of truth, for meaning includes not just “the facts,” but also the feelings around the facts, and how those facts and feelings are woven into meanings within our subjective worlds of experience. The interpersonal system that we call a self, with all its love, hate, desire, fear, joy, and shame, is not a data bank. It’s a meaning- making system. It doesn’t make arbitrary meanings; whenever possible, it checks outside references for validation of the meanings it makes. But as it makes meanings about self-with-other, its first reference is always to feeling, or “affect.” Downloaded by [New York University] at 13:36 13 August 2016 That’s why what we think of as the facts of memory are “filed” under feelings. Let me illustrate. On a certain day a client comes into therapy terribly upset about having been cheated by a colleague, and then he sponta- neously remembers a childhood incident where he felt helpless fury about having been tricked. Another client is trying to screw up his courage to ask a special person to dinner, and he finds himself recalling how he felt like a hopeless geek at his senior prom. What brought those particular scenes to mind? In both cases, we could say that a number of scenes or memories have been filed under a certain self-with-other feeling. “Tricked and furious” opens one file. “Anticipating humiliation” opens another one. 96 Relational Trauma In a client’s meaning-making, the filing system matters more than the memories it contains. The filing system shows how a client has already categorized situations and emotions from reams of memory data about interpersonal processes. Certain event memories are kept at the front of each file as strong illustrations of the feeling. The arrangement of the files is much closer to the truth of who your client is than any supposed facts of his history, because his filing system is how he makes meaning of “facts.” We’re back to psychological organizing principles. To extend the metaphor, we could say that a client’s organizing principles are his program for automatically filing and retrieving “facts,” especially when the facts are about his relationships with others and his place in the world. This is a highly reliable form of memory because this filing/ retrieval program has been generated from countless instances of interpersonal interactions. Just outside of your client’s awareness, it continues its constant operations of making sense. As files are retrieved to make sense, memory becomes “now.” As new experience is filed into existing folders, “now” takes the shapes of the past. Metaphors always fall short, of course, of the reality they aim to capture. But my point is that any memory takes place within this complex activity of making meaning. It’s here that the remembering of relational psychotherapy is undertaken—in this activity where then and now merge, where experiences of past and present co-determine each other. In Chapter 3, we saw that relational therapy understands psychological bad feelings to originate from neither outside nor inside a client, but rather from that place or activity where inner and outer systems interact, producing relational meanings full of feelings. Here we have another angle on that same difficult concept, another approach to the same territory. In this chapter, I am saying that the “remembering” work of therapy is not about the past as such, but about specific ways the past is present in a client’s system of living and making meaning. In short, your client’s organizing principles are how he lives his interpersonal past in his interpersonal present. You don’t have to force or cajole his Downloaded by [New York University] at 13:36 13 August 2016 remembering: it’s there. The layering of now and memory will slowly reveal itself as you pay careful attention to whatever your client is experiencing, thinking, and feeling here and now.

Staying Anchored in the Present

A client comes to therapy because of problems he’s having right now. His problem is not that he’s forgotten what happened to him. His problem is that the meanings of what happened to him do him damage, he’s living Relational Trauma 97 those meanings every day, and he doesn’t know what they are. What happened in the past matters because of now. That’s why, as a relational therapist, you keep yourself and your client anchored firmly in the present. As you explore his current distress, you’ll begin to see connections to interactions that trouble him, and then you can explore the meaning-system your client uses to make sense of his interpersonal reality. This was the sequence with “Megan,” who came to see me because she was feeling lost and confused about her life and worried about the beginnings of a starve-and-binge eating pattern. She had just finished her first year of university, and she wasn’t happy in the program she had chosen. The youngest of three daughters, she was the last one living at home. Her brainy oldest sister was away in a medical residency and the second sister, married to a nice guy, had a new house and a new baby. In her opening sketch of the family, Megan saw herself as the quiet one who never really knew what she wanted. I couldn’t get a clear picture of her parents, but I heard clues that they weren’t happy together. Megan told me that each of them loved her very much. I began to wonder whether this quiet youngest daughter had become her mother’s confidante, the apple of her father’s eye, and a container for the anxiety of their conflicted relationship. I wondered whether her eating obsession gave her some sense of control, at least over her own anxiety. But mostly we talked about what she would do in September. First she told me, very hesitantly, that she didn’t want to go back to university; she wanted to go to art school. Next she dared to say, “But only part-time.” Megan liked the new place where she worked; customers were friendly and the tips were good. If she kept that job, she could make decent money and still go to school part-time. As she told me these things, she realized that she wanted to be financially independent. Then came the bigger realization, quite hard for her to face. She wanted to be independent enough to leave home! This was a large, complicated problem. Megan knew what her parents would say: For her future, she should stay in university; financially, it just made sense to live at home. But Megan Downloaded by [New York University] at 13:36 13 August 2016 knew that they really just wanted her to be there with them. She would hurt their feelings by wanting to leave. She felt guilty and afraid. Then she felt trapped and angry. She cried. She thought she would never be able to say what she wanted to say to them. Again and again we discussed the ways she might explain herself to them and all the ways she thought they might respond. In the end Megan invited them to come into a session with her—so that I could be the one to take care of them, she said. My presence also helped her hold on to what she wanted to say. It came down to this: “I’m not brainy Gwen or bubbly Joan. I’m just me, but I have to be more than just the little sister, the last 98 Relational Trauma kid. I really need to leave home in order to find out who I am. I still love you both very much, and I will visit lots, but I need a space and a life of my ow n .” In that session Megan’s parents seemed to listen to her and understand what she wanted. The next week she told me that each of them had taken her aside for a “little talk” to see whether she might change her mind. But when she held firm in her ideas and steady in her feelings, they backed off. Megan was able to tolerate her uncomfortable feelings in the face of their sadness and their subtle anger about her leaving. By November, when Megan had found a place of her own, she said she didn’t need to come to therapy any longer. She told me that she was pretty sure that her eating wasn’t going to be a problem anymore either. You could say that in Megan’s therapy we never touched her past. Or you could say that her experience of talking to someone who really listened shifted one of the main organizing principles of her short history. Being the listener to both parents while living in the shadow of competent, articulate sisters had opened a big file for her called “I don’t know what I want.” But she found that when somebody heard what she really thought and felt, she could figure out what she wanted. She could find her voice and actually say what she wanted—even though what she wanted would take her away from her parents. We never went back in time; we never had to talk about the little girl who learned she mattered because she could make her parents feel better, or about the years she carried their anxieties as her own. We did go over and over the shape and feel of the system in which she felt trapped, and as she dared to say what she felt, a new, freer system developed between us. This new kind of interaction altered Megan’s caretaking organizing principles just enough to give her a window of escape from them. Though we never spoke of it, something had changed in how her past was present with her. It was enough so that she could speak her own truth to her parents; from there, I hoped, she would go on to develop more self-assured ways of being in the world. Downloaded by [New York University] at 13:36 13 August 2016 It could be argued that in Megan’s case, history was beside the point anyway. Hers was a forward-looking six-month therapy involving no deep psychological disturbances or debilitating symptoms. Furthermore, many young adults revamp organizing principles in order to get ready for adulthood, and they don’t need to visit the past to do so. All of this is true. It could then be argued that adults who have suffered more extensive relational trauma are in a different situation; they do, in fact, need to be directed to the past, at least for a while. In answer, I will tell another story, which I will call “A Tale of Two Hospitals.” It’s only a small part of a long, complicated story, for the story’s heroine, “Lucy,” has been in psychiatric Relational Trauma 99 care for half of her life, ever since her first suicide attempt at 16. My point will be that for Lucy, too, all of the past that matters is in her present.

A Tale of Two Hospitals

Lucy came to me from a residential treatment facility that specialized in the recovery of traumatic memory. I have been her therapist for ten years now, and she also keeps contact with a psychiatrist who prescribes medication and who is her safety-net link to a hospital when she’s suicidal. When she came to me, Lucy had remembered that between the ages of five and nine she had been sexually molested by her father. But her memories were in vague bits and pieces. In her previous treatment program, she’d been told that the key to her healing was to recover her memories fully, along with all the feelings that went with them. Lucy lived most of every day alone in a fog, losing large chunks of time, forgetting to eat and taking drugs to sleep. When small things went wrong, she would feel so helpless and alone that she would cut herself to feel the pain—and to control the pain. When she had to go out, she put on a tough, bright face to interact with shopkeepers and bus drivers. Lucy tried to work at menial jobs to augment her social assistance money. But something would always happen, and she would retreat to her apartment, sure that people hated her, sure that she was ugly and disgusting; sure that nobody cared. Once or twice a year, it was all too much, and she would start plan- ning to die. What this had meant ever since her first suicide attempt was not dying, but a complicated relationship with a hospital. So once or twice a year, she would be in hospital for some weeks, getting over her desire to kill herself. Taking a relational approach to complex PTSD, I knew that my first pri- ority with Lucy was to help her establish more physical safety and comfort in her life. I also wanted to help her feel safer with me. So for months stretching into years we talked about the details of her everyday life—about Downloaded by [New York University] at 13:36 13 August 2016 cleaning and painting her apartment, about starting seedlings and shop- ping for groceries, about fights with a boyfriend who treated her badly, about troubles at work, misunderstandings and fallings-out with friends, and negotiations with psychiatrists and hospitals. We talked about islands of calm in a day or a week, pieces of reality that made sense, and we visual- ized linking them together with bridges. Lucy told me about sci-fi books she liked and brought me tapes of her favorite music. Sometimes she brought her pets along for a visit. “Family therapy,” she said. In and through this everyday conversation, we talked about Lucy’s past, too, but not as a special project, and not about what had been designated 100 Relational Trauma “the trauma.” From diaries she had saved, she read to me her tormented adolescent struggle to establish an identity and find friends who liked her. Through Lucy’s stories, I felt I came to know mother quite well, especially how she could be both intrusively needy and harshly critical. I came to have a sense of her moody, distant father, too, and how he covered his vulnerability with abusive, alcoholic rage. Lucy told me that when she was little, she used to be petrified every night that someone was going to get killed. She told me how her mother dressed her up to be her pretty little girl in clothes Lucy hated, and how she screamed at Lucy when Lucy didn’t do her chores right. I heard about the bullies in Lucy’s playground, her childhood pets, and the different houses she lived in. Sometimes I wondered whether we should be talking about “the trauma” instead of all of this. And then, during one of her longer stays in hospital, the staff decided that Lucy should, indeed, talk about the trauma. She told me about it after, about “losing it” and having to be restrained. She had heard herself scream- ing ugly words at herself, she said, and in that moment she knew that those words had been screamed at her—she knew she had been abused—it was true! After the breakdown, she felt dazed and confused for a while, but much calmer. Above all, it seemed, she felt vindicated in the eyes of the hospital staff: she did carry horrible stuff inside her; terrible things had really happened to her. Her pain “made sense.” She had a right to it. I didn’t understand exactly what had happened to Lucy in hospital, but I hoped for her sake that it was the breakthrough she longed for. But sadly, it wasn’t. Very soon she was acutely suicidal again, and after three brief admissions in quick succession, the hospital staff decided to try another approach. They underlined that part of her diagnosis that read “borderline,” and referred Lucy to a neighboring hospital with a treatment program that reclassified certain “borderlines” as patients with “dissociative identity disorder.” After much initial fear and suspicion, Lucy began to talk with the staff of the new program about the different parts of her that had different thoughts and feelings, and especially about that small but powerful part Downloaded by [New York University] at 13:36 13 August 2016 who stepped in to take over when she and everybody else was sick of her “whiny self, always in pain, always needing, never getting.” That cold, furious part said, “Fuck it. One thing needs to happen here. That whiner needs to die.” Learning about these different parts gave Lucy a new way to understand and respect herself. She came back to me more excited and confident than I had ever seen her. “It’s the dissociation—that’s the problem! None of those hospitals or psychiatrists ever got it—all those years! Out of all that treatment, only you knew it all along. You’ve been saying dissociation for years!” Relational Trauma 101 Actually, I had never said much about “dissociation.” I had talked with Lucy about her different islands of experience with no bridges between them, about powerful self-states that swept over her like each one was the only reality of her life. But it happened that soon after Lucy began her hospital treatment for dissociation, I attended a workshop with Jody Messler Davies, an Interpersonal/Relational psychoanalyst who specializes in treating survivors of childhood sexual abuse.3 Messler’s work, which I will outline below, helped me understand how relational therapy addresses relational dissociation, and from this perspective it was easy for me to align myself with Lucy’s hospital treatment. Lucy and I continue our same style of work together, understanding better what we’ve done and what we’re doing. When she came to me she was living her life in disconnected pieces. Her previous “trauma therapy” had left her with more difficult and disturbing pieces to deal with. At first she could only bring to me the disconnected pieces of her daily experience, keeping her deeply shamed self far away. As we contained the fragmented present within the narrative of therapy, it began to hold together, along with some of the past. After two or three years she noticed, “It’s like I can feel a past behind me, like it’s real, there’s continuity.” She said, “It’s like I can finally be here. But I don’t like it. It hurts a lot.” What hurt most was what she described as horrible shame. If ever she came close to feeling it in my presence, she shut down all her feelings. This long process of getting safer and becoming more present was the background to Lucy’s discovery, with hospital help, of “parts.” Eventually I got to know the cold killer part more directly, and I was allowed closer to the terrified, shamed child-self who thought she deserved to be dead. These two fragments of herself—actually two pieces of how Lucy can experience self-with-other—are the most important of Lucy’s “parts.” But now that talking about parts helps, we can identify other parts (other repeated self-with-other experiences) that turn up to try to protect her or fix things. Lucy and her new boyfriend have come in together to talk about their different parts of self that can’t communicate but just react to each other, Downloaded by [New York University] at 13:36 13 August 2016 causing scary, repetitive fights. In spite of the fights and because of the talking, that relationship has become more open and safe. It has also become a very important place for Lucy to notice her confusing self-with-other feelings and how they fit together into a whole self who’s in a relationship. The more Lucy experiences herself as a whole, real person operating with a psychological system she regulates as best she can, the more her overwhelming shame subsides. Now her shame is tied mostly to specific interpersonal events, and after “running and hiding,” she can usually find ways to repair what happened and then reconnect. She and her boyfriend are talking of getting married. And then, they think, they might move 102 Relational Trauma away—away from their toxic families of origin, away to the mountains or the coast, where they can get a fresh start together. “Leaving you will be hard,” Lucy says. But I think she will manage fine, especially if she finds the support she needs in her new location. She knows how to ask for help now and how to use it. This may be exactly how our long therapy needs to end: Lucy will leave “home,” the home where fragments of her being came together as a tenuous self. I hope that she leaves whole enough to be able to sustain the relationships that will support her in her new life. I wish her well with all my heart. She says she’ll write, and I’ve said, “Sure, keep me posted on how you’re doing.”4

The Antidote to Relational Dissociation

I have told Lucy’s story to illustrate how important it is to keep therapy anchored in the present—because that’s where the past is making trouble. Lucy’s story also shows what kind of trouble the past makes. As she said, “It’s the dissociation!” If the trouble is dissociation, its cure or antidote is a containing, holding, and linking kind of remembering. But even more can be said about relational remembering in the face of relational dissociation. Let me begin with a brief review of Jody Davies’ position. Davies is an Interpersonal/Relational psychoanalyst who proposes a relational model of mind and a horizontal model of the unconscious in which unintegrated trauma lives outside the sphere of what can make sense. Thus, for the traumatized person, the trauma is truly “nowhere.” Davies contrasts this model of mind with a drive-based, vertical model of mind in which trauma is first known and then repressed down into regions below consciousness. She argues that trauma survivors aren’t repressing what they’ve known; their minds dissociated both physical and psychological pain before they had a chance to know it. In a relational model of mind, a child’s experience becomes a sense of coherent self within the holding presence of responsive others. When Downloaded by [New York University] at 13:36 13 August 2016 others fail to respond to a child in pain, dissociating from the pain gives the child protection, but not coherence. Not only is traumatic experience dissociated, fragmenting the child’s self-knowledge, but different ways of being with others also become disconnected from one another, and so being with others becomes fragmented experience, too. If a child’s entire self-with-other experience is a confusion of contradictory pieces, the child’s entire system of self-with-other splinters into disconnected parts, each of which “makes sense” by maintaining its own way of relating to other people. Dissociated self-with-other scenarios become processes with a life of their own—intense internal dramas about rescue, self-punishment, Relational Trauma 103 or revenge, for example, that play out relentlessly between the trauma survivor and the people in her life. In the presence of these scenarios, the relational treatment of relational trauma becomes a whole new challenge—in addition to the rest of what’s required of a trauma therapist. A trauma therapist helps survivors get safe in their lives and manage the intrusive symptoms of post-traumatic stress. She listens as a witness who embodies compassion and justice. She becomes a companion who, down a dark path of mourning, brings personal integrity to the facing of irrevocable loss and unforgivable wrong. All of these ways of being-with are important aspects of relational treatment of trauma. Now we add the task of entering into the repetitive loops of self-with-other interactions that make up a trauma survivor’s fractured sense of self. To do so is to contact the most significant ways in which a trauma survivor’s memory constructs her “now.” If therapist and client can make contact with those powerfully symbolic interactions together, they can also tame them, change them, and make sense of them together. In other words, though a relational “remembering” therapy begins by containing a trauma survivor’s fragments of life and memory while the survivor slowly reassembles them, this is only the first step. A survivor’s core self remains disintegrated as long as her different self-with-other systems are kept separate from one another, and the most destructive ones are the most elusive. A fully relational “remembering” needs a therapist who is keen to understand how a client “remembers” within and through her daily interactions with others, and it needs a therapist who is willing to find out how these self-with-other systems work from the inside, that is, from the experience of being the “other” to the fragment of the client’s self within each system. Taking this next step requires using two therapeutic techniques of remembering that are central to relational practice. They are (1) remembering by way of exploring recurring model scenes, and (2) remembering by way of what’s often called transference. We’ll end this chapter with an explanation of model scenes, and then we’ll spend all of Chapter 5 explor- Downloaded by [New York University] at 13:36 13 August 2016 ing the complications of transference.

A Continuum of Dissociation

Before we talk about model scenes, we should note that not all clients who have trouble with dissociation live in a world as fragmented as Lucy’s. The idea of a continuum is helpful here, too, a continuum of dissociation that mirrors the continuum of relational trauma. At the severe end of dissociation are trauma survivors like Lucy whose fragmented self-systems have 104 Relational Trauma little connection with one another and whose core experience feels like emptiness or annihilation. In a rare condition known as multiple personality disorder or dissociative identity disorder, each self-system operates completely independently, with little or no knowledge or memory of the others. Toward the other end of the continuum are clients like Megan. Her dissociation is far less severe, but she, too, has split away from herself a certain group of troubling self-with-other experiences, meanings, and feelings. Since dissociation is a problem for both Lucy and Megan, the basic principles of relational treatment are the same for both: the therapist encourages the client to bring to therapy all the parts of herself that trouble her—problems, symptoms, memories, feelings—and she holds all of that within empathic care and understanding. The therapist also helps the client recognize the self-with-other scenarios that cause her pain and shame, aspects of her trouble that she hasn’t been able to hold in awareness on her own. With a severely traumatized client, there are many unintegrated bits to hold and a very long process of linking them together. With someone like Megan, there’s not as much missing from the center, and not as many disconnected aspects of self for the therapist to hold. Only part of Megan’s relational life was problematic, and so the work of connecting with what was dissociated didn’t take nearly as long. But with both young women, the essential part of the work was to track and to trace how certain troubling self-with-other systems worked. Lucy’s most devastating experience was to turn to people for help and have them disbelieve that she was in trouble, and she risked having this experience with every trip to hospital. Hints of disbelief would flood her with humiliation and rage. Once the “killer” part of herself walked out of emergency room in a rage, took the streetcar home, and swallowed enough pills to wipe out her “sucky, whiny self” forever. Then some other part of Lucy called me, I called 911, and she didn’t die. Later we talked about what happened, and we began to see that it was the same thing that always happened: Lucy would say “I can’t go on. I just want Downloaded by [New York University] at 13:36 13 August 2016 to die. I can’t keep myself safe anymore.” Then the people on the other side would tell her, in one way and another, that it wasn’t true. Intending to be helpful, they might say that she was stronger than she thought. Or that she didn’t really want to die. Or that she’d felt this way before, and clearly she could go on. They might insinuate that she was making empty threats and “manipulating the system.” Whatever they meant to say, to Lucy it all meant the same thing: they did not believe the truth of her experience. She was trying to tell them her truth, and they were telling her she was lying. This was the interactive story Lucy and I learned to read from her experience. We’d look at exactly what she’d said and what she’d hoped to hear. Relational Trauma 105 We’d contrast the bad times with times when Lucy had felt heard. We’d conclude that what Lucy needed at these crucial times was that people would believe how “falling apart” she felt, and that her pain would matter to them enough that they would want to help. Then she could take whatever form of help might be available to her. In Megan’s brief work, too, we traced a particular painful sequence of self-with-other interactions. In her case, we did the tracing mostly hypo- thetically, as she practiced what she might say to her parents, anticipating their responses. She wanted to tell them she needed her own life, and she felt sure that they would try to keep her in their space, looking after their needs. She wouldn’t have been so sure of that without a history of those sorts of interactions behind her, but she didn’t need to tell me about the history. Imagining the next important interaction gave her enough contact with how that system worked; it was all the remembering she needed to do. I didn’t try to help Lucy and Megan change how they did their parts of the interactions. Forcing a change wasn’t the point. We were just remembering: making contact with something that was past and present at the same time, something that not only caused trouble, but was also very hard to know about. What was the point of making contact? We could hope for at least two kinds of change to emerge on their own. For both Lucy and Megan, important parts of themselves were tangled up in interactions they didn’t want to feel or think about. As they paid attention to what happened to them in those interactions and to how they felt, they found those lost parts of themselves. Then they felt terribly hurt, angry, and sad, but having their real feelings in a strong and present way also helped them, eventually, to feel more whole and strong. Integration of lost parts of self wasn’t the only payoff we could hope for. We could also expect that as we went over and over these interactions, they would lose some of their power to repeat themselves automatically. Just sensing how the old loops worked gave Lucy and Megan more freedom to try new interactions. Each of them first tried out something new with her therapist. But each was able, in her own time, to take her new freedom out Downloaded by [New York University] at 13:36 13 August 2016 to where she needed it in her life.

“Model Scene” Markers of Memory/Now

If you believe that some degree of dissociation is an expectable response to relational trauma, with most clients you will be on the lookout for signs of repetitive interpersonal interactions that have mysterious power in their lives. If you think in self-in-relation terms, you may glimpse snapshot relational images of self-defining moments between your client and other 106 Relational Trauma people. Or you might be interested in looking for signs of “model scenes,” an idea recently developed as part of relational psychoanalytic technique.5 Model scenes are more than frozen images of relational moments; they illustrate interactive relational situations with drama and action. The truth of a model scene is like the truth of a powerful scene in a film or novel that catches the essence of a character’s complicated existence: Macbeth’s dialogue with the dagger; Bogart on the Casablanca tarmac; the long moment of Sophie’s choice. But your clients’ model scenes won’t appear to you so artistically framed. In fact, they’ll be hard to see at first, if obvious later. I’m thinking of the client, not used to remembering her dreams, who said one day with a laugh, “I had the weirdest dream. I was trying to run away from home, and my parents were Hitler and Eva Braun. I had to slide like a shadow out the door and not let them see me.” She laughed at first because it was simply absurd to picture her parents, a respected school principal and his teacher–wife, as Hitler and Eva. But the more my client thought about it, the more she saw that the dream captured core, hidden aspects of her life with them: she feared the cruel, quiet tyrant her father could sometimes be; she despised her mother’s self-sacrificing fixation on him; she felt like a prisoner in the comfortable walls her parents had built around the family, and she had been trying for a long time and in many small ways to disappear in order to escape. This scene also caught the gist of how, in general, she still feared authority figures, didn’t have much respect for women, and kept herself invisible for safety’s sake. A dream is only one form a model scene can take. In the following story a model scene appears as a memory; the vignette captures how a client learned to dissociate from pain while also learning not to need help from her mother: “I’ve had a bike wreck and cut my knee. It’s a deep cut, and it’s bleeding a lot. I’m nine or ten, I think. I get myself home. My knee really hurts, and I’m scared because inside the cut I can see white stuff that looks like bone. When my mom sees all the blood, she freaks out, and all of a sudden, my knee doesn’t hurt anymore. I’m totally calm and I calm her down and I tell her it’s all right; it’s not very bad; I can take care of it myself. Downloaded by [New York University] at 13:36 13 August 2016 So she leaves me alone. And I take care of it.” It’s no surprise that the client who tells this story ignored acute emotional pain in her life for many years. In her mid-forties it began to catch up with her as debilitating fatigue and chronic pain. Even now, however, she doesn’t expect any support or compassion for her situation. Model scenes of family relationships often turn up as mealtime memories, such as: “I’m sitting at the supper table and nobody is talking because my dad came home just a bit drunk, and now he’s angry because my mom’s angry. But nobody says a word about it and we have to be good. I can’t eat my food but I have to. Then my brother spills his milk, Relational Trauma 107 and my dad yells at him and sends him to his room, and I feel like crying but I know I can’t.” A different model scene reflects a different family system: “Everybody’s talking at the table, and whoever has the best argument wins. I’m the youngest, so I’m not quick enough; words get stuck in my mouth. So I feel stupid and like I don’t belong.” The interpersonal feelings that generate these model scenes are still alive and making trouble years later. The child who couldn’t cry is now a middle- aged mom who freezes at the first sign of conflict. The youngest sibling who couldn’t get into the conversation has to work hard, as an adult, to speak up and believe in his own point of view. When the past becomes as clear and present to clients as a model scene replayed, they suddenly have a visceral understanding of their interpersonal trouble here and now. Even stories of trouble here and now, when they repeat the same feelings in similar interpersonal interactions, can stand as model scenes. Each captures an essential tension or dilemma that is often present for your client with others—fearing criticism, feeling unknown or misunderstood, resist- ing authority, or escaping needy demands, to name just a few possibilities. When you and your client pay attention to his model scenes—the key memories, dreams, images, and interactions that disturb or move him— you’ll see how they all tell versions of the same interpersonal stories that together define your client’s sense of self. Within everyday painful interpersonal moments lie both the genesis and the replay of relational trauma, but their everydayness makes them hard to recognize—until they start to play as model scenes. A model scene gives your client the gist of important interactions between himself and others, past and present, in which he felt emotions that were unacknowledged at the time, such as being controlled, rejected, discounted, or humiliated. But when he pays attention to how the scene unfolds and to what it means to him now, he can acknowledge his feelings and he makes better sense to himself. Powerful model scenes played out between clients and their therapists are called “transference” in psychotherapy language, as if the phenomenon Downloaded by [New York University] at 13:36 13 August 2016 were peculiar to therapy. Actually, a negative experience of transference is just one more repetition of a self-with-other interaction, a model scene, that has been painful for a client in many other contexts. This time, however, the painful interaction is happening with his therapist, the very person he has been learning to trust to be on his side and to care how he feels. His new, fragile trust may suddenly shatter. This turn of events may fill him with such helpless rage and despair that leaving therapy seems like the only way out. Sadly, in some therapy relationships, it is the only way out. But as a relational therapist, you don’t lose heart when the therapy relationship becomes a scene of misunderstanding and pain that feels to a 108 Relational Trauma survivor of relational trauma like the same old terrible pain. You know that this deep hurt needs deep understanding, and that this hurt has probably been split off far from the reach of contact and understanding. Here is a chance to make contact with those dissociated parts of self that the trauma survivor tries so hard to keep under wraps—even while they cause him so much trouble. If you can find ways to acknowledge the pain you have caused and thereby build an understanding relationship with your client’s frightened, angry “parts of self,” you will be able to provide him with the most powerful relational remedy available for relational dissociation. Very often, when you’re right there to do your part of this difficult transference work, when you step in to take an active, reflective part in these painful, repetitive loops of your client’s self-with-other experience, there is a way through. On the other side there may be a surprisingly different pattern of relationship for the two of you, a “better” your client could not have expected and you could not have created for him. Chapter 5 is about how clients and therapists can navigate these very difficult but potentially rewarding passages together.

Notes

1. Judith Lewis Herman, Trauma and Recovery (New York: Basic Books, 1992). 2. Ibid., 154. 3. Davies’ 1999 workshop carried forward ideas she introduced in her first book (written with Fraw- ley), Treating the Adult Survivor of Childhood Sexual Abuse. 4. Lucy and her boyfriend did, indeed, get married and move to a small coastal town far away, and she does keep me posted on the new life they are making together. Soon after she left, I sent her a draft of this chapter, and she replied by phone and then by letter, pleased to give her permission for me to use her story the way I had written it. Since that time, and with a good support network, she has managed pregnancy, birthing, and mothering an infant. The family of three is doing well. Recently she sent photos and wrote that even when it’s hard, she knows that this is the life she has always wanted. 5. Joseph Lichtenberg, Frank Lachmann, and James Fosshage, Self and Motivational Systems: Toward a Theory of Psychoanalytic Technique (Hillsdale, NJ: Analytic Press, 1992). Downloaded by [New York University] at 13:36 13 August 2016 5 The Terribly Hard Part of Relational Psychotherapy

Your Writer Is in Trouble!

I’m ready to write this chapter and I want to write it, but I’ve been stopped in my tracks by an uncanny turn of events. I find myself in one of those difficult passages I just promised to write about: I’m trying to get through a painful model scene with my therapist. It began two chapters ago, and I was hoping it would be over by now. I don’t know how I’ll get through it. I’m thinking that maybe this time I will have to leave therapy. More of me thinks not, as I remind myself that I’ve been through these hard times before and I’ve come out all right. That’s exactly what this chapter is about—getting through hard times like these. But if I don’t know whether I’ll get through my own trouble, how can I write the chapter? I tell myself, “Just speak in your therapist’s voice.” From my therapist’s chair, I’m always more confident (though never sure) that a client and I can find a way to work through difficult interpersonal feelings. But to speak in that voice now, I’ll have to dissociate from what’s going on for me. My writing will be here and I will be elsewhere. I’d rather not enact such falseness in a chapter that’s supposed to be about honesty and integration. Downloaded by [New York University] at 13:36 13 August 2016 So I have decided to begin this chapter from inside my current exp erience and find out if that can take me to what I need to say to you, myr eaders. Just now you might be wondering why I’m still in therapy, since I’m an older, experienced therapist. Or maybe you understand that relational therapists are uncommonly committed to becoming as clear as possible about their own organizing principles and relational processes. In any case, let me make a brief case for any therapist being in therapy at any time. In the first place, since therapists are ordinary humans to whom painful things can happen, we need as much help as anyone does to work through difficult times. Second, the job demands large reserves of emotional 110 The Terribly Hard Part of Relational Psychotherapy presence and resilience, and since therapists can’t talk about their work at home or with friends, we often bring the trouble stirred up by our work to our own therapy. In a more personal way than a supervisor or consul- tant does, a therapist attends to our feelings of confusion, frustration, or depletion. Third, most of us therapists take up the work because we know something about emotional pain and psychological dissonance from the inside. Many of us were parentified children in troubled families. Emotional attunement is second nature to us, and we thrive on providing the empathy we once longed to receive. But this means, too, that we live somewhere on the continuum of relational trauma, and also, then, on a continuum of dissociation. A good connection with a therapist can keep us in touch with what we feel, essential connectedness that enhances our daily lives and keeps us grounded in the face of all the emotional complications of doing relational therapy. And finally, of course, we therapists are in therapy when we still feel bad from the inside. In the business of helping others feel better, we are perhaps more optimistic than some about our own chances of being helped. We believe in the process, and so we keep trying. For all of these reasons, I have been in several different rounds of therapy over the course of my career as a therapist. The only reason good enough to keep me in this current therapy is the hope of feeling better because of it. I doubt anyone stays with the terribly hard part of relational therapy unless it’s to try to accomplish something worth the risk. That’s my purpose in my current therapy. Now I will tell you what’s happening there.

The Story behind the Trouble

Not long ago, after completing the opening chapters of this book, I was beginning to feel quite excited about writing it and I said so in a session. My therapist not only empathized with my feelings, he also seemed to Downloaded by [New York University] at 13:36 13 August 2016 think that the book was a valuable project that could make a worthwhile contribution to our shared field of work. He seemed genuinely interested. A few sessions later, I brought him a photocopied draft of the first two chapters of the book. He thanked me and told me that it might be a while before he had a chance to read them. My heart sank. After I left the session I knew that I had to get those chapters back—to undo my asking as soon as possible. I got my chapters returned to me, unread, at the beginning of the next session. Then I began to try to talk about what had happened. A model scene was clear to me. I had dared to hope that my analyst’s interest in my The Terribly Hard Part of Relational Psychotherapy 111 work was genuine and that he shared my excitement about it. But in his response I’d heard no excitement, only polite self-protection, with maybe a subtle tone that my request was a burden. Then I was filled with shame for having asked. I knew at once that I had asked for far too much; the only time he owed me, of course, was paid-for time in session. I had made a terrible and humiliating mistake. It was as if I had been caught asking him to put a childish drawing of mine on his fridge. I tried to say all this, but his silent listening felt like a cold, critical void. I ran stuck and fell silent myself. I hated having to talk to him about what I felt; it completed my humiliation. I told him, “Shame is like a burn, a bad burn. And talking about it is like having to strip the dead skin away so that it can heal.” I wanted him at least to hear how horrible I felt. I felt flattened and grief-stricken, though I didn’t know what I had lost. In the first days after this rupture, I went for long walks, trying to calm myself. Slowly I did grow calmer, and I began to get my feet under me. My equilibrium returned as I was able to think that I didn’t need his approval. I didn’t need him to share my excitement. My book was an adult project in the real world, and what mattered was to do it well and find a publisher. I would do that. He would never hear about the book again until it was a finished project. Or, if it turned out to be a failed project, he would never hear about it again—period. I could feel myself gathering up my angry humiliation and using it as fuel to keep my project going and thus to keep myself going. Indeed, that was the move I had been making from the very moment when I knew, “I have to get those chapters back.” I know that from the outside my feelings look like a huge overreaction to my therapist’s expectable, reasonable response to my request. That in itself is embarrassing. But those feelings may be more understandable if I provide some background that explains why this simple interchange was actually a potent model scene for me. My father was a theologian in a religious tradition that did not allow women to be leaders or thinkers. This might not have mattered a lot to me, except that as his oldest child, I identified with him and couldn’t help Downloaded by [New York University] at 13:36 13 August 2016 but want to follow in his footsteps. Ours was a complicated relationship, because there was also deep trouble in his personal relationships with women, especially the women he loved. And so I tried to find a place with him as a pseudo-son. I learned from him how to hammer a nail, paint a room, drive a mowing tractor, shoot a rifle, and pitch a tent in the rain. I developed, during the years of listening to his preaching, a passion of my own to put words together in ways that would make people think. But I was never invited into my father’s study. In my second year of university, I wrote my first philosophy paper, and I brought it home to him in hopes that he would read it. He never 112 The Terribly Hard Part of Relational Psychotherapy mentioned it again to me. Weeks later I found it lying crumpled behind the couch. As I understand my own history and how it stays with me, that philosophy-paper model scene is itself a condensation of many earlier experiences that convinced me that what I felt and had to say as my own person didn’t matter much to my father. What did matter was whatever he wanted me to think, feel, say, and do. He was easily troubled, easily angered, and I learned very young to do whatever I could to keep him happy. I also learned that I should never ask for too much from him—or from anyone. In fact, I shouldn’t really ask for anything; I should always just be grateful for what I had been given. And now, as an adult with that history, I have chosen to be in therapy with a man who is not just my senior but also a psychiatrist trained as an analyst. This puts him well “above” me, for although I work as a psychotherapist, I am a social worker by profession—one of the feminized professions well down in a mental health hierarchy dominated by mostly male psychiatrists. In my professional life, I have lived in the shadow of the tall towers of psychoanalysis, but I have been barred from the castle. Or so it seems sometimes. As an academic, I have written about psychoanalysis, but I am outside the fraternity, I believe, and always will be. And part of that is by choice, because I don’t want “them” to own me. I want to think and speak for myself. Yet my complicated interest in psychoanalysis is like tilting at windmills, or so my organizing principles say. It will amount to nothing. I could just as well have tried to be a woman theologian trying to speak my truth in my father’s patriarchal religious tradition. (Or I could just as well have tried, as a very small child, to resist his powerful need to control my feelings and shape my being in ways that would mirror him.) This was the fraught relational context in which I became brave enough to talk to my analyst about my own place in the world of relational psychotherapy. After countless tests of his empathy, including careful repairs of previous misunderstandings and ruptures in our relationship, I was secure enough to risk it. I could dare to say to him that maybe what I had to offer was valuable even if it wasn’t psychoanalysis, that maybe my writing could Downloaded by [New York University] at 13:36 13 August 2016 say something that was both quintessentially me, in my own voice, and also useful. I had reason to hope that this particular man/psychiatrist/analyst might see that my ways of thinking and feeling, of being and expressing myself, were worth something just as they were. I wanted my self to matter in his eyes—and in his feelings, I think. That’s how much was riding on my casual request that he read what I had written about the work we had in common. In retrospect I can see that the situation was far too fraught for my needs simply to be met. The situation had to shatter—so that I could experience what it was all about. I thought that if only he had responded with just the right degree of enthusiastic The Terribly Hard Part of Relational Psychotherapy 113 pleasure when I gave him my writing, then all would have been well, even if he hadn’t been able to read it for a while. But that response would have just kept the model scene moving, fraughtness intact, toward some other moment when his response would fall short of my hopes. I doubt he could have kept on being “perfect” enough to protect us from the implosion of shame that happens at the heart of the model scene I am reliving with him. That shame is too large a part of my life experience, with too many trip wires running off in every direction. Furthermore, the situation I set up seems, in retrospect, uncannily calculated to bring the old model scene to life between us. The implosion of shame was hardly an accident. I must have known that I would see some hesitation if I asked him to read a long piece of my writing on his own time and right before his holidays. As I have said to him bitterly since, “I knew better.” Readers might well wonder, “Why did you do it then?” First of all, I didn’t knowingly choose to do it. I chose my small action, of course, but I didn’t see the large picture with its quality of model scene before I chose, or notice the clues that I might be setting myself up for shame. It seems I was compelled to set up that particular old/new scene and risk the shame. Something drew me, an unchosen “why.” I think it was a compelling hope, just out of my awareness, that my therapist’s p ositive response to me would wipe out that whole other system of self-w ith-other feelings and meanings that had been constricting and tormenting me for years. I believe that I thought, without consciously thinking it, “If I set it all up again and he is the exact and perfect opposite of my father, I can at last be free.” There’s a powerful logic there, and in fact, in very small, imperfect increments worked out over time, that’s exactly how relational psychotherapy makes space for change. But the model scene in which I don’t matter is far too powerful and too thoroughly entangled in my personality to destroy with one blow. I can’t vaporize the fraughtness; I need to feel it. As I was saying in the last chapter, integration means to reconnect with the core self-with-other events and feelings that are at the heart of relational trauma. And that’s a third Downloaded by [New York University] at 13:36 13 August 2016 answer to the question, “Why did you do it?” I guess I needed to reconnect with a part of myself who has been too painfully humiliated to reach out or to be embraced. I’m not sure I want to know her now or that she wants to be known. For in that split-off relational world where she lives, others have no time or space for her. She feels like nothing, a nobody, to them, and then she feels greedy and disgusting for wanting more. That’s the core relational truth at the heart of my model scene, though the scene takes the shape of an effort to change that truth and the inevitable failure of that effort. Other scenes are clustered around that relational truth but further from the center and more protective of it. I could mention winning a prize, when 114 The Terribly Hard Part of Relational Psychotherapy I was six, for the second highest marks in my class, and my bewildered surprise at my parents’ pleasure. And then the penny dropped: “Oh, this is how I can matter!” My father didn’t read that philosophy paper of mine, but I finished my philosophy major with honors. I can feel myself doing it again, typing away at this project, looking for a publisher, determined to get it done in spite of my therapist. The last time I saw him I said, “I’m bigger than whether this therapy turns out okay or not. I can leave it if I have to. And it feels really good to say that. My life, my self, is bigger than this. You can’t destroy me. I will survive. No, I’ll do better than survive.” Bravado. But also a way to keep my balance—to keep from falling into that powerful self-with-other fragment of not mattering, that pit of shame. After a lifetime of practice, I do it well. I also know it’s only a second-best solution. But it might be all I have, and if so, it’s far better than nothing. I imagine readers wondering, “If you can see all of this so clearly, why aren’t you over the shame already? Why do you have to keep playing your game of ‘I don’t need you’?” To tell you the truth, I don’t know for sure. I think it’s because I feel all alone in this. I wish insight were the cure. I wish that just the repetition, the powerful experience of “old” feelings surging through me, a catharsis of pain and grief, would release me. I wish there was something I could do to change how I feel. Even writing doesn’t help. Although I can’t see my way out, I’m not without hope. My hope is that I won’t be alone in this forever. I can’t feel that it’s happening yet, but maybe if I keep on telling my therapist what I feel, I’ll begin to know that he’s still there. That would help. And maybe if I’m calmer I’ll be able to make those brief, careful visits to that unbearably humiliated little girl and find out that we can survive the contact. But my feelings go back and forth, up and down. Right now I can’t shake the conviction that my therapist is against me. Whatever he says is dangerous; his voice makes me angry and afraid that I’ll lose my shaky balance. Yet I still want to keep on hearing from him. I want the danger to wear off. I want to be able to survive that contact, too, especially the part where Downloaded by [New York University] at 13:36 13 August 2016 my unbearably humiliated self is right there before his eyes. Right now that’s what I can’t stand. I want to be very far away. But I keep coming back, because I believe in the slow, patient work of integration. Surely the feelings will become less intense with each visit to the site of shame. Bit by bit, acknowledged and respected, the danger will diminish. My therapist can’t be a parent I never had; he can’t even complete one perfect gesture to right a wrong done to me. But he will keep offering many small and imperfect, but consistent and intentional moments of understanding, and they will help me find my way back to the security of the relationship. The Terribly Hard Part of Relational Psychotherapy 115 That’s the theory. The problem is that I still can’t feel that he understands. But as I’ve said, I still want to hear from him. I want those moments of understanding again; I miss how they feel. In spite of everything, it must be true that I still trust him, because I’m counting on him to hear, without giving me defenses or explanations, how I hate being with him, how I despise what I feel, and how I wonder whether I can ever trust him again. As the danger wears off, perhaps I’ll once again feel his understanding and my trust. I can say all of this hopefully, but I can’t imagine how my next hour of therapy will feel much better.

A Way Through

In fact, after I had written those words of mixed-up feelings and guarded hope, I spent most of the next session locked in a shamed, angry silence. I had made a terrible mess for myself, it seemed, and nothing I could say would help—yet he still waited for me to speak. By now this felt almost like a taunt to me, a mockery of my helplessness: Surely I could do this analysis properly and find what I needed to say! Clearly I was just nursing a childish tantrum! But I couldn’t speak these thoughts; I could only retreat further. Finally, after six sessions, two before and four after a holiday break, my analyst took the initiative to say, “I think it might help if we went back and talked about what happened.” I wondered why he had waited so long to intervene, to say something. But I remembered my angry, scared reactions to any words from him in the very first sessions after the rupture; perhaps he’d just been waiting for time to ease things a bit. I could also imagine that he had been offering his silence as open, nonintrusive acceptance while I was experiencing it as cold disconnection and a taunt. By this time I couldn’t go directly back to talk about what happened. First I needed to say what was silencing me now: “I feel stupid about not being able to talk because it’s like I got myself into this trouble and I should Downloaded by [New York University] at 13:36 13 August 2016 be able to get myself out. But I can’t.” He said it made sense to him that I couldn’t talk: “It’s clear to you, partly because of what your history tells you, but also because of things that have happened between us, that I won’t listen to you or understand you.” “Yes,” I said. “But it’s worse than that. You’ll be angry and disgusted, too.” “All the more reason, then, that you can’t talk!” Then I felt safe enough say, “What I can’t get over is that picture I have of myself asking you to read stuff I’ve written. It makes me so ashamed. Because I shouldn’t have asked. I was asking you to spend time outside of the time I pay for.” 116 The Terribly Hard Part of Relational Psychotherapy “Well, first of all,” he answered, “this relationship isn’t limited in that way. It has its own meanings and feelings, and it stirs up new feelings like wanting something. There’s nothing wrong with asking for something extra. You just might get it. It was good to ask—a positive step for you.” This did not feel fine at all, even though I knew what he meant. “No, there has to be something very wrong about wanting and asking because of how I feel afterward. Asking makes me feel that there’s something really wrong with me.” “Then there must have been something in my response to your asking that made it go wrong for you,” he suggested. “When you said you wouldn’t be able to get around to it for a while, then it seemed that it was a burden and a chore, and I shouldn’t have asked.” He noted the irony that in trying to prevent my disappointment about a delay in his reading, he had disappointed me much more deeply. He asked what kind of response would have been more what I needed. I had thought about that. “If only you had been excited to get it, like I was excited to give it to you—then I don’t think it would have mattered how long it took you to read it.” But I told him the rest of my thought, too: that the situation was just too fraught and probably had to shatter, sooner or later. He disagreed about the situation having to shatter. Was he just trying to keep me from still making it my own fault? Someday, in another kind of space, I’ll ask him whether my concept of “fraughtness” makes sense to him, whether he agrees that sometimes what’s being worked out between two people is so loaded with disowned stuff from the past that it needs to “go wrong” and break open—so that the disowned stuff comes clear and new integrations can start to happen. Now that we were talking, I could tell him how I was using my humiliated anger to fuel both my writing and my determination to get my work published in the real world. “That’s a good plan,” he said. “But there’s just one wrinkle in it. When you come in here, you still feel bad about yourself.” “Exactly!” I thought. “So how will I feel better about myself? Not until we work this thing out between us!” That didn’t seem impossible anymore, Downloaded by [New York University] at 13:36 13 August 2016 but I still had my doubts. Remembering the intensity of my reactions still made me flinch with shame. His long silence had made the shame worse, and somehow that silence had felt intentionally shaming. I began the next session by asking him why he had waited so long to suggest that we talk about what happened. I told him my idea of why: that in his mind the best way to do analysis is for the patient (me) to do all the associating. The analyst shouldn’t have to help the patient. It would be second-best analytic work if I were to be helped—bailed out of my own mess, as it were. I should be able to get myself out of it. (This isn’t what I believe about my own work with clients, but insofar as analysis is somehow The Terribly Hard Part of Relational Psychotherapy 117 different from “ordinary” therapy, perhaps this would be part of the difference: “No being helped!”) As I spun out this theory, I could see how it echoed the basic model scene: In the given nature of things, I’m inferior to him (in this case as an ordinary therapist is inferior to an analyst); if he thinks of me, it’s with some kind of disgust or derision; and my best efforts won’t change what he thinks. He heard me out and then asked if I’d be interested to know the real reason why he waited so long to suggest that we talk about what had happened. Yes, indeed, I was interested! “I really thought you would never want to go back to it again,” he said. “I thought it was so painful, you wouldn’t want to touch it.” I was stunned. How could he think that? Didn’t he know me better than that? Don’t I always try to talk about hard things? As I reminded him at once, in my family of origin nothing can ever be talked about, and that’s just horrible. Feelings build, tension mounts, nerves fray, and even if it all goes underground, there’s no chance of easy, friendly closeness. Against that background, for someone to say calmly, “I wonder if we could talk about what happened,” is an amazing relief. How could he not know that? He didn’t answer that question, and it still puzzles me. Maybe he was operating from organizing principles very different from mine. But it was enough that he gave me a reason for his silence. Our difference may be puzzling, but once spoken it’s not such a threat. We can move ahead anyway. Moving ahead, I needed to tell him that I had begun to write the two of us into Chapter 5, and that I might just keep us in the book. I felt that if I didn’t talk to him about it, the writing would become a secret, silent presence in our work together, and I didn’t want that. “And if you’re very good and ask nicely,” I added, gently mocking both of us, “someday I might let you read what I’ve written about you.” I quickly admitted that this was a sly way to draw attention to unresolved trouble between us. “I’m sure that I will never again ask you to read something that I’ve written!” “You’d have to be completely convinced that I was interested and wanted to read it before you could ask.” Downloaded by [New York University] at 13:36 13 August 2016 “That’s right,” I said. “And I really can’t imagine that happening.” “But you’re playing with the idea,” he replied. “With that bit about if I’m good and ask nicely.” I had to grant him that, and I was glad he understood my playing. When I looked about for other unresolved bits to talk about, I expected to find the shame I had felt about the intensity of my reactions and feelings. But it was gone. Had it vanished once I knew that his silence hadn’t been to shame me? All I could know for sure was that in this calmer, more connected self-state, I found myself satisfied with the way I had seen our relational trouble through. “It’s like when I play a sport,” I said. “I always 118 The Terribly Hard Part of Relational Psychotherapy play hard; I want to do it the best I can. That’s how I feel about this therapy: I like that I do it hard. I like that about myself.” Suddenly I had a brief vision: a little blue book in my hand and then in my therapist’s hand. I knew what it was. “It was my book, all finished and published,” I told him. “If it got that far, then you might look at it; then it would be important enough to matter.” “I’d be willing to watch you score goals but not watch you play.” “Right. And you sure wouldn’t want to watch me practice!” He laughed, and in that moment I liked the feeling between us. Then the session was over.1

Comments

Six relational theorists could have six quite different opinions about what happened between my therapist and me. I’m in no position to make a final statement. I’m including the story in this chapter because it illustrates some important points I want to make about how to understand and manage those times when therapy feels relationally terrible to your client and also, then, to you. First of all, although I was able to stay in therapy, my strong, consistent feelings were: “I hate how I feel; I hate what you’re doing to me (even if you don’t mean to); this relationship is hopeless; I’m bitterly angry, and I want out!” I want you to know that I truly could not see my way through. As a relational therapist, you need to understand that such intense hopelessness, rage, and despair can be held within a constructive therapeutic process. Those feelings can all be completely true for your client—and yet not the end of things. If you can know this with relative calm, you will provide fundamental safety and security for your client, even as she despairs and rages at you. Your quiet confidence in the process of working things out between you will probably help her decide to stay with the process rather than leave it pre- Downloaded by [New York University] at 13:36 13 August 2016 cipitously. Although leaving might promise quick relief, she may also sense that it wouldn’t be good for her to end therapy with one more retraumatiz- ing experience of a painful model scene. Intuiting that these are the stakes for her, she needs you to trust the process on her behalf when she can’t. Second, I want to emphasize that a difficult time like this is only part of a much larger process of relational therapy. I wouldn’t have gotten through it—or even dared to get into it—without having spent a long while developing a relatively secure and resilient relationship with my therapist. I expect that the benefits of getting through it will emerge only slowly in our ongoing relationship now that the crisis has passed. The Terribly Hard Part of Relational Psychotherapy 119 Although working through these kinds of relational ruptures can be a very important part of the larger therapy process, I’m not suggesting that it’s the most important or most powerful work to do in therapy. Most relational psychoanalysts, including self psychologists, would say that working through breaks and impasses is crucial if change is to happen in therapy. It seems that feminist self-in-relation theorists would make these repetitions of negative experience secondary to developing healthier, more positive self-with-other patterns in therapy. I lean toward the former position: these negative self-with-other model scenes are invaluable when they play themselves out so strongly because they make plain exactly what’s getting in the way of healthier, happier relationship. When they appear, they make possible the conscious integration of previously dissociated feelings and meanings. This process clears the way for developing more positive self- with-other patterns. But in the end, the point about the therapeutic value of relational ruptures may be moot. Nobody, neither client nor therapist, would ever intentionally instigate them. They just happen sometimes. Then, whether a certain client’s therapy is rife with relational turmoil or it happens only rarely and quietly, it’s crucial to her entire therapy project that the two of you find a way to deal with the trouble honestly and thoroughly every time it comes up. And finally, I want to make it clear that dealing honestly with relational trouble and thereby getting to the other side of a negative model scene doesn’t all by itself “fix” anything. I imposed an arbitrary ending on my own story because it didn’t tie itself up neatly; nothing was finished or fixed for good. I know I will never again ask my therapist to read something I have written—at least not on his own time. What about that happy ending, then, where I finally give him my writing, he likes it, and I am never again afraid or ashamed? If I can’t have that, what was the point of going through all that angst? The point is that something has changed and is changing. The connection between my therapist and myself fells lighter and less fraught than it Downloaded by [New York University] at 13:36 13 August 2016 was before. What happened? I reconnected (unwillingly!) with a tightly wound bundle of humiliated feelings, and I did so (hating every minute of it!) in the presence of someone who offered steady patience and understanding. I survived to tell the tale. I can talk about wanting and shame more freely in therapy; it’s not such an unspeakable secret. And it’s a good bet, I think, that outside of therapy, I won’t have to work so hard to avoid situations where shame might break through. Nothing has been fixed; nothing is finished. Instead, new possibilities open up, new chances to be in the world with more entitlement, ease, and freedom. My happiness is not guaranteed, but I can live with that “ending.” 120 The Terribly Hard Part of Relational Psychotherapy How Do These Bad Experiences belong to Good Therapy?

It’s time, now, to step back a few paces and set my story within a larger context. My telling of it assumes that these relationally hard times belong to good therapy, but I should clarify that they belong only to good relational therapy. In some kinds of therapy, relational ruptures cause nothing but trouble. When a mode of therapy carries no mandate to explore and work through the relational dynamics between client and therapist, the work usually stays “cooperative”—played out as a comfortable exchange between the therapist’s benign, helpful authority and the client’s compliance. In this context, if relational trouble happens, a client probably does well to get out of the therapy. If he stays, he will either bury the trouble, which will sabotage his therapy work, or he’ll embark on a struggle to find out whether it’s he or his therapist who’s doing therapy wrong. That kind of win-lose situation can only replicate a destructive relational model scene for a client, and one which a nonrelational therapy can’t turn toward constructive learning. In short, only a relational perspective makes therapy a safe enough place for working out relational trouble between client and therapist. Let’s review the main points of that perspective. First, as a relational therapist, you understand that the bad feelings about himself that a client brings to therapy have their origins in how he experiences himself in relation to others in his life. Second, you expect that as the therapy relationship becomes more significant to your client, these very fears and anxieties will come to life between the two of you. Third, your therapeutic intention is not to change how your client interacts with others, but rather to help him experience the meanings and feelings of his interactions more directly, and always with compassionate understanding for his subjective experience and the dilemmas of his life. You know that his lifelong principles of self-protection will soften only in the warmth of compassionate empathy, and that only then, as his organizing principles slowly change from the inside out, will he start to experience new kinds of connections with others.

Downloaded by [New York University] at 13:36 13 August 2016 But it’s this compassionate empathy that, in the therapy relationship, also draws your client into more painful dilemmas than he had ever anticipated. As he spends time with you, he begins to glimpse and desire emotional goods he had long ago given up. He begins to enjoy interested, sympathetic attention, he wants to be known and remembered for exactly who he is, and he longs to matter deeply to someone, to be special. At the very same time he is certain that these wants will be denied or turned against him so that he’ll end up even more disappointed and humiliated for having wanted. He “knows” this will happen because it’s a self-with-other experience that has formed his way of being in the world. As he lives on The Terribly Hard Part of Relational Psychotherapy 121 this knife-edge of anxiety in therapy, he alternates between careful retreat and daring to try for new experience. As I did, he might dare to ask for something he would never have asked for before. And then sometimes the worst does happen. The doom falls, just as he knew it would, and he finds himself swamped by helpless rage and bleak despair. The shame he’s been dodging and masking out in the world has exploded, full force, in this relationship. The self-loathing voices are loud in his ears, and he takes desperate measures to silence them. Why does the worst happen sometimes? Not because the client brings it on himself, but rather, because you, his therapist, are a human being who doesn’t always get exactly what’s going on between yourself and your client. On certain days, you might be just tired or distracted, or maybe what your client is talking about is hard for you to hear for reasons that have nothing to do with him. But in any case, you fail to pick up his cues that tell you what he needs right now. And because of the intentional intensity of the therapy situation, this “miss” of yours suddenly stands in for all the misses he’s known in his life and all they’ve meant to him about being “too much” or worthless or forgettable. Once again I’m suggesting that in the relational therapy situation, there’s probably something inevitable about these “misses” and ruptures of understanding that spin you and your client into unwitting replays of painful model scenes. To say they are inevitable is not to say that they are your client’s fault or your fault. For the client, the inevitability of being misunderstood isn’t due to his neediness or sensitivity; nor is the inevitability of your failure to understand him due to your own unresolved issues. Simply put, misunderstanding belongs to the humanness of the therapist–client exchange. That’s not good and it’s not bad; it’s just life. Talk of reactivated model scenes and organizing principles suggests that what the client brings to the therapy relationship is what makes it go wrong. But a relational therapist knows that when things go wrong in therapy, something happened in the therapy. In my story, though I might still suspect (given my organizing principles) that what happened was that I asked Downloaded by [New York University] at 13:36 13 August 2016 for too much, my therapist insists that “what happened” was set off by his response to my legitimate asking. I was doing fine, he says, feeling stronger, hoping for new things, even daring to ask for them—something like a small child learning to walk on her own. But then, as he puts it, he happened to put a chair in my path. When my particular desire and striving met his particular response, what happened was a rupture in our relationship. In traditional psychoanalytic psychotherapies, my therapist would be expected to examine his response for signs of “countertransference” feelings that motivated his response to me. The point would be to neutralize those feelings and “clear the field” for my feelings. But in a more relational 122 The Terribly Hard Part of Relational Psychotherapy therapy, the point of such self-scrutiny is that he is able to accept his part of what happened between us as inevitable, expectable, or understandable, and to stay engaged in the relationship. This approach to countertransference is counterpart to the redefinition of transference that relational theory proposes.

A Relational Definition of Transference

In traditional psychoanalytic theory, transference is the patient’s projection of his own internal conflicts on the blank screen of his therapist’s personality. It’s a psychic action separate from the countertransference the therapist might counterproject, based on his own unresolved internal conflicts. Each person launches and receives psychic messages and influences from a bas- tion of isolated individuality. In a relational view, by contrast, when any two people are together, two subjectivities or complex senses of self, with their respective organizing principles, are being elicited and regulated by each other. Each subjectivity is intimately involved in the shape and feel of the relationship and in how each experiences self and other in it. Therefore, as the relationalist Lewis Aron argues, any analysis of what’s going on in therapy must be an analysis of the relationship, not just of one person’s contributions to it.2 “Resistance” to therapy is a client’s legitimate self-protection against aspects of the therapist’s personality that feel threatening to her. Likewise, her so-called “negative transference” is an interpersonal event—an integral part of all the ways she and her therapist, with their respective organizing principles, mutually construct and regulate their relationship.3 From a relational perspective, transference and countertransference are the idiosyncratic ways through which a certain client and therapist attempt a relationship as best they can. As Stephen Mitchell puts it, transference is both contextual and constructed: it’s the client’s response to particular interpersonal circumstances, and it’s produced for a particular purpose. Though it may be based on past experience, the prime purpose of transfer- Downloaded by [New York University] at 13:36 13 August 2016 ence is to provide the client a point of entry into this relationship. Likewise, countertransference is the (largely unconscious) form through which the therapist tries to reach the client, using her own experience as a way to enter the client’s story.4 With this relational perspective in mind, it’s clear that when things go wrong in therapy, it doesn’t make sense to explain it first of all in terms of what the client is bringing from her past. It makes far more sense for the therapist to ask her client, “What just happened? Where am I misunderstanding you? What did you hear in my response to you?” The Terribly Hard Part of Relational Psychotherapy 123 The language of transference applied to such normal interpersonal events serves to remind us of the intentional intensity of the therapeutic relationship, the power it has to hurt or heal. The relational therapist Donna Orange suggests the word cotransference as a way both to honor the intense complexities of the therapeutic relationship and also to emphasize that therapists participate with clients in the intersubjective field or “play space” of the therapy conversation. In that space, she says, the organizing activity of the client and the therapist are two faces of the same complex, ongoing dynamic between them. Neither activity needs to carry the negative connotations associated with both transference and countertransference.5 As therapists, we all know that sometimes the complex dynamic between client and therapist becomes painful in ways that aren’t resolved; the therapy relationship self-destructs. In traditional terms these failures are blamed on unmanageable negative transference: the client’s expectations and responses are destructive distortions of reality. More relationally minded traditional therapists admit to a transference–countertransference impasse: They just can’t get past their own defensive reactions in the face of impossible demands or relentless anger. Radically relational theorists have a different perspective. They note that client and therapist are always communicating from different organizations of experience as they try to make sense together. When either person feels threatened by the other’s organizing of their mutual experience, protective operations appear. If the client feels misunderstood, pathologized, or demeaned, she may respond by shutting down, “getting worse,” or attacking the therapist’s competence. Feeling ambushed and helpless, the therapist may try to regain control by “diagnosing” the client’s self-p rotections as resistance, negative transference, or something deeply wrong in the client’s psychological makeup. When a client’s feelings are interpreted as a distortion of reality, she has two choices. She can give in and let her reality be wiped away. Or she can Downloaded by [New York University] at 13:36 13 August 2016 fight back—against her therapist’s belief about her, her therapist’s reality, which is threatening to erase her own reality. This is how the stage is set for a transference–countertransference crisis and a downward spiral toward relational impasse. Each person has to insist on her own organization of experience to prevent being erased by the shaming judgment coming from the other. Things wouldn’t disintegrate so badly, however, if the therapist could recognize the core of experienced, subjective truth within the client’s hurt and angry feelings. To do so, the therapist has to believe that whatever the 124 The Terribly Hard Part of Relational Psychotherapy client feels, it’s not a distortion of reality. It is reality—the client’s real feelings about something that’s actually happening right now in the relationship between the two of them. Of course we don’t want to be implicated in our client’s distress, especially when we feel, “I didn’t do anything! I don’t deserve this! I’m being misunderstood!” But radically relational theory tells us that we will be surprised at how well things can turn out if we put our own truth on hold long enough to listen for and then believe the truth that our client is telling us.

How Does a Relational Understanding of Transference Help a Client?

What does this relational revision of transference, and especially of negative transference, mean for a client in relational therapy? It means that when he feels you’ve misunderstood, criticized, belittled, or ignored him, you want to hear about it. He can be confident that “good work” means talking honestly about what he feels in the therapy relationship, even if the feelings are disturbing. It means you’ll listen not in order to map his psyche, but because you believe tending well to relationship is essential to anyone’s well-being. A relational revision of negative transference means that it’s safe for a client to speak his disgruntled protests, his pointed questions, and his contrary thoughts. “Safe” means that as his therapist you won’t blame, shame, or pathologize him for what he feels and says. Instead, you will work with him to find out where the two of you are at odds, paying special attention to where you missed his cues about the kind of response or understanding he needed. If relational ruptures are, indeed, the product of “cotransference,” or the interaction of your client’s and your own relational organizing principles, then whatever is happening cannot be your client’s fault, alone. In fact, it can’t be anyone’s fault, alone. Any two people can be “organized” Downloaded by [New York University] at 13:36 13 August 2016 so as to miss each other, scare each other, and set each other off in all kinds of unpredictable ways. That’s life—in relationship. What happens to the past in this revision of transference? It doesn’t disappear, for as we’ve seen, the past can be alive and powerful in the present; whatever matters from the past is operative in here-and-now organizing principles. A question remains, though: Do clients need to make conscious links between past and present? Do clients need to understand the historical roots of their side of transference in order to integrate the dissociated experience it embodies, accept their emotional history, and grieve their losses? Or is it enough that clients have The Terribly Hard Part of Relational Psychotherapy 125 an in-depth experience of healthy relationship that reworks destructive relational patterns? These are important questions, and it’s important to answer them in a way that doesn’t make us choose between insight and experience (just as we don’t have to choose between past and present). We can hold it all together if we track the sequence of processes in relational therapy. In my own story, I wished very hard that just making contact with my humiliated self would be my cure. But the breakdown of the dissociative wall— connecting with the pain of both then and now—could not make me feel better. Reexperiencing trauma, even in the form of negative transference, is not in itself helpful. Integration and healing happen only when the new/old traumatic feelings are understood in a new relationship, and can thus be laid to a better rest. As a relational therapist, you prepare space for such integration by taking good care of the therapy relationship from the beginning. After a client reconnects with traumatic relational experience in her relationship with you, you concentrate time and energy on understanding her experience and reworking it in depth and detail. Relational therapy knows that the bumps and grinds of life and the therapy relationship will produce plenty of new/old memories, transferences, feelings, and thoughts to integrate, but unless there’s a new relational way to be with it all, nothing will change in how a client can feel and think about herself. In a nutshell, it’s good news for your client when “negative transference” is reinterpreted as a process of mutual regulation, or cotransference. It’s good news, first, that the trouble she thought was only inside her and coming only from her painful past is actually something that’s happening right now between her and her therapist. It’s even better news that the trouble that’s happening right now isn’t just her fault, her distortion of reality: The two of you are doing it together, somehow. But the best news of all is that since you’re doing it together, you can probably find a way to understand what you’re doing and then do it differently together. That’s how your client will be able to get to the other side of painful old model scenes with Downloaded by [New York University] at 13:36 13 August 2016 you. That’s how the therapy holds open space for new organizing principles to emerge. That’s how insight and experience, past and present, become woven together into a new reality. In an evolving relational process that sometimes seems to have a life and a mind of its own, relational therapy becomes first a place where a client feels better as she feels understood, then a place where she sometimes feels worse than ever (but finds herself, in the end, still understood), and finally a place where new interpersonal confidence can emerge, along with new insight and self-integration—providing a sturdier, more durable kind of feeling better. 126 The Terribly Hard Part of Relational Psychotherapy Hard Times from a Therapist’s Perspective

A relational revision of negative transference changes a therapist’s job description. You don’t get through an impasse by helping your client take responsibility for her feelings and own her projections. But neither is it your job to take responsibility for what happened. The whole notion of taking responsibility shifts when transference is no longer a matter of “your baggage” and “my baggage,” but rather a matter of mutually constructed relational dynamics. Now “taking responsibility” looks not like admitting to fault, or even to “baggage,” but like keeping yourself honest and open to the other person in the relationship. It’s with this sense of response-ability that you can own what you have done in the relationship without feeling defensive and guilty about the effects of your unintentional mistakes and omissions. In this spirit, you won’t shrug off what’s happening by putting it on your client or her “transference.” You won’t try to explain it away by talking about your good intentions. Instead, you will move toward and lean into what’s happening. You will do your best to step inside your client’s negative experience of you, even “wearing” the hurtful intentions and feelings she attributes to you in order to understand how the relationship feels to her. All the while that the two of you are trying to get through this hard time together, you will keep checking in on her ongoing experience of you. The therapeutic tasks I’ve just described add up to a very tall order. This work is not easy. Depending on the nature of the model scene you and your client are enacting, the relational truth you inhabit together can be quite painful. Any of these phrases might capture who you are to a particular client in a given moment:

• You’re going to think badly of me for what I’m saying now. No, you are thinking badly of me. • You don’t have problems like this; your life is perfect. Next to you, I’m a real loser, and I hate telling you this loser stuff about my life. • Sure, you understand what I’m saying, but you don’t really care.

Downloaded by [New York University] at 13:36 13 August 2016 • If I tell you my secrets, you’ll use them against me later. You’ll bring them back when I’m vulnerable. • When you add something to what I say, that means I have to think what you think. You want to take over my thinking. • You congratulate me, but you’re really pushing me away. All that matters is how I perform. • If I do well, it’s really something about you—you’re the therapist who made this possible. It’s your success, not mine. • You’re feeling sorry for me. That means I’m pathetic. You think I’m pathetic. The Terribly Hard Part of Relational Psychotherapy 127 • If I believe you care about me, I’ll find out differently later and be terribly humiliated for having been gullible. Humiliating me will feel good to you. • If I get close to you in any way, you’ll hurt me, use me, in ways I can’t even imagine. I don’t know what’s going to happen, but the threat is real, all the time. • If I start to count on your understanding and need you, you’ll feel like I’m clinging; you’ll scrape me off with disgust.

Of course, your first impulse will be to disagree with any such conviction the moment you hear it. Even if you only sense it, you’ll want to prove yourself otherwise. This isn’t what you feel toward your client! This isn’t who you are! This just isn’t the truth, and furthermore, being in a relationship shaped by such a truth feels ugly. Doesn’t your client need to understand that you actually feel something completely different? Reassuring your clients that you care for them and accept them seems like a natural approach to take when emotional convictions as negative as these emerge in therapy. As a relational therapist, however, when such feelings start to surface, you will do something that doesn’t seem natural. Rather than disagreeing with your clients’ distressing experiences of you (and rather than trying desperately to be such a good therapist that the distress will disappear) you will try to understand how it feels for them to be in those painful self-states and to have such troubling fears and dire expectations of you. Here you are counting on one of the most counterintuitive but reliable principles of relational work with relational problems: There’s little chance that you can change a client’s negative experience of you directly. None of your reassurances will make any difference. But if you consistently understand that experience from your client’s point of view, eventually you become not only the one who is feared and mistrusted, but also the one who understands your client’s fear and mistrust. And that’s the pivot point for change. For your client, to have her negative feelings simply accepted and understood is a very particular and unexpected form of being under-

Downloaded by [New York University] at 13:36 13 August 2016 stood, and it’s the first move in building a different kind of relationship between your client and yourself. I’ll illustrate this counter-intuitive principle with a vignette from my practice.

A Story from the Therapist’s Side of Relational Trouble

One day a quite fiercely independent, professionally successful, and rather lonely client (I’ll call him Dave) was telling me about one of his recent accomplishments. Earlier in the session he had been talking about making 128 The Terribly Hard Part of Relational Psychotherapy better interpersonal connections in his life, something I really hoped would happen for him. So I responded to his story of achievement by suggesting that eventually he’d be able to feel both accomplished and connected with others; he’d be able to “put it all together.” Dave went quiet then, but it was close to the end of the session and I didn’t know anything was wrong until he came back the next week. Then he was so agitated he couldn’t sit down. He told me that after the last session he’d been so angry he’d gone straight home to his own back- yard, where he ended up hurling snowballs at the back of the house. Dave knew exactly what I had done to make him so angry. My “suggestion” of putting it all together totally undercut the good thing he was trying to tell me. I had told him that his good thing wasn’t good enough, that it wasn’t, in fact, good at all, because it wasn’t up to my standard. “What’s the point of telling you something good about myself, if you’re just going criticize!” he said. “It’s like you’re telling me there’s something wrong with being proud of myself! Okay—it is wrong! These voices in my head keep telling me I’m stupid, I’m childish, so I deserve this. I want to smash something. I feel like smashing myself.” At least Dave had learned in the process of our work together that whatever his feelings were, I wanted to hear about them—especially if they were about what was going on between us. “Negative transference” had just come to rolling boil in that room. Now what would I do? How would I respond? I’ll leave the immediacy of the scene for a moment to compare how different theories of transference would lead me to respond to Dave in different ways. If I worked with a classical definition of negative transference, I might have said to him, “I understand that’s what you feel I did to you, and that it’s very painful. In fact, I did something different, and that’s how we know that these powerful, painful feelings are coming from somewhere else, probably from somewhere in your past. I’m wondering if these are familiar feelings, whether you’ve been here before—perhaps with your mother or your father.” Downloaded by [New York University] at 13:36 13 August 2016 If I worked with a more progressive, interactive view of transference, I might have said, “I can see how my suggestion felt critical to you. That’s a very plausible construction of what my words meant. But there were other ways you could have heard me, too. So I wonder why you understood me in that particular, very painful way.” In other words, I’d admit that Dave’s feelings didn’t come from nowhere, but from something I really did. Yet I’d emphasize the power of his past to construct our interaction in this particular way. In a more interpersonalist mode of working with transference, I might have said, “It’s hard for you that out of a whole session, what stays with you The Terribly Hard Part of Relational Psychotherapy 129 is something that feels critical and undercutting. As we’ve noticed before, all you can do at a time like that is withdraw, taking your anger away with you. But I think something is changing for you, too—you’ve come back to tell me about it. Maybe now we can get a bigger picture of your options.” My point in this mode is that there’s something limiting about Dave’s interpersonal style, but it’s getting less constrictive. My ongoing task, as an interpersonalist therapist, is to engage with him so that I can let him know, without blame, how his style works. This is a potent way for Dave to learn how to expand his relational repertoire. But I’m a relational therapist who actually thinks more in terms of organizations of experience than in terms of transference. And so I accept the truth of my client’s experience. Dave had been feeling expansive and I had punctured his golden bubble with a sly criticism. Now he needed to hear, “Yes, that’s what I did to you,” as he struggled to cope with the intensity of his reactions. Disturbed and shamed by that intensity, Dave needed to know that his reactions made sense. That’s where we had to begin. I knew that. And yet, after Dave’s opening explosion, I found myself trying to explain what I had been intending to do in the previous session, hoping Dave would understand that I had been trying to help, not hurt him. Fortunately, he had the gumption and the relational honesty to say to me, “I can’t hear that from you right now.” “No, of course you can’t,” I said, and I brought myself back sharply to the work at hand. I wanted to say I was sorry for what I had done, but I knew that an apology wouldn’t help either. It would be just one more way for me to try to feel better, to get my goof behind us. What we needed, instead, was to be right in the middle of all the trouble my mistake had caused. First of all I had to hear the trouble, and I had to hear it thoroughly and well. I learned that there were two kinds of trouble—what was between us and what, as a consequence, Dave was suffering on his own. Cut off from supportive connection with me, he kept deriding himself for his own stu- Downloaded by [New York University] at 13:36 13 August 2016 pidity. Then he would counter this self-loathing with what he called a swift kick in the butt: “Forget it. Don’t be such a loser. Get on with things.” Dave was sleeping poorly, and he spent his days in a funk, trying not to snap at colleagues. As he told me how bad things were, I listened carefully, encour- aging him to say more and hoping that my responses would let him see that I took his distress seriously. Dave had to tell me forcefully and in detail how horrible he was feeling, and he had to be sure that I got it. That took one session. Only after he knew he’d been heard on that score could he return, in the next session, to the “scene of the crime” in order to try to learn more about what had 130 The Terribly Hard Part of Relational Psychotherapy happened. He was calmer now, and we could go directly to his experience of my lapse and walk through it slowly. Dave said that it had been such a shock to him. He had come to trust that I would be on his side, and then I wasn’t. I noted what a risk he had taken, just to tell me that he was feeling good about himself. It was an unguarded, hopeful, open moment. I agreed that I had, indeed “set him up for it” by being a good listener. I had led him to believe that it was safe to be proud of himself with me—and then WHAM! I had delivered a betrayal of that new, tender, fledgling trust. And for all those reasons, this was a serious injury, I said. As Dave grew more confident that I wouldn’t disregard or belittle his experience, he could tell me more. In the third session after the rupture, he mused, “It’s like you want me to be good, but not too big for my britches. It’s like my being good should make you feel pleased about yourself—‘Look what I made happen here!’ But it can’t be different from what you want. I have to be your kind of good. And you want me never, ever, to show you up. You’ve gotta keep me in my place, keep reminding me who’s boss, who really knows things around here.” That’s when he made the connection, “When I left that bad session, when I was throwing those snowballs as hard as I could, I felt like I used to when I’d show something I made to my dad. He always found something not quite right with it, something to improve. And I’d just want to destroy it, crumple it up, smash it.” I saw the connection: “I did to you the same sort of thing that your dad did—I undercut you in the guise of being helpful.” “Yes! And for the same reasons.” “Because I don’t want the competition,” I ventured (wearing what he was attributing to me). “But it’s more complicated than that, isn’t it? There’s a double message coming from me: ‘Grow up, be strong like me. But you’ll never do it right.’” This fit for Dave. The accuracy of my understanding mattered, but the huge relief was to be understood from inside his own experience. The Downloaded by [New York University] at 13:36 13 August 2016 symptoms that had followed the rupture between us—anger, irritability, anxiety, depression, self-loathing, and sleeplessness—faded rapidly. And then our relationship began to feel much more trustworthy and secure than it had felt before the break. I understood this as follows: during the repair of the injury, Dave was having two experiences of me at once: the hurtful one, which we worked to understand as fully as possible, and the experience that I was completely committed to understanding him without protecting myself at his expense. This latter experience was now eclipsing the first one. However, Dave will always have a realistic memory of getting hurt by my clumsiness, The Terribly Hard Part of Relational Psychotherapy 131 which might happen again. But we can deal with it if it happens; Dave knows that, too. This is another sign of a more complex, resilient, and differentiated relationship, a relationship being performed differently between us.

Final Comments

For Dave and me, this episode was only one part of a long process of relational growth and change. We couldn’t have gotten through it without having first developed reliable mutual rapport, and the outcome of the episode was a subtle but profound strengthening of mutual trust that we can now carry forward. The episode was generated not by Dave’s pathology, but by an interaction that went wrong between us. Something happened. Drawn by the experience and promise of empathic understanding, Dave took an important relational risk. And then I failed to understand what was going on between us and what he needed from me. His risk and my failure created a compressed version, a “model scene,” of a very important aspect of his relational life, and it stirred memories of times in his formative years when he had been misunderstood and undercut in similar ways. By itself, Dave’s sudden, painful connection with disowned feelings and memories wouldn’t have helped him. What he needed was to feel his hurt in a relational context that was radically different from the one where the original hurt had been inflicted. As soon as I realized that Dave was injured, I knew it was critical that I, the very person who had hurt him, do all I could to understand how he felt and what had happened to him. It was this steady intention to understand him that made this a different relational experience for him. When his hurt feelings mattered, they were no longer overwhelming or shameful. He could live with them more easily. He could explore their history and their meanings. He could let them go, too. But what about my feelings? Before I end this chapter, I should at least Downloaded by [New York University] at 13:36 13 August 2016 ask the traditional questions about my “countertransference.” Why did I respond to Dave’s sense of accomplishment by suggesting that he could be both accomplished and connected? Probably because I like being with him better when he’s “connecting.” I want him to experience a fuller, richer relational life. I was disappointed when he fell back on his achievements in order to feel good, and perhaps a bit impatient, too. Probably I felt a twinge of envy at his professional success, so that my words were, indeed, intended to “keep him in his place,” as he suspected. Now it’s good that I know about my tendencies to want certain things for my clients, to be impatient, or to feel envious or inferior sometimes. 132 The Terribly Hard Part of Relational Psychotherapy It’s important that I monitor those tendencies so that I don’t throw around a lot of impatience and competition in my therapeutic relationships. On the other hand, those tendencies are part of me. If I interact as a whole human being, eventually they may emerge. I just have to be ready to deal with the effects of my human fallibility, called “countertransference” in this situation. A more dangerous kind of countertransference occurs as unthought responses to a sudden rupture in therapy. Who likes to make a mistake? I’m a therapist, making a life’s work out of helping and caring; I hate to be experienced as an inflictor of pain. It’s appalling to see an apparently small “miss” become so hugely destructive. These are the most critical countertransference moments. How do I manage my guilt or anger or despair? How can I avoid pitting my own reality against my client’s reality? When things go so wrong, how can I not worry non-stop or throw up my hands and walk away? I can’t escape these questions, for it’s relational therapy that I do. That means I’m really in these relationships—when they go well, but also when they go badly. If you’re a relational therapist, it’s not a problem that your feelings are present and invested in the therapy you do; in fact, your emotional presence is an essential part of what you offer. But it does matter a great deal how you “perform” your feelings in therapeutic relationships, especially when there’s trouble. You have to decide what to put aside and what to use. Whatever you use has to be helpful both to the client and to your relationship with him. If you focus on understanding your client’s experience as fully as possible, you may have a rocky ride, but you will probably come through the trouble together. The personal feelings you had to put aside may not dissipate, but then you make some time to air them gently with yourself or with a colleague. This may sound like a convoluted process, but it’s not so different in structure from what good parents do. Parents, too, strive to be emotionally present, available, and genuine, and at the same time they contain and manage their feelings in ways they believe will be best for their children. Downloaded by [New York University] at 13:36 13 August 2016 Relational therapy didn’t invent the use and management of self for the good of the other. Relational therapists borrow the self-for-other wisdom that good parents, mentors, teachers, and spiritual guides have always counted on, and they turn it to a very particular purpose: using self to counter the effects of their clients’ toxic self-with-other experiences. All of us in therapy, clients and therapists alike, want never again to taste the bitterness of toxic relationship. It’s our heartfelt desire not to have to go through rotten times with each other. If we’re lucky, it won’t happen often. But when it does happen, we have reasons to hope that getting through these hard times honestly and together will be worth the trouble. The Terribly Hard Part of Relational Psychotherapy 133 Notes

1. When I had finished this story about us and knew I would keep it in the book, I brought it to a session for my therapist to read. I didn’t want to write behind his back. The request to read on my time felt fair and safe to me. When he had read it, he said that although he doesn’t always like how he’s seen as a therapist, he didn’t mind being this therapist. 2. Aron, A Meeting of Minds, 82. 3. Ibid., 127, 77. 4. Mitchell, Influence and Autonomy in Psychoanalysis, 146. 5. Orange, Emotional Understanding, 67–68. Downloaded by [New York University] at 13:36 13 August 2016 6 The Wonderfully Good Part of Relational Therapy

Wonderful Ordinary Goodness

“Wonderfully good”—that’s a bit over the top! How does something as natural and unpretentious as relational talk therapy get to be wonderfully good? It happens when people who have rarely felt happy with themselves or comfortable with other people start to feel better in ways they never expected. Feeling an everyday kind of good is a strange new experience for them and it can be quite a wonderful surprise. Many of us take this kind of feeling good for granted. We know what we do well and what people like about us. We have a sense of belonging with family and friends. We’ve found a productive place in the world and expression for our creativity. Our values match up with our lives. When life is good, our relationships are working well. We give and receive understanding. When there are problems, we talk about them; when we’re hurt, it’s safe to be angry. With this kind of security with others, we feel balanced within ourselves. We’re able to bounce back from disappointment. Losses are painful, but we can let others help us grieve and recover. We’re able to accept our failings and mistakes, and we’ve learned that laughing at ourselves can help. On the whole, we’re content with who we are. Downloaded by [New York University] at 13:36 13 August 2016 Such goodness is ordinary. It doesn’t depend on social status or material wealth. We don’t have to be stars or heroes or saints, rising above the hurts, conflicts, and confusions of everyday life. But we are able to be here, okay in ourselves and connected with others. This unremarkable well-being is exactly what has always eluded our anxious, depressed clients. When they came to therapy, all they wanted was relief from feeling bad. They couldn’t imagine what “good” would feel like; they didn’t even know to hope for it. But with no fireworks or grand illuminations, no sudden breakthroughs or transformations, this wonderful sense of well-being has sneaked up and surprised them. The Wonderfully Good Part of Relational Therapy 135 This everyday kind of “wonderfully good” is in counterpoint to the terribly hard part of relational therapy we’ve just discussed. The painful feelings of those difficult times may be connected to traumatic model scenes, but they, too, are stirred up by everyday failures of empathy and understanding. When relationship goes wrong in everyday ways, the pain is no less bad for being ordinary. Likewise, when relationship goes right in ordinary ways, the well-being it brings can be unexpectedly wonderful.

The Connection between Hard Times and Good Times in Therapy

Both the hard times of the last chapter and the good times of this chapter are set in motion by a relational therapist’s empathy. When your main concern as a therapist is to understand what your client means and how she feels, she starts to believe in her own perceptions and emotions. She begins to feel not so isolated, not so angry and sad, and she gains some genuine, respectful empathy for her own struggles. As her relationship with you becomes more and more important to her, she brings forward more of who she is; she lets herself make contact with experiences and emotions she usually keeps well hidden, even from herself. As she does all of this, she begins to realize that not only does she feel safe in this relationship, sometimes she also feels a new kind of frightened. Your empathy has invited her to be more open and vulnerable than would normally be comfortable for her. The risk she’s taking scares her. Something tells her that this is going to go wrong. As we saw in the last chapter, sometimes these fears are realized when a therapist who has been consistently present and understanding suddenly fails to be there or to get it. Such breaks are painful and they matter a lot because there’s so much riding on the relationship. In this chapter, we will spend more time exploring just what is riding on the relationship. The interpersonal ruptures that can make relational therapy terribly hard are only part of a much larger process that in its essence offers to under- Downloaded by [New York University] at 13:36 13 August 2016 stand, respect, and to a significant extent meet a client’s most basic needs for emotional well-being. This larger process may sometimes include dramatic ruptures and repairs, but overall it is made up of many small, repetitive moments when a client’s expectations of getting hurt are surprised by something good instead. It all starts with needing. From infancy through old age, we all carry legitimate emotional needs with us every day. The circumstances of many clients’ early lives taught them, however, that emotional needs can’t be met, and so they tried to squelch them. Such needs remain a very important component of adult life—needs to belong, to matter, to be respected 136 The Wonderfully Good Part of Relational Therapy and honored for one’s uniqueness, to express and create, to have feelings received, to feel safe and secure. But clients who squelched their emotional needs in childhood don’t know how to find or even feel what they need now. They are likely to think that such “neediness” is childish and shameful. If some of those needs should start to come up in their relationship with a therapist, they’re sure trouble will follow. It’s important that you understand how these ordinary, good needs cause such trouble for your client. Since he squelched his needs in childhood, they may indeed turn up in childlike forms at first, longings to be special, close, and beloved. For him, that’s appalling. Even so, since they have been squelched for so long, the needs he detests may have a lot of urgency about them, which also heightens his anxiety. As a child he had good reason to decide that needs were the problem and should be silenced. If he hadn’t needed, nothing would have hurt him. That empty hurt feeling became an “I’m bad” feeling. Now, in the principles that organize his psychological life, wanting and needing are tightly linked to shame. Since the first session of his therapy, you have tried to meet this client’s needs for respect, support, and understanding. And from the beginning, his response to your offer has been thoroughly entangled in model scenes and organizing principles that tell him that he can’t trust this goodness, that wanting good connection is a stupid mistake. The problem is that he does want it—more than he knows. Your empathy wakes up his strong self-with-other needs, but it takes a while for these new feelings to take shape and move from the shadows into his awareness. But when he starts to feel both the good and the bad, the promise of nurturing, enlivening connection and the fearful shame of wanting it, it’s more than he can feel all at once. His feelings alternate between hope and dread. It’s almost inevitable that after he has felt good for a while—connected, understood, self-respecting—something “bad” will happen to cause disconnection. Then wanting feels futile and dangerous, and he feels empty and stupid again. Though some of these breaks can be large and distressing, as the last chapter illustrates, most of these misses Downloaded by [New York University] at 13:36 13 August 2016 and worries are relatively small and can be talked through in a session. Once, for example, one of my clients berated herself for not knowing ahead of time that a certain man was going to cheat on her. I tried to undo her self-blame by saying, “You know, it’s really not your fault when you get fooled by a man who’s manipulative and devious.” She looked stonily at the floor. “You do this,” she said. “You tell me something isn’t my fault, and then I feel powerless.” Clearly I had missed the emotional point of her story. “Ah,” I said. “I see what you’re saying. You should be able to tell in advance because then you would have more power in the situation.” The Wonderfully Good Part of Relational Therapy 137 She looked up and nodded and went on from there. She had corrected my “miss,” bringing my empathy back to her experience, and now she would think and feel her way through this issue in her own way, with me paying attention to what she meant. (In our relationship, too, she was learning that she could have the power she needed.) Another client often asks me toward the end of a session whether her talking has been too much for me. We have explored what lies behind her question: her conviction, nailed down in a childhood home of chaotic abuse, that others are either too fragile or too distracted to hear her. There- fore, she feels like she doesn’t matter and shouldn’t be heard. That’s what turns up again and again. But when she asks her questions, it’s important that I scan myself, too. If I have been a bit distracted by personal worries, or I haven’t had a good night’s sleep, it’s important that I say so, simply and briefly. Because if I don’t, she’ll still sense that something is off between us, and she will take that to mean that something is wrong with her. That’s how subtle a “miss” can be. When these inevitable misses and worries happen in a therapy that’s working well, talking them through brings your client back to the positive side of needing and connecting. Each talking through and reconnecting reinforces her belief that this relationship is safe and that it will give her more than she’s hoped for before. Just to be able to say “I’m worried what you’re thinking,” or “You’re not getting it,” is more than she thought possible at first. And then, as she continues to talk about her problems and feelings, she will become aware of some new edge of anxiety in the relationship with you. There’s something else that she wants from you, perhaps, and she knows she can’t have it. Or she’s sure you’re thinking something bad about her. Or there’s something new she wants to tell you about herself, and she’s sure you won’t like it or even understand it. Whatever the problem is, it’s another chance for her to talk her way through bad feelings and back to good connection. So it goes, over and over, and the cumulative effect is a relationship of more complexity and security, and also more possibility for Downloaded by [New York University] at 13:36 13 August 2016 interesting, good surprises.

Two Dimensions of Transference: Self Psychology

Robert Stolorow and George Atwood, theorists of an intersubjective version of self psychology, call this oscillation between hope and dread in therapy a shift between two dimensions of transference. Your client’s fearful expectation and experience of repeating the past is repetitive transference. Laid down as psychological organizing principles, repetitive transference 138 The Wonderfully Good Part of Relational Therapy appears over and over again in many guises, and it needs to be met by countless counter-repetitions of your understanding. These repetitions, important instances of a consistent empathic connection, help engender the good relational feelings that self psychologists call selfobject transference. According to Stolorow and Atwood, these two kinds of relational feelings, this repetitive transference and selfobject transference, are not two separate kinds of transference, but rather two different dimensions of one complex transference that develops and changes over time between client and therapist.1 Repetitive transference was the topic of the last chapter. In this chapter, to explain how relational therapy builds lasting emotional well- being, we spend time with selfobject transference. Self psychologists believe that as a client comes to understand how his repetitive transference plays out, he will come to understand how his psychological organizing principles make sense of his interpersonal experience for him. This is the most significant aspect of his “unconscious” for him to investigate in therapy.2 But while he is doing this, and also in the quiet, comfortable spaces between bouts of uncomfortable work with repetitive transference, something ultimately more important is happening for him. His shaky, insecure, fragmented self is being strengthened through selfobject transference. Some self psychologists drop the word “transference” from their description of the client’s positive experience and simply speak of a client’s selfobject needs and selfobject experiences. Not only do the client’s emotional needs deserve respect and understanding, they also deserve to be met as well as they can be within the limits of the therapy situation. Howard Bacal calls this therapeutic stance optimal responsiveness.3 He and Kenneth N ewman suggest that therapists provide selfobject experiences by doing the following:

• Attuning to clients’ affective states • Validating clients’ subjective experience—including identifying Downloaded by [New York University] at 13:36 13 August 2016 with the “rightness” of their perceptions • Providing affect containment, tension regulation, and soothing • Sustaining or restoring a client’s weakened sense of self disrupted by selfobject failure • Recognizing each client’s uniqueness and creative potential4

Good Experience as “Selfobject Transference”

Simply put, a selfobject experience is a self-with-other experience that feels supportive, enlivening, comforting, freeing, and life-enhancing. Your The Wonderfully Good Part of Relational Therapy 139 experience of the other’s being with you feels so “just right” that you hardly notice it. Think of how you feel most good in yourself when you’re with a close friend. Think of the prototype of that experience—a lively, confident toddler who doesn’t realize that her security and happiness are being created for her moment by moment by the people around her. Her selfobject surroundings allow her just to be herself—to explore, do, feel, relate, grow, and develop in her own way. Sadly, some children don’t receive much concentrated attention to their needs, and some receive some kinds of it and not other kinds—for example, lots of safety and protection, but not much admiration for the child’s accomplishments, or lots of pride, but little companionship or understanding. If a client has such gaps in his relational experience, they may lead to what self psychologists call deficits in his self experience. A large part of his therapy can be a repair of those deficits, which will give him a second chance to develop a cohesive, competent self in secure relationship with others. The therapist provides the selfobject experiences the client uses for such repair. In order for the repair to “take,” the therapy relationship has to have significant intensity, an intensity summed up in the word “transference.” When there is enough intensity, the selfobject dimension of the therapy relationship can put into motion major changes in what a client expects and experiences in the rest of his life. Heinz Kohut, the father of self psychology, identified three major forms of selfobject transference. In idealizing transference, the client needs to feel connection with and protection by someone good, strong, and wise, someone he can trust and hope to emulate. A mirroring transference is structured by the client’s need to be noticed and affirmed in his strengths, ambitions, and creativity. He needs someone to admire and smile, to back up his dreams and plans. An alter ego or twinship transference focuses on an essential alikeness between client and therapist. “Being like” is an important kind of belonging; it counters feelings of being alone and alien in the world.5 In a textbook on self psychology written after Kohut’s death, a close colleague, Ernest Wolf, identifies three more important needs to be met Downloaded by [New York University] at 13:36 13 August 2016 within a self-sustaining selfobject ambience. In a merger transference, the client needs the therapist to be exactly attuned to every detail and moment of her experience. An opposite kind of need leads to an adversarial transference; here a client can assert difference toward someone who will take a firm opposing stand but who will also continue to be supportive, responsive, and affirming of the client’s self. A third kind of need is for efficacy in relationship. A client needs to know that she has an impact on the therapist and can evoke the kinds of responses that will help her.6 To this list of selfobject needs and transferences, Stolorow and Atwood add what they call self-delineating selfobject transference. This transference 140 The Wonderfully Good Part of Relational Therapy takes shape with clients whose early experiences of misattunement and invalidation have left them with a very tenuous sense of self. They have a shaky hold on their own perceptions and opinions. They feel their emotions as bodily sensations, but they can’t put their emotions into words or symbols to make sense of them. In the therapy relationship, a client with this kind of amorphous, chaotic self-experience will depend on the therapist’s responses to give form and words to what he feels until he begins to have a durable sense of being present as a feeling self in his own right.7

What Does Selfobject Transference Mean for Your Client?

The language of selfobject transference summarizes important aspects of the everyday goodness a client can experience in the relationship with his therapist. The most basic kind of well-being is a client’s confidence that his existence is valid, that his feelings make sense, that his thoughts can with- stand others’ differences of opinion, and that his unique self is recognizable and durable over time. If he is one of those survivors of relational trauma who has lived with many kinds of dissociation, his quest is to know: “I am here and I am me.” In the chapter on trauma, we saw how important it is for you, as this client’s therapist, to attend carefully to all the many scattered details of his experience, becoming for a while a container of pieces too painful for him to manage. Through your here-and-now attention to all of his thoughts and feelings, he begins to recognize a self at the center of his fragmented experience. In time, he becomes able to integrate these past and present fragments into a reliable sense of “This is the road I’ve traveled to be here. This is who I am now.” In the language of self psychology, his selfobject experiences with you help him delineate a self. If that’s where your client is coming from, self-delineation is just the beginning of the good experiences possible for him; there’s much more that he missed out on. Likewise, for clients who have a clear sense of self

Downloaded by [New York University] at 13:36 13 August 2016 but don’t like that self very much, therapy offers a wealth of positive experience that touches in some way what they have profoundly missed. What selfobject experiences haven’t happened for them? Perhaps a client has missed the sense of someone who is always close by when he needs her, someone to help calm and soothe whatever trouble he’s feeling. Another client may miss someone who is strong for her in ways she’s not, someone capable and wise. With this someone to back her up, she can feel strong and capable herself. A client might need someone who sees exactly what’s good about him. Her smile of approval has no strings attached, so he can take it in: “Yes, The Wonderfully Good Part of Relational Therapy 141 that’s me. I can shine. It’s good to be the best I can. She likes what she sees, and so do I!” Or a client might be desperate for a best friend, a soulmate, someone who sees the world just like he does. When the two of them are doing things side by side, he knows he belongs in the world. Another client might be missing somebody who’s glad to hear the strong things she has to say, who enjoys taking her on. She wants someone who can play as hard as she likes to play, someone who’s not scared of bumps and knocks. Then she can be as assertive as she wants to be—and safe, too, with him. These are selfobject transferences in the language of everyday wanting. In their simple forms, they can sound like childishness exposed. Perhaps that’s why it’s so hard for clients to admit to themselves and to you that these are, indeed, the experiences that they crave. It’s up to you to be confident that all of these desires, in various forms, belong not only to healthy infant and child experience, but also to healthy adult relational experience. Does it matter if you put the name “idealizing transference” on your client’s deepening trust in you, or “mirroring transference” on how much it helps him when you smile at his success? What matters most is that your client is having those experiences. But it might also be useful to have a concept about what’s happening, because it’s more complicated than a cure by kindness. When good selfobject experiences accomplish “healing” or change for a client, they do so by influencing his organizing principles. What’s helping him is a change in how his relational experience can be processed, or a change in his self-structure, as some self psychologists would say. Now it’s true that clients don’t have to be able to see or understand such changes to profit from them. On the other hand, self-understanding usually strengthens the process of change. Here’s where the idea of transference can be helpful; it allows both you and your client to step back a bit to see what’s happening. Together you can acknowledge that your client is feeling better not just because you are a nice person, but because of specific new kinds of interactions taking place between you, interactions that have Downloaded by [New York University] at 13:36 13 August 2016 the power to change how he feels about himself. Relational therapy may be most effective when new experience is accom- panied by a client’s new insights about how his self-with-other system works. Just as important as the insights is his experience of working with you to make sense of what’s happening. These experiences of understanding together add context and depth to his experiences of getting relational needs met. “Transference” is a word that reminds both of you of the intentional work you’re doing together: you’re allowing deep, important needs to emerge in the therapy relationship, along with all the conflict and trouble they may cause him. In the midst of these complex, powerful experiences, 142 The Wonderfully Good Part of Relational Therapy you’re working together to find words and meanings for them, so that your client comes to understand more fully: “So this is how my system works!”

Other Developmental Stories

Self psychology says that therapy should be a sustaining selfobject milieu for your clients. Through selfobject experience a person comes to feel like a delineated, cohesive, and vital self, a self-respecting and contributing member of the human community, supported in her ambitions and affirmed in her values. But self psychology’s story of how a self develops is a speculative one worked out from therapists’ experiences with adult clients. There are other interesting stories about the power of relationship in human development that begin, instead, with infant and child studies. I’ll look briefly at some of them because they, too, support the idea that a relational therapy can help repair developmental damage clients have suffered, and thus help them experience a new sense of well-being in the world.

Attachment Theory

Mary Ainsworth and John Bowlby have identified three main patterns of attachment between infants and caregivers.8 A caregiver’s consistent availability and sensitive responses to a child lead to secure attachment and the child’s confident ability to venture out and explore. In anxious resistant/ ambivalent attachment, the child doesn’t know for sure that the caregiver will be available and responsive—sometimes she is, but sometimes she dis- connects or disappears. The child tends to worry about separations, cling, and be anxious about exploring the world. When an inconsistent caregiver also rebuffs the child’s advances, an anxious avoidant attachment is set in motion. Eventually this child avoids contact in order to hide her needs, and she masks her anxiety and anger with self-sufficient competence. Downloaded by [New York University] at 13:36 13 August 2016 After the first two or three years of a child’s life, Bowlby says, these patterns become habitual, or “working models” of how all significant interactions work. A securely attached child will update her working models as she grows because of the free communication between herself and her parents. She can move on to more mature forms of secure attachment as a base for more mature forms of confidence and exploration. Since an insecurely attached child lives in a less communicative, responsive environment, her working models of attachment are likely to persist unchanged, first with her original caregivers, and then with others, even when they treat her quite differently than her original caregivers did. The Wonderfully Good Part of Relational Therapy 143 Working models of attachment are similar to what I have called self-with- other organizing principles. Bowlby holds out the hope that although change becomes more difficult as we age, there are always chances that our working models of attachment can be influenced for the better. When working models of self-with-other aren’t held too tightly, life experience can continue to alter them to match new relational life situations. But the more anxious and insecure a working model is, the more likely it is to be rigidly repetitive of early experience. Here therapy can help, Bowlby says. Therapy becomes a new attachment in which a client’s working model of attachment can be subverted, if ever so slowly. How can this happen? In healthy parent–child relationships, working models change through what Bowlby describes as free-flowing, warmly personal conversation, laced with feeling. This is the kind of conversation relational therapy works toward. In the beginning stages of therapy, a client may be afraid to bring much of herself forward. But each time she does, there isn’t the disinterest or rejection she anticipates. Slowly she finds she can speak more freely of herself and her feelings. Even difficult times of misunderstanding eventually prove the reliability of this new model of attachment. New security gives the client a base for new explorations and undertakings. And all the while, this new working model of relationship is becoming more export- able to other relationships in the rest of her life. Attachment theory offers this picture of the developmental repair therapy can make possible for clients. It suggests that a secure base will allow them to explore life with more confidence. But beyond that, the “goods” are all in the negative: clients won’t feel so anxious, angry, or depressed. For a more positive description of the “goods” of healthy development and redevelopment, we next look briefly at the work of Daniel Stern and Joseph Lichtenberg, whose theories on childhood development are linked with relational psychoanalytic theory.

Daniel Stern Downloaded by [New York University] at 13:36 13 August 2016 Stern describes four different kinds of relatedness that emerge in sequence between an infant and her parents and that then carry on into the child’s adult life: (1) emergent relatedness, (2) core relatedness, (3) intersubjective relatedness, and (4) verbal relatedness.9 Each kind of relatedness develops as an intricate matching of cues and responses between parent and child; each requires an infant constitutionally able to give and respond to cues, and a parent who can do the same, offering nonintrusive, interested, consistent, and relatively accurate attunement to the child’s signals. 144 The Wonderfully Good Part of Relational Therapy Emergent relatedness is the self-with-other system within which an infant sorts and cross-matches perceptions and stimuli to make patterned sense of the world, especially of her social world. This emergent domain of relatedness and of self carries on into adulthood as capacities to learn, to manage stimulation and anxiety, and to make contact with others. Core relatedness is the relationship between the infant’s energy and excitement patterns and her parents’ responses to them. Through responses rich with matching and complimentary energy, parents provide a reliable context in which an infant can experience core senses of self such as agency, affectivity, coherence, and continuity. More importantly, she comes to experience a balanced well-being in this core sense of self, an equilibrium that depends on her parents’ interactive presence with her. Later in life, the domain of core relatedness has to do with how well a person can use various relationships to maintain a cohesive, balanced, resilient sense of core self. In intersubjective relatedness the focus of the infant–parent relationship moves to the sharing of subjective experience. In interactions between two selves, parent and child, meanings and feelings are communicated and understood. Affective attunement makes this sharing possible. Parents’ capacities to attune and to empathize determine, in large part, what kinds of affective experiences can be safely included in the child’s sense of self, and they influence the feeling tones of the child’s self-states. Throughout life, the domain of intersubjective relatedness is the “place” for the giving and receiving of empathy and understanding and thus for maintaining self-esteem and comfortable self-states. For Stern, verbal relatedness is the beginning of the possibility of false relatedness, for a child can be spoken to and taught to speak in ways that deny what the child’s body and emotions tell her is really happening. Every- thing that is not included in this social world of language becomes either “private” or “disavowed” or “not-me” experience, according to Stern. In adulthood, these experiences that lie outside of what’s socially sanctioned often generate feelings of inauthenticity, anxiety, and alienation. But if one can share the private experiences and integrate the disavowed and “not- Downloaded by [New York University] at 13:36 13 August 2016 me” experiences of one’s life, verbal relatedness can become a domain in which one is known and affirmed as contradictory and imperfect, but also as a unique and valuable self. It’s clear that this could be a job for therapy. In Stern’s scheme, however, the therapy relationship is able to touch and shape each kind of adult relatedness, not just verbal relatedness. In Stern’s terms, a client’s secure therapy relationship can sometimes take the form of emergent relatedness, helping him make better contact with the world and turn some of his life’s chaos into patterns he can manage. As core relatedness, a client’s being with his therapist will support the dynamic balance of his core senses of self—his emotions, will, and agency, The Wonderfully Good Part of Relational Therapy 145 and who he feels himself to be in space and time. In the domain of intersubjective relatedness, emotional attunement and empathy will broaden and deepen a client’s sense of who he is “inside” and invite him into the positive feelings of interpersonal sharing and connection. And as verbal relatedness, therapy makes space for conversations that bridge the gap between who the client knows himself to be and the social self he believes he must present to the world.

Lichtenberg and Motivational Systems

Joseph Lichtenberg proposes a theory of structured motivation (instead of a theory of structured self) as a way to explain the behavior of infants observed in their natural surroundings and also the behavior and feelings of adults in therapy. He says that human motivation is best conceptualized as a series of systems designed to promote the fulfillment and regulation of basic needs, which he sorts into five categories: (1) the need for psychic regulation of physiological requirements (for food, warmth, and sleep, for example), (2) the need for attachment and affiliation, (3) the need for exploration and assertion, (4) the need to react with aversion, either fight or flight, when in danger, and (5) the need for sensual and sexual enjoyment.10 Exchanges between parent and child give each of the child’s motivational systems its robustness, contours, limits, and feeling-tones. The parent’s feelings are a powerful regulator of the child’s experience of his own motivations. If, for example, a caregiver responds to exploration with encouragement, the child will explore more confidently and his exploratory system will be strengthened. If the responses to a child’s attachment strivings are warm, reaching out to others feels good to him, not shameful. If there is a blank in caretaker response when it comes to a child’s sensu- ality and sexuality, he will be limited in this area of self-knowledge and self-expression. Parent–child interactions that are loaded with feeling become clustered Downloaded by [New York University] at 13:36 13 August 2016 together in what Lichtenberg calls model scenes. In therapy with adults, as we have seen, model scenes turn up as stories, dreams, and memories that represent emotionally loaded formative experiences from infancy, childhood, adolescence, and earlier adulthood.11 In Lichtenberg’s scheme, the model scenes that emerge in a client’s therapy will be linked to the ways in which caregivers responded to his basic needs, which in turn shaped the motivational systems through which he continues to try to stifle or take care of those needs. Sometimes the therapy process can show a client new ways to take care of those needs: the therapy room may become a place for a special kind 146 The Wonderfully Good Part of Relational Therapy of relaxed well-being; in your presence, a client may explore previously forbidden areas of feeling and new ways of being with another person; a client may learn to assert himself in therapy, and to fight back or withdraw in useful self-protection if you inadvertently hurt him. The client will not only be having these new experiences, he will be talking about how his motivational systems work for him both in and out of therapy. Talking about them when they’re “hot,” that is, when he’s embroiled in a model scene in which he is working to get the best outcome he thinks he can have, has significant power to change how his motivational systems work for him, especially when that kind of talking is embedded in ongoing self- reflection within a supportive selfobject relationship.

The Boston Change Process Study Group

In 1995 a group of infant and child clinicians and researchers, practicing psychoanalysts, and analytic theorists (including Daniel Stern) came together in Boston to study the question of how change takes place in psychotherapy. They intended to develop a model of change that would be based on infant research and that would explain the “something more than insight” that produces change in therapy. Thus their work attends more to questions about dyadic process than to questions about the structure of self or of motivation. The group explores the interactive, mutual, nonlinear processes that organize an infant’s emotional states and also his sense of how to do things with intimate others, a kind of knowledge that the group calls implicit relational knowing. Then they make links between these processes and processes of change in therapy.12 All clients bring implicit relational knowing to the therapeutic relationship, the Boston Group says, a knowing that profoundly affects the quality of their relational lives inside and outside of therapy. Therapists bring their own implicit knowledge about relational procedure. Over time, then, a client and therapist will find themselves “getting along” in a way that’s influ-

Downloaded by [New York University] at 13:36 13 August 2016 enced by both partners’ implicit relational knowing. In itself, this can lead to change for a client. How so? Just as a parent can provide a mental/emotional context for expanded and more complex states of shared consciousness with a child, so a therapist can engage with a client in ways that produce for both of them an expanded sense of how they can be in this relationship. The therapist brings to the relationship ways of interacting that the client might not have known about. At the same time the client is bringing challenges into the relational system that require the therapist to expand his own repertoire of understanding and response. As the client–therapist relationship expands, The Wonderfully Good Part of Relational Therapy 147 new forms of agency and shared experience become available within it. These new patterns of organization can also be put into operation in other relationships. The Boston Group believes that changes in implicit relational knowing are what produce the important changes in therapy that can’t be attributed to insight. Such changes come about through unplanned events in therapy. In an improvisational mode of talking and being together, “now moments” happen between client and therapist. These are the moments when something new could emerge that would change what both client and therapist know about the possibilities of relating to each other. If now moments are handled in a way that fosters a “specific moment of meeting,” the relationship does change (if ever so slightly), and the implicit knowing of each partner is altered by the new and different intersubjective context between them. They then return to “moving along” in therapy, a process consisting of many small matches–mismatches, ruptures, and repairs that put the new shape of implicit knowing into play—until another “now moment” offers new possibilities for expanding their shared and individual consciousness.

The Limits of a Self-For-Other Perspective in Therapy

The genius of theories that connect adult emotional health to infant development is that they recognize that “health” or “good experience” is more than what remains when conflicts are worked through in therapy. Develop- mentally minded therapists don’t focus on treating disease or dysfunction so that clients can return to “normal.” They understand that psychological health or emotional well-being is itself an interpersonal creation. They know what effective parents, teachers, mentors, and coaches know: it takes artful, intentional, caring activity to provide the interactive contexts that sustain many different kinds of good learning experiences for those who count on you to help them develop. However, self-for-other relational therapy needs the check and balance

Downloaded by [New York University] at 13:36 13 August 2016 of a self-with-other perspective. Seeing the therapist as only the provider of reparative experience seriously limits a relational perspective. In the first place, the assumption that the therapist’s empathy is only a means through which to meet the client’s needs shifts the therapist away from mutual presence in relationship. Too much focus on providing what her clients need blocks a therapist’s ability to be a real other person engaged with her clients. Therapies that script the therapist as just a provider may also subtly patronize a client. The client knows that she is an adult in therapy. If she thinks about her organizing principles for attachment, achievement, and taking care of herself, she knows that they are woven into her adult 148 The Wonderfully Good Part of Relational Therapy personality. They make her who she is now, and she can’t go back in time to undo them, no matter how well her therapist might meet her needs. Furthermore, she doesn’t want to feel like a perpetual victim of her childhood history. This client needs a therapist who is as present with her, here and now, as she is a provider of empathy for her. A self-with-other focus offers therapy in which it’s very clear that a client is not a regressed child or a victim, but rather an active explorer of how relationship works for her right now and how it could be different. In such therapy, she will do this exploring with you, her therapist, and you will be challenged to explore your own experience, too, and to resist using your empathic expertise as a subtle escape from the immediacy of the relationship. In this mode, a client explores her unfulfilled neediness as desires that are completely appropriate in here-and-now adult relationships. Her problem is that powerful anxiety has twisted these desires into opaque impossibilities. The point of her therapy is not that it will meet her needs, but that she will have the chance, here in therapy, to come to terms with both her legitimate adult desires for connection and the longstanding anxiety that turns them into trouble for her. It’s useful for her to feel and understand her anxiety in terms of her history, but liberation comes as she finds the courage to accept her adult desires and to act on them in new ways.13

The “Goods” A Self-With-Other Perspective Offers

With its developmental and intersubjective emphases, self psychology is both a self-for-other and a self-with-other therapy. Interpersonal/Relational psychoanalysis also contains both themes, but it puts a stronger emphasis on the current, mutual dance of self with other. Aron and Mitchell describe positive outcomes in therapy not as a self becoming stronger and more cohesive, enjoying enhanced capacities to self-right and self-reflect, nor as changes in organizing principles or in motivational or self structures. Downloaded by [New York University] at 13:36 13 August 2016 Instead, they speak of meanings that client and therapist negotiate about what’s happening between them, and of the larger, related meanings that these two partners in therapy co-construct and that turn out to be pragmatically useful narratives of the client’s life experience.14 “Pragmatically useful” means that therapy has generated a sense of self and relationships that a client feels to be important, meaningful, and “authentic,” that is, deeply his own.15 If a client’s life is stuck because old constraints keep foreclosing possibilities for new experiences, one could say, as Mitchell puts it, that his life is stuck because of a failure of imagination. His therapy relationship is where The Wonderfully Good Part of Relational Therapy 149 new things can happen to prime his imagination, things invented neither by you nor by him, but brought to birth by what happens between the two of you and what might happen next.16 These new things might feel good or they might not; what matters is that they will feel meaningful and authentic to him, and that they will be windows for his imagination and pathways to further important movement—the opposite of his habit of shuttered, constricting “stuckness.” This more philosophical version of relational psychoanalysis doesn’t focus on easing life’s pain with empathic understanding. It invites a client to embrace the inevitable clashes and tragedies inherent in human life. It resonates with an existential sense of the conundrums of everyday experience, which at best become creative dialectic tensions to live out with courage and imagination. In this view, the meanings that a client makes of his life experience are not only constructed in relationship with others (especially his therapist), they are also dialogical meanings, that is, though they belong to him, they are also shareable with others in the human community. Sharing dialogue moves a client beyond the limits of victim and dominator positions in social relations, and it enhances his ability to enjoy the meeting of minds.17 Jessica Benjamin’s feminist definition of intersubjectivity highlights self-with-other. First she insists that psychoanalytic discourse must treat women as full subjects, not just as love/hate objects for male subjects. She goes on to argue that all relationships should be “intersubjective,” that is, products of negotiations between persons who mutually recognize one another as subjects. Benjamin is saying that intersubjectivity is something more than the situation created when two or more subjectivities share a field of existence. (This is the field theory of intersubjectivity developed by self psychological intersubjectivists like Stolorow, Atwood, and Orange.) Benjamin reserves the term intersubjectivity for the mutual recognition that can be negotiated between any two subjects, including child and parent. In this kind of intersubjectivity, neither subject exists for the other; each partner is engaged in mutual and reciprocal processes of asserting self Downloaded by [New York University] at 13:36 13 August 2016 and recognizing the other’s self-assertion. Benjamin highlights the necessary instability of such intersubjectivity as it makes space for aggression, competition, and the inevitable breakdowns and repairs of recognition that happen in the course of a relationship. The demands of empathy become conflictual when empathy must run two ways. Domination of one person by the other is always a possibility. But relational analysis is doing its best work, Benjamin proposes, when it helps its analysands develop the capacity for achieving and sustaining the “intersubjectivity” of two-way recognition. The other side of this work is helping analysands develop capacities to contain and work with what happens 150 The Wonderfully Good Part of Relational Therapy when intersubjectivity breaks down—with the internal tensions generated by clashes of wills and frustrated aggression, and with fantasies of reversals and reprisals.18 The women of the Stone Center also speak to the ideal of mutuality in relationship. They believe women have special capacities for empathy and recognition, while linking aggression to masculinity and patriarchy. In their version of relational therapy, the development and exercise of women’s ways of connection become the paradigm for all healthy human development and psychology. Thus self-in-relation therapists concentrate on connecting with their clients. Like the other relational therapies we have considered, this model is also a psychodynamic therapy. Relational experiences between client and therapist, condensed in transference feelings and relational images, generate insight about relational patterns. Stone Center theory maintains that this combination of experiencing connection and developing insight will produce change in clients’ current relationships and in their well-being.19 The Stone Center theorists place most emphasis, however, on what happens within the therapy relationship itself, which they characterize as mutual, as Aron, Mitchell, and Benjamin do. “Self-in-relation” is the primary human reality, they say; autonomy and independence are fantasies. Insofar as a therapist must put the client’s subjective experience at the center of the therapy, therapy can’t be fully mutual. Nevertheless there can be real connection, respect, emotional availability, and openness to change on both sides of the relationship, and therapy can help this experience of mutuality to deepen and grow.20 In this way the therapy relationship produces for both partners what Miller and Stiver call the five components of empowerment: “zest,” action, knowledge, worth, and a desire for more connection—five powerful, in-relation “goods.” Zest in-relation is the opposite of isolated depression. Zest happens when people feel they have a meaningful effect on one another, and then they feel more empowered to take further action. A therapy relationship that’s working well will stir such energy in both you and your client. From Downloaded by [New York University] at 13:36 13 August 2016 all this meaningful interaction comes a great deal of knowledge about each other and about how the relationship works for you. Friends who enjoy mutual relationships feel like they matter more in the world when they have mattered to each other in their interchange. Like- wise, when therapy works well, even you as therapist will feel that your presence has been important. What matters more in therapy, of course, is that your client’s sense of worthiness increases as she feels your honest, interested engagement with her. It’s no surprise that she would want more of this connection. Your client’s relational life improves as she acts on this desire not only with you, but also with her partner in an intimate The Wonderfully Good Part of Relational Therapy 151 relationship, with friends, and even with people beyond her circle of close connection. All of these positive outcomes of therapy flow from what goes on between you and your client. Although these interpersonalist, dialectical, and feminist versions of relational therapy differ in their expressions of philosophy, politics, and ethics, they agree on this point: The well-being or the “goods” that therapy produces are primarily self-with-other phenomena, even though they emerge in the context of a therapy that is clearly for the client.

What If Your Client Falls in Love with You (or You Fall in Love with Your Client)?

As you read about these benefits of intimate connection in therapy, you might wonder: What if these positive feelings in this intense interpersonal relationship lead to falling in love? Well, the truth is that falling in love happens in many kinds of therapy; it would be no surprise that it could happen especially in relational therapy. As you listen to your client, you are consistently warm, attentive, and responsive. She shares her mind and heart with you, and you are there for her week after week. In this situation, a certain kind of falling in love is almost inevitable—she will develop a heightened awareness of your ways of being with her; she will experience intense feelings of various kinds when the two of you are together, and she will have many thoughts and fantasies about you when you’re apart. Some of those feelings and fantasies may be romantic and sexual. That’s natural, too. As adults we know that feelings of emotional intimacy often lead to desires for physical and sexual intimacy. We also know that having those feelings doesn’t mean that a person has to act on them; responsible choice is always possible. So it is in therapy. But there are special considerations when a client falls in love with you. First of all, although a client’s loving feelings are fine and often helpful to her therapy, under no conditions is it fine or helpful for you to respond to those feelings with a romantic interest Downloaded by [New York University] at 13:36 13 August 2016 of your own. You may feel loving and sexual toward her, but if you act on those feelings, you are taking advantage of your client’s vulnerability in the relationship—a clear breach of your ethical responsibility to her. So says every code of professional ethics for psychotherapists. That being said, let’s return to how it might be helpful for your client to fall in love with you, and to how you can respond with her best interests in mind (whether or not your own feelings are involved). Falling in love is just one more instance of the emotional intensity that makes relational therapy effective. It can be described as a particular kind of transference, often called “erotic transference.” In its negative, repetitive dimension, your 152 The Wonderfully Good Part of Relational Therapy client might fear that her love will be mocked or rejected, or, on the other hand, that her love will be snatched greedily and then twisted to abuse her. In the positive, helpful dimension of erotic transference, her experience of having her love welcomed respectfully can lead to new depths of self- respect and stronger capacities for safe, mutual connections with others. So although falling in love is not to be acted out in therapy, if it happens, it’s best for your client not to hide it from you. It’s your responsibility not to become entangled, either positively or negatively, in her feelings, but to listen to them carefully in order to understand her world and her feelings more fully and deeply. In short, it’s your job to receive her loving feelings, and all the conflicts around them, with the same empathy you bring to anything else she talks about. Thus, if your client falls in love with you and is anxious and ashamed about the situation, you can reassure her that this is a natural thing to happen and quite common in therapy. As you help her find ways to talk about her feelings, she learns, once again, that there’s nothing wrong with who she is and how she feels. The relationship expands to contain more interpersonal reality, and her capacity to love becomes more available to her for growth beyond therapy. The two of you will probably be surprised how easy this talking turns out to be, and how simply okay it is to let these feelings be part of what’s happening now in this relationship. Please note, however: if you find yourself having strong, persistent romantic and erotic fantasies about a client, whether or not the client has expressed loving and sexual feelings toward you, you must get yourself to a supervisor or therapist you trust and try to understand the meaning of your feelings—not only in the context of the therapy, but also in the context of your own personal life. As a relational therapist, you will have been trained to enter into emotional intimacy that you don’t mistake for falling in love. If you’re making that mistake now and feeling the pull to cross a professional ethical boundary, chances are that something is wrong or missing in your personal intimate relationships. Downloaded by [New York University] at 13:36 13 August 2016 What about Dependency?

The good feelings of therapy also give rise to another kind of fear, fear of dependency. We’ve come up against understandable forms of this fear elsewhere in this book. Clients who were never able to count on their parents to support them will fear starting to count on you, because they expect that you will only disappoint them in the end. As we’ve seen, these repetitive fears need to be treated with repeated gentle empathy. But there’s another kind of “fear of dependency” I’d like to address now, and it’s not really a fear, it’s a judgment. The Wonderfully Good Part of Relational Therapy 153 Sometimes clients are advised by well-meaning friends and loved ones not to rely too much on a therapist for support and help in daily living. Such reliance, they’re told, will not diminish with time. It’s a dependency trap induced by therapists to line their pockets or feed their egos. Sadly, in therapy as in any profession, there are a few bad apples. Some therapists are poorly trained, less than competent, or even unscrupulous, and some of them do manipulate their clients into long-term dependent relationships. But people who are deeply suspicious of dependency don’t usually discriminate between good and poor therapy. To them, it’s all suspect. Behind such suspicion is the assumption that dependency is the unhealthy or immature opposite of independence, that in optimal development we grow out of dependency and into autonomy. All relational therapies undermine that assumption. The core project of the Stone Center theorists is to turn that assumption upside-down. They argue against a dependence/independence dichotomy, for the two kinds of being-with are completely intertwined in interdependent social relationships, they maintain. Wishing or pretending to grow out of the human condition of interdependency, like denying one’s own vulnerability and emotions, is a recipe for relational and psychological disaster.21 What’s more, the Stone Center says, dependency on others can be both healthy and appropriate; it’s just a fact of interpersonal life that sometimes you have to count on others to help you cope with things you don’t have the experience, time, or skill to manage as well for yourself. Other times you are the lender of help, expertise, and support. The “helping” themes and moments of relationships become unhealthy only when one person needs to keep another person subservient or powerless in the relationship. Otherwise, dependency is normal and growth promoting. In Stiver’s words, dependency allows you to experience yourself “as being enhanced and empowered through the very process of counting on others for help.”22 Stone Center theorists would tell your client that it’s not just all right for her to count on you for your responsive understanding, it’s the only way to grow. Self psychology, too, refuses to see normal psychological devel- Downloaded by [New York University] at 13:36 13 August 2016 opment as movement from dependence to autonomy. That movement, says Kohut, is impossible, for human beings never outgrow their need for selfobject connection. Instead, our healthy development is the story of our growth within sustaining relationships between ourselves and others, and these selfobject relationships themselves keep developing as we rely on them in ever more complex and meaningful ways.23 When you are in a self-for-other mode of relational therapy, you provide a healthy relational environment that alters a client’s self-with-other experience. He will grow not out of dependency, but into modes of dependency that are more reciprocal, empowering and useful to him in his life. 154 The Wonderfully Good Part of Relational Therapy As he makes peace with how much he needs to depend on others for his everyday well-being, he’ll be able to recognize how much he has to offer, too, in healthy interdependent relationships. A self-with-other mode of relational therapy seems at first glance less vulnerable to a dependency critique. In this mode, you are less a provider of good experience than a partner in a challenging project. But the project depends first on developing a relationship deep and real enough to bring to life your client’s most painful ways of being with others, and then on all the work it takes for the two of you to find a better way of being together. From the outside, all this investment of time and energy can look like dependency, too. However, though a client may come to count on this relationship for an intense kind of engagement he’s known nowhere else, the word for this intense, shared adventure of discovery is hardly “dependency”! In fact, the responsible practice of any relational psychotherapy protects clients from dependency that would belittle or control them. As therapist, you enter a therapeutic relationship fully aware of the power a client invests in you and of the responsibilities that go along with it. Her “dependency” is voluntary, and she enters into it for reasons that both of you respect. You know that many relational powers will be awakened in your work together, and you intend to welcome them openly and to make sense of them as best you can. The therapy is about what happens between you, and your commitment to that work is your client’s first protection against unhealthy dependency in therapy. A second protection happens throughout the therapy process: relational therapies put the dynamics of the therapy relationship on the table and keep them there. There’s nothing about the therapeutic relationship that can’t be noticed and questioned. So if your client is feeling in any way trapped or belittled or “too needy”—that’s exactly what she needs to talk about! As her therapist, you stay alert for clues of such feelings, you ease her way into talking about them, and you respond with receptive understanding. Then your client can find her way back to active partnership in your ongoing interdependent relationship. Downloaded by [New York University] at 13:36 13 August 2016 “I Almost Smiled at You Today!” (A Story about Ordinary Goodness)

This chapter has been about the ordinary goodness relational therapy offers. To end it, I’ll tell a story from my practice that illustrates most of the accounts of ordinary relational well-being we’ve looked at so far. “Kim” came in one day and sat silently for a few moments, as she often did. Then she said, her eyes on the floor, “I almost smiled at you today when I came in the door.” I was puzzled. It wouldn’t have been the first The Wonderfully Good Part of Relational Therapy 155 time she had smiled at me in session. Yet this seemed important and hard for her to say. What did it mean to her? What was going on between us that she almost smiled at me? Having worked with her for almost three years, I knew she would explore those questions with me. It took a few sessions, but together we came to understand a certain kind of “goodness” emerging for her—tentatively, along with anxiety. Thinking like a self psychologist, I had learned over the years that Kim needed careful mirroring from me—responsive facial expressions, understanding sounds, and short sentences that summed up what I was getting. Neutral silence from me told her that I was disinterested or not even p resent—which meant that she was wasn’t worth being with. How- ever, when she could feel my interest, she felt a sense of connection with her inner thoughts and feelings and a sense of mattering both to me and to herself. Kim also made twinship connections with me, checking out books I’d read and movies I’d seen, enjoying our shared interests in baseball games and golf lessons. She longed to experience herself as “normal,” as “belonging,” and less like an alien on earth. As we grew into liking to be together, Kim felt less like an outsider in the rest of her life. It wasn’t surprising, then, that she could smile more easily with me. But what mattered here wasn’t just any kind of smiling; it was smiling “as I came in the door.” I thought about Kim’s attachment history. She experienced both parents as emotionally detached, which explained why I had to be so present to her. Since they never shared what moved them or mattered to them, Kim never had a chance to feel essentially or deeply like either of them. This deficit generated her need for twinship with me. But what in her history made it dangerous to smile as she came in the door? In Bowlby’s terms, her working model of attachment was insecure and avoidant. She had experienced not only detachment from both parents, but also rejection when she reached out. As she mused on this, she said, “Well, my dad had those paranoid tendencies, so from him it was like, ‘What do you want from me?’ And my mom was so self-conscious, it was like my Downloaded by [New York University] at 13:36 13 August 2016 knowing her was going to expose her somehow. My wanting to connect just scared them both, I guess. It still does!” We had noticed an insecure avoidant pattern in stories Kim told: how she’d sometimes cross the street not to have to say “Hi” to someone; how the more she liked and admired certain people, the less she was able to speak to them. With me she was always pleasant and respectful, and social smiling was part of the package. But I knew that she held back, expecting very little from me, as if afraid to offer too much or want too much. In this context, I could understand that smiling at me as she came in the door would be an enormous risk for Kim to take. As she explained, 156 The Wonderfully Good Part of Relational Therapy “Then it would be just me in your face, saying, ‘Here I am! Smile back! Or something!’ It seems like way too much to ask. I’ll be in trouble for sure.” The trouble she anticipated, I thought, would be that sting of an aloof nonresponse and the sickening slide into shame that would follow, a sequence she knew well in her bones, if not in her conscious mind. But on the other hand, after almost three years of my consistent, attentive responsiveness, something was getting through to that insecure, avoidant working model of attachment. She’d had the impulse to smile. She told me about it! She was thinking about it from every angle. In terms of Stern’s domain of core relatedness, Kim needed to find out whether I would match my energy to hers, or whether preoccupation with my own needs or my own depression would leave her stranded with her “up,” interactive strivings, and then disorganized and alone with a struggle to regain her equilibrium. In the domain of intersubjective relatedness, the question would be more about whether we could share the feelings and meanings of our inner worlds. Would she see in my eyes and in my face pleasure about our connection, anticipation of taking it further and deeper into knowing each other? Or would she see “Stay away from me!”—an echo of her father’s fear of being used or her mother’s fear of exposure? “I almost smiled at you today!” was a moment full of goodness because new RIGs, new sequences of interactions, were jostling for space with those old RIGs. Already our interactive core relatedness had helped Kim experience a self of more lively, balanced energy. Already our intersubjective relatedness had helped Kim experience the value of her inner world, with its uniquely interesting thoughts and feelings. In Kim’s moment of almost smiling, attachment–affiliation was the motivational system most operative. Despite their emotional det achment, her parents must have provided enough warm, affective response to her infant attachment needs to activate that system well. The good news is that her urge to make friendly contact has survived, in spite of the forces that regularly squelch the urge. As she came through my door, whatever happened—something she saw in my face or manner, linked with Downloaded by [New York University] at 13:36 13 August 2016 an expectation of rejection—activated a secondary motivational system, aversion. To protect herself she shut down her impulse to smile. The ability to self-protect is also good. But the therapeutic good about all of this, according to motivational systems theory, is Kim’s new ability to notice the “model scene” quality of what happened and thus move beyond ongoing unconscious repetitions of the scene. The moment of almost smiling was a “now moment” that Kim turned into a moment of meeting by telling me about it. As we shared the meanings of an almost-smile between us, something shifted in how we each knew each other, and we could hope that Kim’s sense of the possibilities of The Wonderfully Good Part of Relational Therapy 157 relationship, her “implicit relational knowing,” might have been deepened and expanded through that meeting. So far everything we’ve understood about the goodness in Kim’s almost- smile are goods that the therapy relationship has given Kim: a more cohesive self, a better working model of attachment, RIGs that better support Kim’s vitality, the retooling of one of her motivational systems, the expan- sion of her implicit relational knowledge, and, through all of this, new capacities to reflect on how her self-with-other systems work for her. All of these “goods” accrue to Kim, thanks to consistent self-for-other interactions. Does her story also illustrate the power of self-with-other to develop “goods” located in the relationship? Well, in Stone Center terms, there was “zest” between us when Kim spoke of almost smiling. A shared smile wasn’t yet possible for us. As we explored our dilemma, we came to a better understanding of each other and of ourselves in relation, and then we each felt more secure and worthy. As these mutual experiences deepen in therapy, we can expect more well- being within the relationship. From a more interpersonalist perspective, “I almost smiled at you!” was a flash of imagination, a thought unthinkable before, something new between Kim and me after a long time of the same old thing going on between us. We may never know how our work together released that impulse into Kim’s awareness, but now that it’s between us, many “small” things are changing. Now, instead of just being sure that her advances will be trouble, Kim wonders, “What if my smiling at you means something to you I’d never expect, something I don’t even know about?” Pos- sibilities expand, with new fears and new excitement—and for me too. I wonder, “Will she ever actually greet me with a free, spontaneous smile? What would it be like to feel that smile—and to smile back? What might we discover then?” Kim says, “My smiling at friends feels different now. It means different.” She doesn’t know what it means, exactly. She doesn’t know where this “smiling” (more reaching out to others with more expectation of friendly Downloaded by [New York University] at 13:36 13 August 2016 response) will take her in the world. We don’t know where reciprocal smiling might take us. We haven’t even done it yet! But we can feel between us the satisfaction of something old and stuck giving way to something much more warm, alive, and moving even when we just talk about what smiling (and not smiling) means. Making this meaning together feels good. “We-ness” feels sturdier; the give and take of conversation works better; mutual enjoyment and mutual vulnerability have become more possible between us. Does this growth facilitated by relationship or this intense mutuality of relationship mean that Kim is dependent on me in an unhealthy way? In 158 The Wonderfully Good Part of Relational Therapy the session after Kim “almost smiled” she told me, “I bumped into a friend on the street. I saw her coming and I kept walking straight toward her. I said, ‘Hi, Donna! How are you?’ Like with enthusiasm! I felt like I meant it. It felt good.” Kim listed all the ways she had been putting herself forward a bit more in her life. “It’s about expecting that when I put myself out there, sort of in their faces, they won’t find me a bother,” she explained. “Maybe they’re actually happy to see me.” Then she got scared. “But I’m not sure about that. What if I’m wrong? That’s the risk I take if I smile at you. So I don’t. Not yet.” If Kim were dependent on me in an unhealthy way, our relationship wouldn’t help her expand her strength, vitality, and sense of self-worth in connection with others. My “support” would keep her weak, scared, and small. But that’s not what’s happening. Instead, Kim is trying out new ways of being in the world at the same time that she’s trying them out with me. In a situation of unhealthy dependency, Kim and I would duck away from challenging questions about what’s going on between us in order to keep things the same. But we’re not doing that. Even now we know better than to impose closure on this almost-smiling episode. It doesn’t matter whether we smile at each other in the end. What matters is the change set in motion by the question, “What’s going on between us?” Dependency is a closed loop; genuine relational therapy sets in motion interactions that move outward, opening up relationships and the selves who live them. It asks questions that don’t have endings. Therapies, however, do have endings. And beyond the endings waits the final proof of this “goodness” pudding: Does the well-being last when the therapy is over? That’s a question for the next chapter of this book.

Notes

1. Stolorow and Atwood, Contexts of Being, 82–83. 2. Ibid.,34. 3. Bacal, ed., Optimal Responsiveness.

Downloaded by [New York University] at 13:36 13 August 2016 4. Howard Bacal and Kenneth Newman, Theories of Object Relations: Bridges to Self Psychology (New York: Columbia University Press, 1990), 229. 5. Kohut, How Does Analysis Cure?, 192–194. 6. Wolf, Treating the Self, 124–126. 7. Stolorow and Atwood, 34–35. 8. Mary Ainsworth, Patterns of Attachment: A Psychological Study of the Strange Situation (Hillsdale, NJ: Lawrence Erlbaum Associates, 1978); and John Bowlby, A Secure Base: Parent–Child Attach- ment and Healthy Human Development (New York: Basic Books, 1988), especially Lecture 7, “The Role of Attachment in Personality Development,” 119–136. 9. These four domains of relatedness and their connection to clinical issues are summarized in Stern’s The Interpersonal World of the Infant, Chapter 9, “The ‘Observed Infant’ as Seen with a Clinical Eye,” 185–230. 10. Lichtenberg, Psychoanalysis and Motivation. The Wonderfully Good Part of Relational Therapy 159

11. Lichtenberg, Lachmann, and Fosshage, Self and Motivational Systems. In this sequel to Lichtenberg’s earlier work, the authors develop a mode of therapeutic work that is based on working with model scenes that have been developed around certain patterns of needs and responses within certain motivational systems. 12. The Boston Group (Nadia Bruschweiler-Stern, Alexandra Harrison, Karlen Lyons-Ruth, Alexander Morgan, Jeremy Nahum, Louis Sander, Daniel Stern, and Edward Tronick) presented a first edition of their study-in-process to a conference in Finland in 1996. Those papers are collected in a special issue of the Infant Mental Health Journal 19, no. 3 (1998). 13. See Mitchell, Relational Concepts in Psychoanalysis, Chapter 5, “The Metaphor of the Baby,” 127–172. 14. Aron, A Meeting of Minds, 262–263. 15. Mitchell, Hope and Dread in Psychoanalysis, 37. 16. Ibid., 222–224. 17. Aron, 150–154. 18. Benjamin, The Bonds of Love and Like Subjects, Love Objects, especially “Recognition and Destruction: An Outline of Intersubjectivity,” 27–48. 19. Miller and Stiver, The Healing Connection, 121–147. 20. Judith Jordan, “The Meaning of Mutuality,” in Judith Jordan et al.,Women’s Growth in Connection, 95. 21. See Irene Stiver, “The Meanings of Dependency in Female–Male Relationships,” in Jordan et al., Women’s Growth in Connection, 143–161. 22. Ibid., 160, italics in text. 23. Kohut, 52, 208. Downloaded by [New York University] at 13:36 13 August 2016 7 Ending and Going On

Every part of relational psychotherapy is a process. The beginning of therapy is a process of discovering the forms of empathy your client needs from you in order to feel understood. In the course of conversation, your client’s trouble emerges as emotion-laden model scenes between herself and others. In one way and another, these scenes give meaning to your client’s life and to the therapy relationship, and therapy becomes a process of noticing the repetition of painful themes in order to make space for something new to emerge. Meanwhile the tenor and mutuality of the therapy conversation is weaving a secure attachment and a more coherent, authentic, connected sense of self—perhaps the most essential process of relational therapy. And then there is the process of ending relational therapy, which also emerges in its own time. In the middle part of therapy, the thought of ending therapy may seem unthinkable to your client. You have become her selfobject island of calm cohesion, her secure base for new exploration, the connection that allows her to have empathy for herself and empow- ers her to reach out to others. But it is exactly this growing strength that allows the relationship between you to grow and change, too. The dependency she once feared and then came to trust fades as it accomplishes its work. You and your client begin to realize that the story of her therapy Downloaded by [New York University] at 13:36 13 August 2016 with you is approaching its own natural end.

Letting the Story Tell Itself Out

Despite their different worldviews and languages, all relational therapies suggest that the therapy story, played out with many disguises and reversals, has one basic plot: What’s making your client feel bad will move from her life—from her history of interpersonal disconnection and chronic symptoms of distress—into the relationship with you, her therapist. Here this Ending and Going On 161 self-with-other history will be transformed into a new two-person story, motivated by all the major relational themes of her life but played out in a different way. This difference is expectable because you are a new, different person, but it is also intentional. The most important intentional difference is that you pay careful attention to what’s going on, and you invite your client to do the same. Thoughtful attention is what makes this story therapy— a relational story full of meaning, not a series of random, unrelated events. “What’s wrong” for your client has been recognized within the story, and therapy can begin to end as what’s wrong begins to find resolution. By resolution, I don’t mean a final solution or a cure. I mean the kind of resolution that belongs to a story well told: meaning emerges from chaos. Horrible events, painful recurring themes, lasting damage—none of this can be erased. But a tragedy well told and deeply understood moves us with its meaning. Within it, we matter. And when we matter within a story that we can claim as our own, something changes. The change may be as hard to name as what happens within us as a last series of chords brings to an end the complex themes and variations of a powerful piece of music, but we know, we feel, that all that matters most in this story has been aired, and there is resolution. It’s not easy to end when there’s always something more to add, lots of epilogue material. Yet it’s epilogue to a story you and your client both know now. The story you both know takes somewhat different forms for different clients. For one client, the story has been all about finding someone trustworthy who could help her with the delicate gathering and slow reassembling of scattered fragments of herself. The story moved from baf- fling, chaotic pain to meaningful grief shared with someone who witnessed and understood. In the caring presence of another, she has found her own presence. She feels whole because her story is whole now, too. It’s finished enough so that she can move on into a life that belongs to her and into relationships where she can be known as herself, where she can love and be loved. Another client has unpacked most of her story by going through painful Downloaded by [New York University] at 13:36 13 August 2016 ruptures in her relationship with you. Therapy often felt like subtle torture: having to hope for love while dreading shame and rejection. She survived the havoc wreaked by your misses and mistakes, sometimes retaliating, sometimes hunkering down and waiting for something to set her free. She was surprised whenever your persistent, patient empathy loosened a knot, and with every small release both of you could feel the story making a deeper kind of sense. You both know that this story is coming to resolution because the fragility of her hope has become confidence that you are on her side even when you goof, and you no longer seem to have such deadly power to hurt her. In fact, she says that you look a lot like a normal, 162 Ending and Going On everyday person to her now, someone with your own troubles, joys, and challenges. She doesn’t know much about your “outside life,” but she knows you well; the two of you have been through the wars together and come out the other side. A third client has come to know her story through finding in you someone who could be there with her in simple ways she never knew could make such a difference. Your strength supported her when she felt shaky, your smile helped her shine, and your everyday humanness made her feel human too. But this new attachment threw into stark relief the deprivation she came from. Taking in this goodness meant knowing how barren life has been for her and grieving the loss of what she never had. The story of her therapy has become this tapestry of bright against dark. You and she know that the story is ending not only because the tapestry has been richly woven between you, but because she knows she can take it home with her. The many things you have been for her belong to her now. Whenever she wants to, she can think about the tapestry you have created together; she can wrap it around herself for strength, courage, and comfort. Another client’s story has been all about moving from a lonely, dis- empowered, disconnected place, a prison cell of “safety,” toward the risks and rewards of connection. Your empathy allowed him to connect more respectfully with himself. Your understanding gave him the strength to push through his fears and to stick with tenuous new relationships. He has learned to share himself more openly and to rely on people besides you. This plot works to shape a good, strong story, too. In fact, all of these are good plots for transformational relational stories, and some clients’ stories borrow something from all of them. As a relational therapist you know that it doesn’t matter exactly how a client’s story tells itself out. What matters is that you’ve both been paying attention, trying to feel what’s real between you, looking for meaning, and you haven’t been disappointed. A story has indeed unfolded. There’s a trajectory, a beginning, middle, and an end. Whether it tells itself in terms of dissociated experience reintegrated, transferences resolved, deficits filled, Downloaded by [New York University] at 13:36 13 August 2016 or relational strategies transformed, what matters is that your client now has a coherent sense of what was wrong in his life, some words for how you both understood that wrongness and worked it out between you, and the consistent experience that it’s not so wrong anymore. Above all, in whatever way any client’s story is told, it’s a story that took this particular form because he has lived it out with you, the particular person you are. The meanings of his interaction with you have been created by two worlds of subjectivity, two different, unique ways of organizing experience and relationship. And so your therapy is a first and last edition of this story, a one-of-a-kind creation never to be replicated. The shape of Ending and Going On 163 your joint story is not the shape of your client’s “stuff.” It’s the shape of how his stuff met and clashed and melded with your stuff, and how the two of you sorted out the meanings of all of that. As a relational therapist, you bring into every therapy relationship not only your convictions about how therapy works and your capacities for empathy, understanding, and insight, but also the strengths, gifts, needs, and quirks of your personality. If this therapy has been meaningful and powerful for a client, it’s because you have been there with him as a person. And it is this particular person to whom your client will soon be saying good-bye.

Saying Good-Bye

It’s sad to say good-bye. Grief hurts. But to be allowed to say good-bye with gratitude and love as well as with sadness is a privilege. In a moment etched in Canadian memory, Justin Trudeau spoke a eulogy for his father, Peirre Trudeau, and ended with the words, “He has kept his promises and earned his sleep. Je t’aime, papa.” In the following days, colleagues and I noted that many of our clients talked of having been moved to tears by that moment, and then they wept again in therapy. They had been reminded of their own deep longing to be able to say a heartfelt “Je t’aime, papa.” Or “I love you, Mom.” With us they also mourned that they would never have a chance to say that kind of loving good-bye to a parent. It seems we humans long to be able to feel a clean, deep, uncomplicated grief when we lose someone we have loved and honored. We don’t want the loss; it causes us pain. But we need the grief, it seems. When we have the support we need, we move toward mourning. It’s as if we know that feeling grief is a way to fill the absence and emptiness of loss; it’s a way to let loss strengthen us. We grieve in order to be able to take the memory of a loved one with us and to let it keep on teaching us who we are. Downloaded by [New York University] at 13:36 13 August 2016 When our clients lament, “I will never be able to grieve my father or mother like that,” they are saying that they, too, need and want a clean, deep, remembering, strengthening kind of grief. To be robbed of such grief is another grievous loss. If they add, “When my parent dies, I will be grieving for the relationship I never had,” we understand that they are laying claim to a healing kind of grief anyway. In fact, the mourning process is already underway. One of the gifts of mourning is that it ends. As I might say to a client who is grieving for a loving relationship that never was, “I think that when you don’t know what you’re missing and what’s hurting you, then that pain 164 Ending and Going On never ends. But when you start to know what it is that you never had and you’ll never have, then it becomes a something. It becomes not just nameless pain but a something you can truly grieve, and even though it may seem bottomless at first, that grief can come to an end sometime too.” When relational therapy has gone well and it’s time to finish, saying goodbye will evoke both of those kinds of grief for a client, grief for what she never had, and grief for what she’s losing. In this therapy in which she has reflected at length on all the major relationships and themes in her life, she already will have grieved for what she never had. The nameless pain of wanting will have become a something for her. She does know what she missed, which would have remained a mystery if she hadn’t felt some of that missed goodness with you, her therapist. Over the course of this therapy, you have been the embodiment of many different aspects of what she never had and what she can’t go back and have now. She has worked her way through those longings and losses one by one. But a final good-bye will stir those feelings again, for it means she’s giving up the last vestiges of hope that you might give her what it would take to change the story of her life and erase her pain. Leaving therapy faces her once again with the fact that her own story is the only story she’ll ever have. Although she can be grateful that this is at least something to grieve now, and that therefore the grief will end, every time she does this kind of grieving, it just hurts. There’s nothing good to carry away from it except a deeper knowing that she can bear being present in her own skin and in her own life. But there’s also a second kind of grief for your client as she ends therapy, grief for something she has had and is losing. If therapy has gone well and it’s time to finish, she will be saying good-bye to someone who has become a very important part of her life. Your interest and care have been genuine. In certain ways, you know her more deeply than anyone else does, and she knows a great deal about your presence and being, too. The two of you have felt many feelings together, from fear to pain to joy, and you’ve worked hard to be honest with each other. In this relationship she’s learned more about herself than she ever thought possible, not because you have acted as Downloaded by [New York University] at 13:36 13 August 2016 a teacher, but because you have been willing to engage and respond as a full participant in her process of self-discovery. Now she will be losing contact with you, giving up the regular experience of being together. That’s what she’s losing, and it’s something like losing a loved one in whose presence she felt loved and valued. She will miss your presence. The thought of life without you feels lonely and sad. But if, with your encouragement, she allows herself to move toward these emotions, to feel, for perhaps the first time in her life, a clean, deep, uncomplicated grief about losing someone she loves and respects, she will find herself strengthened. She will probably find some words for what you have meant to her. Perhaps Ending and Going On 165 she’ll speak those words directly to you, and you will tell her something of what she has meant to you, too. The two of you will reminisce about the hard times and high points you both remember, and you’ll acknowledge the good work you’ve done together. You will help her realize that keeping herself open to memories and feelings about ending will make her loss more than just absence and emptiness. It will help fill the emptiness with a living, moving, many-faceted image of your relationship to carry with her, a vital memory that will keep on helping her know who she is. In so much of your client’s therapy, what you do together is for her well- being, and yet, as you participate in your mutual process, you can’t help but be moved, challenged, and strengthened yourself. So it goes with a good ending. There’s an element of grief in it for you, too, and sharing memories and feelings about ending will be as good for you as for your client.

What Will Stay with Your Client after Therapy?

Memory is now and now is memory. If this is true about the effects of trauma in our lives, it is also true about the effects of love, care, and understanding. In other words, not only will you stay with your client as a remembered voice of compassionate understanding and as an internal presence backing her up, not only will she have clear, lasting images of how it felt to be with you, but many effects of your relationship will change her way of being even while never crossing her conscious mind. If memory is now and now is memory, that is, if memories are filed on account of their interpersonal emotional potency and according to their emotional meanings, and if, although this whole filing system remains mostly out of her awareness, it’s constantly making sense of all of a client’s current experiences of self and self-with-other, you can be sure that the potent emotional experiences of your therapy with her will have infiltrated her whole meaning-making system. She won’t have to remember those important experiences, for they will be in her psychological bones, in her Downloaded by [New York University] at 13:36 13 August 2016 RIGs, or organizing principles. Their effects will have already sneaked up on her as goodness that she never could have expected. We’ve discussed the different forms such goodness takes: how she has absorbed your supportive and admirable qualities so that she feels whole, self-aware, and strong in a flexible, resilient sort of way; how she has developed more secure forms of being attached to others and new “model scenes” for speaking and finding what she needs; how she has found herself reconnected with others in ways that empower and enliven her; how she has discovered possibilities for meaning-making and creative self-expression that she could not have imagined before. Each of these kinds of goodness 166 Ending and Going On is an ongoing process, not a finished accomplishment or cure. As I’ve said many times, relational therapy is all about self-with-other in action; therefore, each of these forms of goodness, a radical revision of how a client can be herself, is simultaneously a profound change in how she can “perform” herself in relationship with others. What stays with a client when therapy is over? The results or effects of relational therapy may be nonspecific but they are not inconsequential. Your goal together has not been to develop particular insights or a new set of skills. You have been hoping, instead, for changes in the ways she experiences herself when she’s with others and when she’s alone with her remembered, internalized images of others. These changes won’t be something she has learned and will need to recall. They will be systemic, organic, and self-perpetuating. Because of these changes, the way she performs and feels her life will be significantly different, even though the circumstances of her life may not have changed much at all. But what about all the old stuff in old memory files? Has it been dumped? What about those powerful model scenes that for years have been telling your client who she is and what’s possible for her? What about those strategies she has used for so long to make a semblance of connection while protecting herself from inevitable violation? Do the changes I’m talking about mean that she has been able to replace her destructive old interpersonal software with a completely new version? Sadly, no. The old stuff can’t be dumped or erased. But the good news is this: your client’s system now has the capacity to run more than one program. Now she can notice when the program being run is causing her problems, and often just noticing gives her access to another possibility. To put it another way, the old model scenes aren’t the only truth about life anymore. They haven’t been replaced by another truth, but they are now in competition with alternative self-with-other truths laid down in recent interpersonal memory. The different relational theories we’ve looked at would express this old/ new state of affairs in different ways. Self psychology would say that we all Downloaded by [New York University] at 13:36 13 August 2016 need continuing empathic selfobject support in order to live productive, meaningful lives. In the face of pain or stress, we may fall back into our oldest, most fragmenting ways of experiencing self-with-other. Chances are that sometimes this will happen for your client when therapy is over—as it likely did during the course of therapy. As a result of her good therapy, however, your client not only has access to a new capacity to “right” herself, absorbed from her selfobject connection with you, she has also been able to create sustaining selfobject relationships with others, and it is this new ongoing experience of selfobject support, both internal and external, that will pull her out of the old places. Ending and Going On 167 In the Stone Center story, the effects of your client’s disconnected, lonely past have been overridden by the empowerment and zest of genuine connection. But her old doubts and anxieties will still lurk in the shadows, to emerge when things go wrong. Here again it’s essential for her not to deny the old but to bring it into the presence of the new, into a newly supportive circle of social relationships. In this new place of being connected, your client’s old relational images don’t disappear, but she finds herself in different relation to them. She lives now with a capacity for empathy that has softened the edges of the old images and loosened their grip, even when they still bother her. And staying in good connection with others helps her stay with a new set of relational images, one that does her far more good on a daily basis. Relational psychoanalysis doesn’t promise to help your client wipe out the old and invent something brand-new either. Instead, it helps her seize her freedom to make new meanings out of old experiences, once their patterns have come to life in the give and take of the therapy relationship. It’s a freedom she discovers in cooperative engagement with you, her therapist. Your relationship—a nonhierarchical, creative endeavor of mutual recognition—becomes a paradigm for living a life more open to others and more open to possibilities, imagination, and creative self-expression. Of course it’s always possible that she will find herself once again in a deadening, self-destructive interpersonal pattern. But having broken free once, she will know how to try to find out what’s going on; she will know how to talk it out, act it out, pay attention, and push on it—until something gives. What stays with your client after the ending of an effective relational therapy? In short, she does. Having experienced another’s compassionate presence, she can stay with herself. Having experienced significant changes in how she can be with others in the world, she can come home to herself— that is, to the possibility of performing self-with-other with increasing self- confidence, zest, and authenticity. Downloaded by [New York University] at 13:36 13 August 2016 Relational Changes Carry On ... and On

If, at the close of therapy, a client has changed in how he can perform and experience himself with others, these changes will start to show themselves in all of the important relationships of his life. These changes began early in therapy. Sometimes he didn’t know what had been hurting him until it changed unexpectedly. And then those changes gave him the most reliable information about what he could hope for in the future—previously unthought possibilities for new connections with others and with himself. 168 Ending and Going On One unanticipated benefit of relational therapy is that a client’s capacity for meaningful conversation with others improves. He learns from you not only how to be heard but also how to listen. He picks up how to “make sense” mutually with someone else. He learns how to tolerate differences and talk about them. He has found out, by making his way through difficult model scenes with you, that it can be worthwhile to stay in connection and work on “what’s happening” even when he wants to quit and run away. All of this pays off most in his most significant relationships. He can’t expect his partner or his best friend to listen to him with your kind of one-way sustained attention and unflagging empathy. That wouldn’t be an equal partnership or a mutual friendship. But it often happens that once he knows from talking with you that he’s worth listening to, he starts to open up and talk a little more with his significant others. Since he’s less afraid he’ll be discounted, he’s less defensive and prickly at the first sign of misunderstanding. Often this creates more space for his partner or friend to understand him. Furthermore, the good feeling of having been understood by you becomes a kind of settledness within him, a space where he has time to listen to another’s worries. He knows now what he’s giving when he gives another person undivided attention and the most accurate empathy he can find within himself. When two people in an important relationship talk openly with each other, each focusing on understanding the other’s meanings and feelings, the relationship can break free of the fears and expectations each person has brought to it from the past. This commitment to having empathy for each other’s experience (which isn’t the same as commitment to agree with each other) can carry a couple through very difficult times of conflicting wants and bitter frustrations. As they keep talking, as they each keep saying where they stand and what they think and feel, and as they each keep listening to the other with the intention of understanding and finding a way through together, they are bringing something new into being, a relationship that in its own way can be as powerful as a therapeutic relationship to Downloaded by [New York University] at 13:36 13 August 2016 change how both participants can be a self and a self-in-relation. If your client is a parent, coming to understand his own childhood and the relationships between himself and his parents will have a profound effect on his relationships with his children. A study by attachment theorist Mary Main suggests that parents who have come to terms, in thought and feeling, with their own histories of insecure attachment are far less likely to repeat the behaviors that would replicate insecure attachment for their children.1 In short, your client’s understanding of his childhood relationships can free him to be himself with his children, rather than an unconscious copy of his parents. Ending and Going On 169 If there’s anything your client has learned in therapy about his own child-self, it’s about the importance of empathy. He knows he could have survived everything that happened to him far better—he might even have thrived despite major losses and frustrations—if only someone had taken the time to pay attention to his reality and his feelings. Now his empathy for his own child-self has opened up his empathy for his children’s experience, and he has come to know with you how paying attention is done. And so now he can relax and just be there with his very small children. With his older children, he can enter the world of school, friends, hob- bies, and sports with his care and affirmation, but without having to make things right for them. He can approach his adolescents with confidence, knowing that he can both honor their privacy and offer them an important listening ear. If his parents are alive and if he has brothers and sisters, he’ll probably find himself hoping that his relationships with them can change, too. He has realized that he learned disconnected forms of relationship at home. Since he has spent so much therapy time dealing with painful relational images and model scenes from the past, they have lost much of their power to disturb him. It makes sense for him to think that if he could connect better with his parents and siblings now, he would be able to shake off more of the effects of those bad old disconnections. And it’s true that if a client’s family, despite its “dysfunction,” still has some healthy flexibility, some self-reflective humor about itself, and some capacity to foster talking about hard things, a client may be richly rewarded for his efforts to reconnect with family. He might be able to find his way toward mutual adult relationships not only with his siblings but also with his parents, and all of that would indeed do him a world of good. However, the forces for sameness and against change are powerful in most families, and the more damaged, frightened, and defensive the family members are, the more tightly they will cling to the ways they have always protected themselves. There were reasons your client could never connect much with his family before, and those reasons probably haven’t Downloaded by [New York University] at 13:36 13 August 2016 gone away. He may possess an expanded repertoire of relational organizing principles—but they may not. As a colleague once said to me about her efforts to communicate with the isolated, fragmented people in her family: “I’ve just realized that I’m doing all the right things—but with the wrong people.” It can be difficult for a client to accept that these people whom he always wanted to know and love might be the wrong people for him to try to be close to now. But mixed in with his disappointment and grief, there can still be an important difference in how he can be with them: He can knowingly choose to give up the struggle to connect “for real.” He can find that 170 Ending and Going On mix of closeness and distance that works best both to protect him from further hurt and also to express his compassion for their isolation and his respect for the complex persons that they are. It’s sad, but also good, he finds, not to need them to be different anymore. Your client’s differentiation of a self in relation to his family has not been an easy process. They haven’t helped it along much by changing with him. And yet even in these difficult family-of-origin relationships, his movement hasn’t been toward “autonomy,” toward being cut loose. It’s been toward learning how to be this son and brother in this family, this self with this particular history and heritage, and also this self who doesn’t have to replicate the pain of previous generations. Your client’s capacities to be a differentiated self-in-relation and to connect where connection is possible will serve him well in all of life, not just in close social and familial relationships. In relational theory, healthy self-with-other experience is the matrix from which all other competent, generative, creative capacities emerge. Self psychology tells us that selfobject needs, when met, develop into confident ambition, a commitment to ideals and community, and the capacity to feel and express empathy for others and to provide, in turn, for their growth and security. Interpersonal/ Relational psychoanalysis leans toward a vision of existential authenticity, but that dream is grounded by the relationality of its vision: authenticity is understood as engaged, respectful response to the other. Acknowledging his indebtedness to Benjamin’s feminist theory on this point, Aron says that one of the major goals of relational psychoanalysis is that analysands achieve the ability to participate, in all of life, in relationships of nondomi- nating mutual recognition.2 Stone Center theorists insist that individual relationships of mutuality are the ground for all healthy social relations. What matters is not how individuals develop autonomy, but rather, how individuals open themselves to mutually empowering relationships that extend outward in networks of respect and empowerment. Stone Center theorists hope to raise the profile of relationships that foster such growth, and in so doing, to redefine public Downloaded by [New York University] at 13:36 13 August 2016 visions and goals. They believe that women in particular, because of their relational strengths, must provide the leadership to move all of our societal structures away from systems based on violence and coercion and toward systems based on mutual connection and empowerment. In summary, and put briefly, this relational therapy is not primarily a journey inward. From the moments of “diagnosis” (what’s wrong?), to the therapist’s intention to be-with as fully and deeply as possible, to the kinds of goodness that flow from this connection, relational therapy is always moving away from the fantasy of individual self-sufficiency and toward the realities of human interdependence. Relational therapy offers no recipe Ending and Going On 171 for transcendence, no escape from the realities of history, culture, conflict, and oppression, no exit to a better life, no rising above pain. It offers only a better chance of being linked with others in this life, of knowing the joys of kindness, respect, and love, and of trusting that whatever befalls us, we don’t have to be alone. More could be said, but that’s likely enough. Ending is a phase requiring a conversation of its own, but not a long one. So it goes in therapy. When the ending is over, when you’ve reminisced and summed things up, when you’ve attended to gratitude, appreciation, regrets and good-byes, there’s nothing more to do but to let your client go on her way, ready and able to live the changes that therapy has set in motion. She is still the same person, living the life she’s been given, and yet you can both hope that her life can be profoundly (if quietly) different now—just because she’s finally more present, more comfortable and secure in herself, and more deeply connected with the people in her life who are on this journey with her. What you can do now is wish her “Bon voyage!”—and remember her. I wish you a good journey, too, as you undertake the challenging, difficult, and yet profoundly satisfying work of relational psychotherapy. May you find community that supports your continued development as a person and as a therapist.

Notes

1. Mary Main, “Recent Studies in Attachment: Overview with Selected Implications for Clinical Social Work,” in Attachment Theory: Social, Developmental, and Clinical Perspectives, ed. S. Goldberg, R. Muir, and J. Kerr (Hillsdale, NJ: Analytic Press, 1995), 407–474. 2. Aron, A Meeting of Minds, 148–154. Downloaded by [New York University] at 13:36 13 August 2016 8 Twelve Years Later

Ending and Going On was the last chapter of the first edition of this book, written twelve years ago. Therapy ends, I said, and life goes on. And so it has— for clients and therapists, and also for students and theorists of relational therapy. If a decade ago you read the first edition as a therapist in training, you’re a colleague now, and you know that we’ve seen relational themes gain strength in both psychoanalysis and psychotherapy. As relational forms of practice have become more clearly articulated, new clarity has moved practice in new directions, and then fresh theory has emerged. So it goes in our profession. In this final chapter of the book’s second edition, I will summarize four major articulations of relational theory that have appeared in the last twelve years. Then, to show what this theory means in practice, I will use it to reconceptualize the key case of Chapter 5, my experience of transference impasse with my analyst. Since life went on in that relationship too, I will also be able to use the new theory to explain how that therapy evolved and moved toward resolution. My closing discussion will suggest that while new theory offers new answers, it also raises new questions. And so the conversation continues, even as the book ends again.

Downloaded by [New York University] at 13:36 13 August 2016 Twelve Years of Theory

The essential principles of relational psychotherapy have not changed in twelve years. Relational therapists still believe their clients carry the effects of early relational trauma in how they experience and perform self-in- relation. They continue to invite their clients into a therapy relationship of intersubjective empathy, in hopes that new self-with-other experience will make new psychological organizing principles possible for them. “Self-with-other” is still at the center of relational theory, but twelve years later it is no longer just a useful concept; it belongs to how the human Twelve Years Later 173 brain is understood. A neurobiological argument for the radical relationality of human consciousness is the most noticeable new idea in relational theories of psychotherapy and psychoanalysis. But the argument that our brains are inherently social doesn’t stand alone; it’s intertwined with other important ideas—mentalization theory, theory about dissociation and enactment in the therapy relationship, and a nonlinear dynamic systems theory of change. Together these theories create the “new look” of relational theory and set the agenda for future explorations. In brief, the new narrative (for the old story) goes like this: a child’s healthy emotional/relational sense of self develops as a caregiver holds the emotional mind of the child in his or her emotional mind. Mentalization theory calls this process of responsive, containing connection “mentalizing.” Neurobiological affect regulation theory locates this between-minds process in the communion between the right brains of parent and child and explains how sustained failure of affect regulation leads to relational trauma and psychopathology. In the absence of right-brain emotional/relational connection, a child learns to hold self together through dissociation and enactments of feeling rather than through conscious, integrated emotions and intentions. In relational psychotherapy, this child, grown-up, is given a second chance at right-brain-to-right-brain attunement. In other words, she is offered a new attachment relationship within which to experience the regulating and mentalizing of affect. We could also say, as psychoanalysts of the Inter- personal/Relational school put it, that the client joins a partner-in-thought for the process of turning her dissociated enacted emotion, often a part of their mutual dissociated enactment, into meaning. All of these current relational theories would agree that when therapy is effective, change won’t be linear, predictable, or based on particular new insights or intentions. When understood in terms of dynamic systems theory, change in therapy has to do with emerging qualities of emotional fittedness, shared intentionality, trust, and vitalization between client and therapist. So these are the new moving parts in the updated engine of rela- Downloaded by [New York University] at 13:36 13 August 2016 tional theory. Since they are so dynamically interrelated, we could begin anywhere. We will begin with a theory that puts a previous structure of thought into action. The concept of mentalizing “operationalizes” attachment theory for the practice of psychotherapy.1

Mentalization Theory

Mentalization theory has origins in a reflective-functioning scale that Peter Fonagy and colleagues developed to assess the quality of adult 174 Twelve Years Later attachment interviews. With this tool, they investigated how parents’ level of reflective functioning, or capacity to mentalize, affected the quality of their children’s attachment style. The researchers found a strong association between secure attachment and parental capacities to hold a child’s mind in mind, and also between insecure attachment and m entalizing failures.2 A parent who can mentalize well understands her child’s experience vis- cerally while remaining clear that it’s different from her own experience. She attunes to her infant’s emotional states and presents them to her infant in a way that’s both contingent and marked, that is, both accurately related to the infant’s state and also “tagged” in some way to show that although the parent is communicating genuinely, it’s also not her personal emotion, but rather something “for sale” to the infant. The parent’s expressions gradually form the basis for the child’s ability to mentalize emotion: Feelings become recognizable; they can be shared; they don’t have to be acted out. Mental- ization creates a child’s affect regulation and impulse control and also a child’s sense of self. For a child, “Mother thinks, therefore I am.” Through this process of having one’s “inside” understood by another person in a visible, physical “outside” way, one’s mind develops from the outside in.3 Secure attachment relationships provide children with a secure base for exploring not only the external world but also their own minds in relation to other minds. Parent-child mentalizing interactions create the experience of intimate connection between separate thinking/feeling selves. Thus, a capacity to mentalize is first of all children’s awareness that minds exist, their own and others’. It enables them to recognize mental states, such as thoughts and emotions, in themselves and in others. Mentalizing allows them to imagine the inside experience of other persons, and to see themselves from the outside. The ability to mentalize makes it possible for children to learn to see both sides of a misunderstanding, just as it makes possible mutual intersubjective dialogue later in life. Fonagy and colleagues believe that clients whose childhood relational trauma left them with an insecure working model of attachment need Downloaded by [New York University] at 13:36 13 August 2016 treatment that has a mentalizing focus. They note, “Ainsworth linked secure attachment to sensitive responsiveness. Now we know that the core of sensitively responsive caregiving is mentalizing—and mentalizing emotions in particular.”4 Likewise, we could say that the concept of mentalizing captures the intersubjective action of empathy in psychotherapy, and this interactive empathy, I have argued, is indispensible to relational treatment of relational trauma. Recall that in Chapter 2 I described empathy as three interactive abilities: (1) the ability to feel into another’s experience with depth and breadth of understanding, (2) the ability to communicate this feeling/understanding Twelve Years Later 175 sensitively and accurately, and (3) the ability to feel with another while maintaining clarity about one’s own separate self and exp erience. What therapists do to make their empathy known and used is now called mentalizing—shorthand for all the complex self-with-other interactions that move empathy beyond the therapist’s understanding and into a shared client-therapist experience that can effect change. Through mentalizing interactions, a therapist both invites a client into self-understanding and helps create the capacity for it. A mentalizing enactment of empathy is what makes possible a client’s self-empathy. We mentalize when we respond to our client’s emotion in ways that are both contingent—a sensitive, accurate match—and marked—not identical with his emotion, and therefore clearly coming from our separate self. The process is most effective when we help a client recognize his emotion while he’s in an emotional state. Sometimes the emotion needs to be modulated down to make reflection possible, and sometimes it needs to be amplified so that what’s dismissed or suppressed can be met with accurate, articulate, invitational empathy. When mentalizing is effective, it’s not the property either of our mind or our client’s mind; it’s by definition a joint enterprise of mutual, cooperative awareness. Our part of mentalizing is more art than science; it requires our emotional engagement, spontaneity, imagination, and creativity. Attitude matters far more than technique. We bring to our clients open-minded acceptance of whatever is true and real for them; we explore with a gentle, keen curiosity that assumes no expert or prior knowledge. We focus on their current mental state, even when they are remembering the past. We share what we notice in a genuine way, without judgment, reflecting not only our clients’ thoughts and feelings, but also what we understand of their motivations and intentions. As we notice what clients are thinking and feeling about certain events or issues, we might become aware of alternative perspectives. Then we might speak of them as other possibilities, but without pushing a client toward any one of them. We are open and transparent about our participation in this joint pro- Downloaded by [New York University] at 13:36 13 August 2016 cess. When we notice clients assuming something we feel is untrue about our attitudes, feelings, or beliefs, we clarify our position as we understand it. Judiciously and tactfully, we let our clients know what we’re thinking and feeling in response to them. This allows them to correct what we might be misunderstanding and reinforces our mutual experience of our different knowable minds. We acknowledge our failures to “get it,” and when clients shut down or are overwhelmed by emotion, we explore what we might have contributed to the situation. We never claim to understand their process better than they do. We don’t leave our clients alone in long silences; we ask what’s happening for them, we share what’s going on for us, and we 176 Twelve Years Later welcome their thoughts on what might be going on for either of us. Safe mentalization includes our clients’ exploration of our minds—and finding themselves in the process. Mentalizing emotion means making emotion meaningful, but not in a third person, interpretive way. It’s not a process of telling a client what he thinks or feels or how his mind works. That’s pseudo-mentalizing, and it can be worse than useless when it leads to compliant agreement and a client’s estrangement from his own experience. A genuine process of mentalizing produces insight that a client experiences emotionally, and it can be filled out as a felt narrative of self. It’s the client coming to his own clarity about first person emotional experience. Men- talizing is feeling clearly—which is not the same as thinking clearly. A client’s experience of having clarity about emotion while “inside” the emotion is based on his experience of being understood not objectively but intersubjectively, an understanding that happens together, from the inside out. The whole back-and-forth process of clarifying emotions helps to constitute a self, in psychotherapy as in childhood development. In the words of Fonagy and colleagues, “Mentalizing emotion entails making up one’s mind.”5 For them, making up one’s mind means allowing one’s precon- scious, enacted emotions to become more fully and transparently conscious, taking ownership of emotion as a vital aspect of self, and in this process, changing what one thinks and feels. The development of personal agency is an important part of the process. When clients are able to have accurate, articulate empathy for their own emotional selves, they understand that emotions are always about something, always a way of grappling with the world and making sense of events. They recognize that emotion can quickly and reliably help them see things as they are, especially in relationships. Mentalized emotions lead to strategies that put agency and responsibility to work. The ethical dimension of emotion becomes clear, along with the existential value of emotional integrity— the experience of coherence within a rich, complex emotional life. Downloaded by [New York University] at 13:36 13 August 2016 As relational psychoanalysts and therapists, Fonagy and colleagues believe that mentalizing is especially potent when it responds to emotions that arise in the therapy relationship. In this process of “mentalizing the transference,” we take care to validate our clients’ experience of our shared interactions. We allow them to explore with us what both they and we might be feeling—or enacting instead of feeling directly. We own our own contributions to distortions and misunderstandings between us, welcoming perspectives that are different from what seems true to us. Always alert to our clients’ reactions to our input, we work collab- oratively toward an understanding of what’s happening between us that Twelve Years Later 177 fits for them and for us. Mentalization of the transference is emotional understanding of our shared current relational experience; it’s not an explanation of present behavior based on the client’s unconscious repetition of the past.6 In the process of therapy, clients may come to understand their histories differently, but the change they need occurs not in their autobiographical memory. Relationally traumatized clients need changes in “procedural knowing” about how to live with themselves and others. Such changes in implicit relational knowing are made possible in a relationship that specializes in mentalizing emotion. On this point, Fonagy and colleagues cite Daniel Stern, who insists that meaning and narrative can be created only through an interactive meeting of minds.7 They believe that with his focus on the present moment and on spontaneous, “sloppy,” unpredictable interaction, Stern has captured mentalizing in action. What he calls “moments of meeting” they call “mentalizing interactively in the transference.” References to procedural knowing and moments of meeting are a direct link from mentalization theory to the Boston group of clinicians, including Daniel Stern, who have used dynamic systems theory to explain how change happens in relational therapy. We will follow the link and discuss that theory next.

Dynamic Systems Theory

In Chapter 6 of this book, I referred to the Boston Change Process Study Group (BCPSG) and their opening key concepts, available by 2002: (1) “implicit relational knowing,” that is, nonverbal, procedural knowing about how to “do” relationship, and (2) the potency of “now moments” when they are seized as “moments of meeting” between client and therapist. In these emotionally charged interactions, a client risks change in her way of knowing another, and the therapist’s response is not only empathically accurate Downloaded by [New York University] at 13:36 13 August 2016 but also unusually spontaneous and personal. Such moments have excep- tional power to alter a client’s implicit convictions about what’s possible for her in relationship. In their subsequent writing, members of the group continue to put implicit relational knowing at the center of what relational therapy aims to change, and they don’t deny the power of moments of meeting. But they have moved away from a focus on high intensity moments in order to understand how many quieter moments also lead to new forms of relational knowing and being together for client and therapist. They propose that the moving along process of therapy is made up of strung-together 178 Twelve Years Later present moments, “chunked” into relational moves that each express intention. These micro-process intentions of client and therapist interact to form an ongoing dyadic system of intention and meaning. It’s within this system that changes in relational knowing happen both in sudden shifts and in small increments, and they happen according to the logic of dynamic systems theory.8 Without dynamic systems theory, we might not be able to understand how the inherently unpredictable, noncausal, nonlinear process of therapy, happening second by second at what the BCPSG calls the “local level,” could ever foster coherence and well-being. From a dynamic systems perspective, however, this sloppy indeterminacy simply belongs to the complexity of a system created by two minds trying to read each other’s implicit intentions. In fact, sloppiness is useful, since it both allows and demands co-creativity in the continual search for “fittedness” between two participants in meaningful conversation. Welcoming sloppiness also changes our attitude toward repetition and redundancy in therapy—the sloppy takes form bit by bit—and it gives us more tolerance for what might look like error in a therapy interaction but could actually be just expectable flux or the new emergence of unexpected properties of the relationship. We feel our way along such unscripted relational transactions through a process of mutual recognition: each partner reveals intention and recognizes the other’s intention, and when recognition is working well, each has a direct apprehension of an increased fitting together of their mutual intentions toward jointly held goals. A simple example: A client makes the relational move to share a thought, showing an intention to get understanding; the therapist apprehends that intention and makes a reciprocal move: a nod, smile and word of recognition, “Ah ... yes.” The client intuits the therapist’s intention to understand by registering the implicit “fittedness” of the therapist’s move, and then, expecting further understanding, the client expands on his own thought. Most of the moment-to-moment intentions and goals of the therapy dyad are implicit, as is the increased coherence or organization of the dyadic system as a whole. We and our clients can be Downloaded by [New York University] at 13:36 13 August 2016 confident that everyday, moving-along fittedness is happening when we feel enhanced well-being or “vitalization” in the relationship. Though we have conscious choice about how we behave with our clients, we can’t script or engineer changes in our relationship with them. As a dynamic system with many independent variables in motion, our mutual therapy relationship will self-organize. Change in such a system’s self- organization is not random; the system always moves toward more coherence, but the process is unpredictable, and it happens in discontinuous ways. Change in the system happens because, while we work consciously at having a meaningful conversation, we also work unconsciously at Twelve Years Later 179 recognizing the implicit, affective intent in each other’s relational moves— in order to come not only to shared verbal understanding but also to a “fitted” sense of mutual relational intention. The meaning that matters most in the BCPSG’s definition of psychotherapy is the meaning that lives in the implicit domain of affect and intentionality. Implicit relational knowing, a process that begins with an infant’s mental/emotional RIGs (representations of interactions that have become generalized), cannot be well-symbolized in language. Implicit knowing can be brought to consciousness only with great difficulty, and even then a narrated version may never really capture it. Implicit knowledge is not more primitive than verbal knowledge; in the course of development, it is not replaced by language or transformed into language. Rather, as we age, the implicit domain of knowledge about human behavior, always larger than explicit knowledge, grows in breadth and elaboration. In this implicit domain, intention is the basic unit both of experience and of meaning. When we intend, we mean. Psychotherapy is most interested in the intentions we have to adjust the states of relationships. “Intentions are the elemental psychodynamic units at the level of perception and interaction and from these, other psychic structures are composed.”9 In this light, interpretations about conflict and defense can be seen as abstractions of what is truly profound. The deepest level of meaning is lived experience, since this is where intentions are revealed, intentions that enact implicit relational knowing. This is how BCPSG theorists turn the traditional psychoanalytic meanings of “deep” and “superficial” upside-down. Deep meaning, they say, resides in our lived engagement with others around central developmental needs, and in how we hold those patterns of engagement in implicit memory. The sloppy, everyday, “local” level of interaction in therapy provides the raw material for grasping these deep psychodynamics. We can’t help but respond to them implicitly, and we may also translate them into explicit understanding, using psychodynamic concepts to approximate Downloaded by [New York University] at 13:36 13 August 2016 what we experience. It’s not that verbal knowledge doesn’t matter. The two kinds of knowledge—implicit and verbal-reflective—are not in competition. In fact, they are not really two separate phenomena; they are often intertwined. It’s not the case that the implicit is nonverbal; implicit meaning lies between the lines of logic and in the affective music of what is spoken. Our words for mental experience are often metaphors grounded in physical experience. Both implicit and verbal-reflective meanings are organized around intentions, and both emerge in sequences of small chunks of time that can be grasped intuitively as a kind of narrative. 180 Twelve Years Later These two modes of expression are, however, generated from different perspectives, the implicit from immediate subjective experience, the verbal-reflective from a delayed, more external perspective. And so there is also a disjunction between the two modes of meaning. But the difference is not to be understood as a fracture or a loss. Neither mode of meaning creates a distortion of the other mode. Instead, as the verbal arises from the implicit, the disjunction between the two is itself an emergent property of this verbal “arising.” Here again BCPSG theorists turn to dynamic systems theory to bring coherent understanding to a complex, in-motion process. Their point is that in the real world of conversation, we hear not one or another mode of meaning or a disjunction between them, but rather whole gestalts of meaning, each a micro-meaning-system made up of (1) an intention implicitly experienced, (2) a verbal reflection more or less grounded in the implicit and emerging from it, and (3) an inevitable discrepancy between (1) and (2). A dramatic breach of coherence between implicit and verbal is meaning, too. As we talk back and forth with our clients, meaning evolves and comes to more coherence as each of us intuitively grasps and responds to how the three forms of meanings interact dynamically. Change in psychotherapy, the BCPSG theorists conclude, is produced by the quality of the client–therapist relationship. They note that change in psychotherapy has always been linked with “nonspecific factors” in the “therapeutic alliance.” They maintain that change in therapy is due, instead, to qualities that can be precisely specified and are properties of the actual therapeutic exchange between client and therapist. These qualities don’t belong to the therapist’s interventions, but rather to a dynamic interpersonal system. In fact, the prime quality of such a system is that it is interactive. Other qualities include: that it creatively negotiates sloppiness and indeterminacy; that it searches move by move for a mutual sense of fitted responses; that such fittedness leads to mutual vitalization; that the system produces a series of nonlinear shifts toward more organization and coherence; and that these shifts include in relational experience what was previously excluded, reflecting changes in implicit relational knowing. Downloaded by [New York University] at 13:36 13 August 2016

Theory about Mutually Dissociated Enactments

Both mentalization theory and BCPSG theory about change processes in psychotherapy have their roots in theories of infant development, as do self psychology and intersubjectivity theory. Throughout this book, I have also discussed a stream of relational theory that is less developmentally minded and more focused on how adult clients create existential meaning in dialogue with their therapists. In the last decade, analysts of this Twelve Years Later 181 Interpersonal/Relational (I/R) tradition have focused on the problems of dissociation and enactment within the psychoanalytic relationship, and their theorizing has converged in significant ways with theories of mentalization and non-linear systemic change in psychotherapy. Early interpersonalist psychotherapists believed that clients’ patterns of interaction with others caused them psychological harm. As “participant- observers” in therapy, they intended to help their clients change their problematic interpersonal patterns, first in therapy and then in their larger world. Instead of interpreting their clients’ unconscious sexual and aggressive drives, they sought to bring to their clients’ awareness their patterns of interaction, choice, and meaning-making. They believed that within insightful, challenging therapy relationships, clients could break old patterns and discover new authenticity and freedom. But the aspects of self that generate problems are not easily brought to awareness; they tend to remain alien and not-me. Analysts of the I/R stream recognize a powerful process at work to keep not-me far away from a conscious experience of me. They describe this process not as “vertical” repression down to the unconscious, but rather as dissociation, a “horizontal” disconnection from what cannot be integrated and remains in uncon- sciousness, outside of awareness and unformulated as knowledge. Thus coming-to-know is not an excavation of truth buried long ago, but rather a search for elusive not-me parts of self moving unrecognized through here- and-now relationships. We catch sight or feel of these unknown aspects of a client’s self as they interact with us in therapy; the relational unknown shows itself through enactment. The key question for I/R analysts is about unconscious enactment in the therapy relationship: “What’s going on around here?” The question becomes more challenging when therapists realize that they, too, dissociate from difficult, not-me experiences of self. Relational psychoanalysts long ago gave up the belief that they could stand outside a therapy relationship to observe it from a neutral place. They came to embrace the inevitability of self-disclosure and to argue for mutuality in psychoanalysis. Lately Downloaded by [New York University] at 13:36 13 August 2016 they have been keen to discover what it means to analysis that both they and their clients may “go unconscious” and fall together into an enactment when the therapy relationship becomes difficult. Exploring unknown aspects of self in therapy is a risky endeavor for almost anyone. Most of us have areas of unprocessed developmental trauma, aspects of self that have been disconfirmed in our early relationships. Not only have these parts of self never been known, but to know them now carries the threat of overwhelming shame.10 This unbearable experience of not-me is what a client must keep out of self-awareness. A good way to do so is to throw up a defense that elicits the therapist’s shame; 182 Twelve Years Later “I am not contemptible; you are contemptible” is the unconscious solution to the problem.11 When we find ourselves, as therapists, in an unconscious world of shame and contempt, we dissociate from our own vulnerability with our own defenses. The enactment is then mutual; both we and our client are dissociating from shamed not-me identities that threaten to break in. Within the enactment, both of us are also disconnected from other more coherent aspects of ourselves and from the possibility of mutual intersubjectivity. As we each feel personally the impact of the other’s not-me, our unconscious subjectivities collide, and so collaboration is out of the question. But these collisions hold powerful therapeutic potential, for enactment is also communication that involves unconscious state-sharing between partners in the relationship. These unconscious states can be brought to conscious formulation (not necessarily verbalized) through a process that in its simplest form is called affect regulation. The process can also be called mentalization, which—even when it uses words—is a joint endeavor not to think accurately, but to feel accurately from inside shared emotional experience. This co-constructed articulate empathy about what’s going on is the work we must try to facilitate even while we are feeling—and not feeling—what we don’t understand. Clearly we can’t be useful partners in this work unless we are willing to accept our own emotional vulnerability with empathy and articulate it to ourselves. In other words, we must, as best we can, pursue our own vulnerability behind the veil of our own dissociation.12 We must also, with affective honesty, communicate our intent to be with our client’s dissociated fear and shame while doing the work. Only the willingness of each partner to share emotional experience, to struggle with the other’s experience, and to do both with authentic mutuality makes the process of working through a mutually dissociated enactment safe enough to tolerate. Trying to move through enactment with mentalizing empathy is not a linear or interpretive process. Even as emotions are recognized, they don’t necessarily “make sense” of what’s happening. Nothing rational or ver- Downloaded by [New York University] at 13:36 13 August 2016 bal dissolves not-me dissociation; what changes, eventually, is a sense of affective relatedness between partners. 13 Dissociated selves must be held long enough within the intention of an accepting connection for them to feel somewhat recognized. Even tenuous, fragile recognition releases new potential for relational negotiation and intersubjectivity.14 As each partner begins to perceive the other in a slightly different way, connection with a more whole, integrated sense of self-with-other becomes possible. Verbal-reflective insight may follow these implicit shifts, but it’s not essential to the change process. Change in the client’s self-narratives will occur according to the inner logic of a non-linear, self-organizing dynamic Twelve Years Later 183 system. The power of any new narrative will be in the telling—in the tell- er’s expanded sense of self and newfound freedom to experience self with other openly and reciprocally. Even as the paralysis of enactment resolves into the movement of narrative, “It is not so much that we learn the truth, but that we become more than we were.”15 This is a new way to express the Interpersonal/Relational tenet that “the primary source of therapeutic action is the relationship, not something created through it .” 16 Mutual dissociated enactment happens to relationship, and then, as enactment resolves, nonlinear, dynamic change emerges in different forms: in the recognition of not-me parts of self that allows their presence within self and relationship; in joint, intersubjective mentalizing; in the co-creation of new stories; and in mutual shifts from dysregulated to regulated affect. With the language of affect regulation, Interpersonal/Relational theory invokes brain science. Dissociated enactment happens because not-me is an unbearable neurobiological affect state, unbearable because it has never been held within the brain-to-brain “regulation” of understanding acceptance. Not-me is the neurobiological experience of a deep, core failure of affect regulation, a failure of other-with-me. That’s why not-me can be brought back into self only through enactment, that is, only through an experience of other-with-me when I am in that very state of not-me. This not-me state is a non-verbal, right-brain state of distress; in that state, I need an other who can sustain right-brain connection with my right brain.17

The Relational Brain

Philip Bromberg, an I/R analyst, asked Allan Schore to write the forward to The Shadow of the Tsunami and the Growth of the Relational Mind, his 2011 book on processing dissociated mental states with relationally traumatized clients. Schore responded with a neurobiological perspective on dissociated enactment, explaining that the dreaded “tsunami” experience Downloaded by [New York University] at 13:36 13 August 2016 of not-me is a flood of unregulated hyperarousal, and that dissociating this affective experience is the only option when there is “a lack of integration of the right lateralized limbic-autonomic circuits of the emotional brain.”18 This lack of right-brain integration prevents relationally traumatized clients from knowing or communicating core emotional states; nevertheless, according to Schore, enactments allow those states to become experienced in the right-brain state-sharing that happens in “safe enough” moments of heightened affect in therapy. Enactments are nonverbal communications of emotional states between client and therapist. When regulated, these 184 Twelve Years Later conversations between limbic systems facilitate the top-down and bottom- up integration of the right brain.19 Among brain-oriented theorists of psychotherapy, Schore is unique in his focus on the right brain. Louis Cozolino, by contrast, explores how psychotherapy enhances neural network growth and integration throughout the brain.20 Mentalization theorists echo Cozolino’s language when they point out that attachment relationships have the task of ensuring the full development of the social brain. They note that the multifaceted nature of mentalizing requires the participation of many diverse brain structures.21 In Daniel Siegel’s interpersonal neurobiology, brain, mind, and relationships are irreducible and interconnected aspects of what we experience as a flow of energy and information. We are psychologically distressed when that flow veers toward chaos, and psychologically limited when rigidity impedes the flow.22 Siegel proposes that brain-wise therapy enlists the power of the mind to monitor and modify this flow, to make changes where our subjective lives suffer chaos or rigidity. The healthy alternative to both is “integration,” which Siegel describes as the integration of various neural networks in the brain—not only right-brain vertical integration, but also the integration of right and left hemispheres of the brain, the integration of memory, narrative, and multiple self-states, and the integration of the “I/we” experiences of intersubjectivity.23 He proposes a therapy of mindfulness, an applied science of mindsight, to enhance all such neural integration.24 Bonnie Badenoch’s guide to practicing interpersonal neurobiology begins by validating each of Siegel’s paths of neural integration, but her clinical focus keeps returning to the essential work of right-brain integration for relationally traumatized clients, whether this is accomplished through affect attunement, lively negotiation with intensely felt parts of the client’s self, or creative art and sandplay. People with histories of failed affect regulation and relational trauma need healing of the right hemi- sphere circuits that underlie mental health, she says. Right-brain vertical integration is the foundation of all other integrative work. Long before our Downloaded by [New York University] at 13:36 13 August 2016 clients have the capacities for self-directed mindfulness, right-brain integration can be facilitated by our emotional connection with our clients’ inner worlds. Thus Badenoch speaks of languages of attunement when she describes her work with these clients.25 Such clients, traumatized in their relational development, are exactly the clients that relational therapy has in mind. As I said in the introduction to this book, intensive relational therapy is designed to help especially those clients who need relief from life-long unconscious self-with-other patterns that are both tenacious and destructive. This, then, is the prime reason that Schore’s right-brain approach is particularly relevant to relational theories Twelve Years Later 185 of psychotherapy: relational trauma is right-brain trauma that needs right- brain help. It’s also useful that Schore’s clinical affinities include attachment theory, object relations theory, self psychology, and interpersonal/ relational psychoanalysis, and that he strives to make his research and writing relevant to his relational colleagues. Twenty-first-century brain science tells us that the human brain is a social organ, shaped and sustained by interpersonal relationships; Schore makes the further point that the essence of its relationality resides in the functions of the emotional/ relational right brain. Schore understands attachment as a bond of emotional communication expressed through gaze, voice tones and rhythms, and other mutual bodily responses between caregiver and infant, encoded as right-brain information. Synchronous affect communication corresponds to an infant’s positive state of affect. When the infant experiences negative arousal, synchrony is lost until the caregiver is able to repair it and in the process help soothe the infant’s distress-affect. This responsive right-brain-to-right-brain regulation keeps the infant’s autonomic nervous system within an optimal range of arousal and allows his relational/emotional brain to continue to develop well. Should a caregiver respond intrusively or fail to respond to the infant’s need for emotional regulation, the infant’s autonomic nervous system will react first with hyperarousal and then with dissociation. If these dysregu- lating interactions happen often, an infant will make a self-protective habit of dissociating from emotional connection. Then the development of his right brain, or relational/emotional brain, suffers. In this way, the repeated trauma of dysregulation becomes stunted right-brain connectivity. In adulthood, chronic right-brain dis-integration produces both the threat of internal chaos and rigid self-protection, along with profound disconnection from one’s own emotions and from emotional contact with others. If relational therapy is to address this right-brain trouble, it must do so in right-brain ways. A right-brain therapy process depends on accurate attunement and felt being-with, or in other words, on reliable repetitions Downloaded by [New York University] at 13:36 13 August 2016 of right-brain connections that help expand right-brain capacities. The therapist’s responses follow as closely as possible on the client’s immediate experience, communicating interest, support, and understanding, in an affective resonance that shifts with the smallest shifts in the client’s affective state. Whenever there is a moment of affective charge, the therapist holds it with heightened affective resonance, with words, perhaps, but without interpretation. In time and with many safe repetitions of such interpersonally resonant moments, the client will be able to stay with amplified affective states and perhaps even put words to them. This is how unconscious affect becomes 186 Twelve Years Later regulated affect, which then can become subjectively experienced emotional states and tolerable parts of self. The client no longer has to dis- engage from emotional contact with all other people to keep himself safe from dysregulation. A safe emotional connection with another person also makes it possible for the client to be with his own emotions more comfortably. In terms of neurobiology, this regulating therapeutic relationship creates more interconnectivity in the client’s right brain, both horizontally and vertically. More right-brain systems become involved in his processing of emotion, and with more plasticity. He experiences a broader range of emotion and more complexity in both his emotions and his defenses. This more developed way to self-regulate will be more flexible and useful than dissociation. Rather than being alien threats to self-cohesion, the client’s emotions will now expand and unify his sense of self. He will be in a better position to solve problems using both logic and feeling, and more able to find connection and satisfaction in interpersonal relationships.26

Relational Theorizing as a Process of Dynamic System Change

Now we’re in a position to explore how these four new versions of relational theory interact with one another and with previous therapy to shape current relational work. This interaction can be seen as part of a dynamic system of relational theorizing, which continues to undergo self-organizing processes of change and development. Throughout this book, my premise has been that a relational theory of psychotherapy can be understood as a coherent entity. Despite different emphases, self psychologists, self-in-relation therapists, intersubjectivity theorists, relational psychoanalysts, and attachment theorists have been committed for several decades to many common principles, for example: What happens to us in our early relationships has profound implications for Downloaded by [New York University] at 13:36 13 August 2016 our emotional well-being in adulthood. Our early relational history becomes encoded in unconscious patterns of emotion, thought, and behavior. The distress we bring to therapy feels personal, but the patterns that cause it are fundamentally interpersonal. Psychotherapy brings problematic self-with- other patterns to light, especially as they are played out in the client–therapist relationship. Therapy changes patterns for the better by helping us reflect on them and by engaging us in a new relationship that gives us chances to form healthier patterns based on restorative self-with-other experiences. These themes are general properties of a theoretical system called “relational psychotherapy.” The variables within its theoretical subsystems Twelve Years Later 187 are many, and in the course of the last dozen years the variables have inter- acted with one another through articles, books, and conferences, and in the context of a changing environment—one that includes a plethora of brain studies and pointed questions about the efficacy of nondirective, process- oriented therapy. Within this dynamic system of theorizing, new properties of understanding have emerged, coalescing as new subsystems with names such as mentalizing, dissociated enactments, the relational brain, and dynamic systems theory. If relational theorizing is a dynamic system, it is constantly reorganizing itself toward progressively more coherence. Every new organization of theory creates new assemblies of the system’s elements, and with each new assembly the preexisting elements undergo change. Does this mean that when new theory emerges, coherent theorizing requires a thorough rewriting of previous theory? Possibly—and then a completely new primer of relational psychotherapy would be in order. But in this chapter I’m hoping to do the next best thing: point out where the new theorizing makes more sense of what was not quite coherent before, and share my understanding of the larger coherence created by the emergence of the new from the old.

Insight and/or Experience?

Relational theory has proposed that a therapy relationship leads to change in two ways: It enables clients to reflect on their emotional/relational organizing principles with greater insight, and it provides a new experience of relational empathy and authenticity. Relational theorists have struggled with the relative significance of each factor and how they are interrelated. Is change simply some lucky or best combination of insight and corrective emotional experience? Is there a more coherent way to talk about how the therapy relationship induces change? The emergent relational theories we’ve discussed all move toward Downloaded by [New York University] at 13:36 13 August 2016 more coherence on this question. For example, rather than seeing insight and emotional connection as two different processes, neither of which is exactly the engine of change in therapy, mentalization theory proposes that r eflecting on emotion while in the embodied emotion creates co herent selfhood. Coming to feel and to possess one’s own emotional mind through intimate, interactive contact with another person’s emotional mind is simultaneously the insight that fosters emotional change and the experience of being deeply accepted and understood. M entalization theory describes how to do the insightful “talk” of the talking cure within an attuned state of being-with. Emotion may be the focus of what we 188 Twelve Years Later “hold in mind” for clients, but it’s emotion understood in the context of related mental states, including thoughts and intentions. BCPSG theorists hold meaning and emotional experience together too, as they focus in on what causes change in psychotherapy. In their high- resolution, slow-motion shots of what happens between client and therapist, intention emerges as the basic unit of shifting mental states. Intention means and it also carries emotional valence. Intentions negotiated between client and therapist are the “chunks” of thought/felt psychological experience that together create patterns of implicit relational knowing. A client’s procedural knowledge of how to “be-with” becomes more confident, free, and secure within the experience of moving with a therapist toward more fittedness of intentions toward shared goals. An emotionally felt sense of shared intentionality is what produces change, even while the shared goal is a better understanding of the client’s experience. Thus BCPSG theory both prioritizes implicit experiential knowing and also welcomes the verbal reflection that arises from the implicit. The therapy conversation generates gestalts of meaning made up of implicit experience, the “emergent” explicit reflection it produces, and the relationship between the two. Insight and experience are not at odds or even on two separate tracks, but belong to one dynamic system of knowing. For Interpersonal/Relational psychoanalysis, context, process, and affect have become the keys to change, replacing content and cognition. The therapist focuses on being actively involved with shifts in the client’s states of emotional being, noting interactions and collisions among the client’s (and the therapist’s) me and not-me affective states. As the therapist becomes a safe partner in this exploratory process, the client’s brain needs less recourse to protective dissociation, and then his mind can support more intersubjective dialogue. Each time therapist and client can bring more shared awareness to something that is taking place between them, the domain and fluency of their dialogue is enlarged. This experiential process, according to Bromberg, is the essence of the “insight” that dissolves dissociation and eases distress.27 Downloaded by [New York University] at 13:36 13 August 2016 Developing I/R theory about dissociated enactment has brought Donnel Stern to new language for a nonreflective, experiential form of insight. He now proposes that both verbal and nonverbal meanings can be formulated, the verbal as “articulation,” the nonverbal as “realization.” Realization is based on perception—the affective feel of a situation, especially what it feels like to be with someone. Clients and therapists find ways to move through enactments and integrate not-me experience through shifts in perception, not through verbal-reflective insight. A relational therapeutic process allows client and therapist to feel new meanings together, and sometimes, but not always, to formulate those meanings verbally. New felt Twelve Years Later 189 meanings are what expand both participants’ capacities to live with themselves and with others.28 There is also a “relational brain” explanation for why insight and emotional experience are not two separate processes: As Schore reiterates, the right brain is the home of the entire emotional/relational mind, a mind that includes not only visceral emotion, implicit relational knowing, and links between emotions, images, intentions, and motivations, but also a right-brain thought process that creates not a linear/logical narrative, but a felt sense of self. A new right-brain thought/felt sense of self is the kind of visceral insight that marks moments of change in therapy. It could be called affective self-with-other perception or “realization”—but by any name it is a genuine and powerful formulation of meaning that does not need rational-verbal articulation.

Personal Change and/or Systemic Change?

Another apparent dichotomy for relational therapy turns up in the question: When therapy works, is change intrapsychic or intersubjective? Is it located in the client or in the relationship? Every relational theory has answered, “In both!”—but with its own emphasis and balancing of weight between the two locations. Self psychologists believe that their empathic connection with a client makes possible selfobject experiences that will repair deficits in the client’s self-experience. Intersubjectivity theory puts the interaction of therapy within a reality co-created by the subjectivities of client and therapist, and this interaction, with mutual reflection on it, is what changes the client’s psychological organizing principles. Self-in-relation theorists define healing as a relational phenomenon, a return from chronic disconnection to the experience of reliable in-relation empathy, mutuality, and interdependence. Interpersonal/Relational analysts insist that a client’s emotional truth is always embodied in the nature of his relatedness with others, and that therefore healing happens as that relatedness changes. Downloaded by [New York University] at 13:36 13 August 2016 What has emerged from the dynamic coexistence of these theory variables is a more coherent account of how change in a client’s personal experience is grounded in the we-ness of the therapy relationship. Here the Boston Group leads the way, maintaining that the negotiated intentions of partners in therapy create dyadic states of consciousness that become a dynamic interpersonal system; the system itself then negotiates sloppiness, searches for mutual fitted responses, produces nonlinear shifts toward more coherence, enhances shared trust and energy for its participants, and also effects changes in the client’s system (and often the therapist’s system) of implicit relational knowing. 190 Twelve Years Later Mentalizing, with its relationship to attachment theory and a parent’s responsibility to hold a child’s mind in mind, can sound like something we therapists do to change a client’s mental state. Mentalization theorists, however, push the theory strongly in a we-ness direction, toward the idea that clients will find their minds “within our minds” as we explore together the emotional states that arise between us. In this vein, they claim that nonlinear dynamic systems theory describes joint client–therapist mentalizing in action. In response to mentalization theory and from what he believes is a more radically relational (I/R) perspective, Donnel Stern argues that although reflective function may pave the way for change in relational we-ness, in most instances of profound trouble, change in relatedness must come first. This is the case because we cannot reflect on any of the unconscious aspects of the emotional states we share with clients. More specifically, mutually dissociated enactments cannot be mentalized by either partner; by definition such enactments are unconscious. Enactments are resolved through nonreflective affective shifts in perception between partners. These shifts make it possible for the partners to resume shared reflection and creation of narrative. In other words, the mentalization most critical to integrating dissociated not-me experience always follows a shift in affective relatedness; what happens within emotional we-ness is always primary.29 Right-brain theory builds on the we-ness of attachment theory, which links childhood security to certain patterns of parent–child interaction called attachment styles. Right-brain “connectivity” is a more compre- hensive picture of a child’s emotional well-being, produced and supported by all the qualities of emotional attunement that move between the right brains of parent and child. Consistent affect regulation yields open, flexible emotional/relational capacities. In synchrony with the other new relational theories, right-brain theory stresses that this right-brain well-being is not the linear result of certain parental actions; it is, instead, one of the dynamic properties of an ongoing interactive system. Likewise, when a client experiences shifts in her emotional/relational capacities, these changes belong to her right brain as it communes with our right brain, or to put it Downloaded by [New York University] at 13:36 13 August 2016 in Schore’s more technical terms, her personal shifts can be understood most fundamentally as micro-shifts in mutual bidirectional right-brain- to-right-brain processes.

A New Take on Self-Disclosure

As this new theorizing reconfigures older ideas about the nature and location of change in therapy, it also reconfigures the meanings of mutuality and self-disclosure within relational practice. When Lewis Aron wrote Twelve Years Later 191 A Meeting of Minds: Mutuality in Psychoanalysis in 1996, he noted an explosion of interest in self-disclosure. As soon as therapy was understood to be a two-person endeavor involving the interactive subjectivities of partners, the question arose: What exactly is it that we therapists bring to the mutual conversation? Aron pointed out that with every interpretation or intervention, as well as with our general habits of response, we disclose far more of ourselves than we ever know. Beyond that, he recom- mended that we “show some emotion” while maintaining a creative tension between offering our clients cognitive, interpretive understanding and affective, interpersonal engagement.30 But from the perspective of newer relational theory, not only is self- disclosure unavoidable, permissible, and often useful, it is in fact absolutely necessary to the process of change in psychotherapy. What has emerged as necessary is a very particular kind of self-disclosure, and it appears in each of the new subsystems of theory we have discussed. For example, while offering contingent, marked responsiveness to their clients’ emotions, mentalizing therapists also share their own feelings, thoughts, intentions, and motivations that arise in response to clients’ mental states. Since they believe mental states are generated by the relationships in which they emerge, these therapists trust that sharing the workings of their emotional minds in relation to their clients’ minds gives their clients a chance to clarify the workings of their own minds. Therapists (such as those in the Boston Group) who think of therapy as a system of personal intentions moving in unpredictable ways toward mutual fittedness are open about their intentions to connect and understand. How they participate in shaping directions for therapy reveals their personal “realness.” The most striking example of mutual fittedness arising from the real is a “moment of meeting,” a moment when a client risks connection in a new way and the therapist’s response is unusually spontaneous and personal. What follows is a sudden qualitative shift, felt by both client and therapist, in their mutual implicit relational knowing. For the Boston Group, however, even everyday client-therapist intersubjectivity includes Downloaded by [New York University] at 13:36 13 August 2016 the partners’ mutual knowing of what is in the other’s mind, as it concerns the here-and-now nature of their relationship. Such knowing, whether articulated or not, moves the relationship toward further inclusiveness and the qualities that support well-being. Mutual knowing and being known is the essence of Interpersonal/ Relational psychoanalysis, and mutual dissociated enactment stops that process cold. The process warms up and resumes only when client and therapist together find a way back to relatedness. Enactments are not only inevitable; they may also constitute a therapist’s most important clinical opportunities with particular clients. To make the most of these 192 Twelve Years Later opportunities, what we need, Stern says, is to accept our vulnerability. This means we accept that our clients influence us unconsciously and that we cannot think our way out of an unconscious dilemma with them. Rather, we openly share with them our sense of dilemma and our waiting for a shift in our mutual perceptions of each other. Only after an affective percep- tual shift happens can we mentalize it with them, creating a narrative that makes sense of how our mutual vulnerabilities collided. Relational brain theory also backs up the emerging new significance of affective self-disclosure. We disclose the depth and complexity of our personal being when we engage in a right-brain-to-right-brain-regulating relationship with another person. “Regulating” means being emotionally “right there” and available, keeping relational contact, and interacting with an openness that helps us and our clients make emotional sense of our shared interactions. None of this can happen unless we bring our whole embodied emotional selves to the relationship. From each of these new theoretical perspectives, self-disclosure is a crucial aspect of our empathic, authentic relatedness with our clients. When what we disclose is our experience of the emotional/relational system we share, and when we pay attention to timing, tact, and conversational rec- iprocity, we can hardly show or say too much. We need not be anxious about “losing boundaries,” for clarifying who is thinking and feeling what about whom clarifies not only a sense of self, but also a sense of differentiation between selves. This is not “wild therapy” or “peer therapy.” The mutual therapy relationship remains asymmetrical, oriented to the client’s quest for wholeness, healing, and freedom. Our own emotional and relational lives are at issue only as they shape our experience of this interaction here and now. When we use self-disclosure to help move the therapeutic relationship toward more mutual fittedness, trust, and vitalization, questions about “gratifying” ourselves or our clients with what we share seem beside the point.

Downloaded by [New York University] at 13:36 13 August 2016 In Summary

The theorizing of relational therapy is reorganizing itself in response to the following new ideas as they arise from and interact with previous theorizing: (1) The cognitive insights and the emotional/relational experiences that lead to change in therapy emerge from one complex process, a dynamic interaction of explicit and implicit, thought and feeling. (2) This dynamic meaningful process of change, irreducibly and fundamentally relational, happens at the “local level” of micro-interactions between client and therapist, both cumulatively and in sudden, non-linear leaps to Twelve Years Later 193 new coherence. These shifts in relatedness precede changes in implicit relational knowing and changes in articulated insight. (3) Facilitating this interactive, dynamic, here-and-now process requires a specific kind of self- disclosure from us as relational therapists: our full, real presence at that local level of interaction, including our willingness to share the workings of our emotional mind as our client searches to find his mind/self “within” our mind—or in collision with it. These new organizations of relational theory have emerged not because the theory itself has an inner logic that moves toward self-realization. Rather, all of relational theory arises from what happens in real relationships “on the ground” between clients and relational therapists. Theory changes as therapists put what they understand into practice and then try to account for what happens next, especially when they don’t entirely understand it. If the new themes we have discussed truly offer a more coherent organization of relational theory, we should be able to see and feel that coherence in new accounts of practice. At this point in the chapter, then, some case material would be useful, especially if we could look at the case first in terms of the old coherence and then in terms of the new.

Twelve Years Later: A Case Example

For more than a decade, I have fielded questions about the transference impasse I came to with my analyst, documented in Chapter 5 of this book. I wrote the account to help myself through the impasse, and I included it to show that moving through a difficult transference enactment can be a useful part of a longer-term, helpful therapy. I’m returning to it now because the original case material can be reformulated in terms of the new relational theory we have just discussed, and also because the case has moved forward to a resolution best understood, I think, in those new terms. As you will remember, I asked my analyst to read something I had written, and when he said he couldn’t for a while, I was flooded by shame. In Downloaded by [New York University] at 13:36 13 August 2016 terms of the relational theory I understood at the time, I saw the event as a repetition of my failure to find the connection I had once wanted with my father. I enacted this longing with my analyst, and then I made of his response a story that matched my organizing principle: I should not have asked—because there’s something deeply wrong with my need for connection and with how I express it. As I struggled to bear my shame, I decided to value being able to feel the pain of the old experience and what it had taught me; I thought this would help me toward more self-integration and less punishing organizing principles. I was using intersubjectivity theory about repetitive transference to make sense of what was happening to me. 194 Twelve Years Later My therapist did not dismiss my interpretation of my own repetitive transference or my willingness to “work it through,” but insisted that nothing would be gained—nothing would be better—unless I could feel better with him again. As a solid self psychologist, he attended to the selfobject transference, doing what he could to repair the rupture. He framed my need as positive—like learning to walk—and his first response as “putting a chair in my way.” In other words, my archaic selfobject needs were legitimate, getting them met was making me stronger, and on the whole they deserved a positive response from him. After my fall into shame, my analyst accepted whatever I could tell him about how I felt, and I knew that in these difficult sessions he intended, as always, to understand me from inside my emotional experience, which included my experience of him. When I was convinced that he was not willing to listen to me or understand me, he did not argue with my reality. I was not able to move on, though, until he made a move of his own to “go back” to what had happened between us. I asked him then why he had waited so long. I couldn’t understand the reason he gave, and said so. But just the fact that he answered my question allowed me to find my way back to conversation and relatedness with him. The story moves on to closure, but as many readers have sensed, it’s not complete; something is missing. The clues to what’s missing are in the story. As I struggled with my shame, I needed, it seems, something more than words of empathy or silent, empathic presence. The “something missing” is in my incredulous question: How could he think that I wouldn’t want to talk about what happened between us? And it’s in his failure to answer that question. It’s not that I needed that specific piece of information or any particular answer from him. What I needed was for my therapist to interact with me as himself, a real person with his own thoughts and feelings in relation to me, not just as someone who would reflect “my experience of him” back to me with empathic understanding. I needed him to share his own real experience of our impasse, to share more about “how he could think.” I took the little he was able to give me of his process in relation to Downloaded by [New York University] at 13:36 13 August 2016 me and made the most of it. Mentalization theory tells me that I needed to know about his part in our shared emotional process in order to understand my part in it. I needed a chance to find my emotional mind in his mind. When my therapist didn’t say what my request felt like to him, I could only assume what I implicitly “knew”—that my wanting to be read was an imposition, a shameful expression of a shameful need. His silence was another blank for me, filled in by my fears. If he could have shared his sense of dilemma or how he was hoping we might get through this trouble, I might have been able to feel like a fellow fallible human being, a collaborator in our joint process, rather Twelve Years Later 195 than like a defective patient. If we could have been curious together about our joint process, I might have been able to stay inside my emotion and find coherence within it, rather than escaping from it into an interpretation based on my history. I might have discovered that when I asked, “Could you please read what I’ve written?” what I wanted to know was, “Could you enjoy being with me? Or is my desire to be with you mind-to-mind, to know deeply and to be known, dangerous to you?” Rather than feeling ashamed of my desire to be “read,” I might have come to understand it as an expression of a simpler, more archaic need just to be close, delighted in, enjoyed, welcomed, and received, emotional mind to emotional mind—a need for the “together” experience of mentalizing, in a word. Ironically, a thorough, transparent, interactive mentalizing of the impasse event would have in itself given me the direct emotional connectedness I was searching for so awkwardly— that is, with a performance of intellectual competence instead. At the time of the impasse, I was aware of a shamed young self in the shadows who was longing to matter to my analyst, and who had gone about it this way. I did not know what else to do, though I knew that his approval or admiration would feel hollow to me. I did not understand the need that drove me—because I could not bear to feel the not-me experience both hidden and revealed by my enactment. I could not bear to feel my longing to be close as a harmful imposition. It seems my not-me got away from me and imposed anyway, going for connection the dangerous way she knew— while the rest of me did whatever I could not to be dangerous. Communication involving both me and not-me often involves double binds. I don’t know what it was like for my therapist to have me both expressing need and refusing to need—in code and with heightened affect. And that’s exactly my point: it would have been better for me to know what it was like for him. It might have been not only the clue I needed about what was going on, but also the connection I needed. That’s the point I/R analysts make about dissolving or resolving enactments of dissociated not-me experience: clients, especially clients in the throes of a not-me enactment, Downloaded by [New York University] at 13:36 13 August 2016 need lots of help realizing “what’s going on around here.” They need their therapists—the other half of what’s going on—to say what it’s like for them, or at the very least, if they are caught in a dissociated enactment of their own, to admit to their vulnerability and confusion, even while they hold the faith that working through this impasse together is deeply worth doing. The experience of not-me shame is a tsunami of affect that obliterates coherent selfhood. I can attest to that. A flood of shame follows an acute experience of interpersonal affect dysregulation and internal dissociation. Relational right-brain theory explains how this happens, material for another book.31 My point now is that while I was being annihilated by this 196 Twelve Years Later tsunami, I needed to know that someone was right there, holding onto me and holding steady, feeling the intensity of the fear-shame chaos with me. I needed for the heightened emotion of my enactment to feel safe within an emotional state I shared with my therapist. I needed on-the-spot regulation of acutely dysregulated affect, right brain to right brain. But although I was able to stay in therapy on the memory of being empathically understood, when the shame tsunami hit I could not find the right-brain connection I needed to make my state tolerable. I had to self-regulate to fight off dissociation. I walked, thought, and wrote, enlist- ing left-brain skills to manage right-brain chaos and pain. What kind of connection was I missing from my therapist? Probably just the non-verbal body language, voice tones and eye contact therapists use to say, “I’m right here with you.” “I get it.” In all of our years together, my therapist could always tell me what he understood, but it was hard for me to see or feel emotion in him. In an affective crisis, I needed to feel more of his emotional self. It’s a thing parents know: to be good at regulating affect, you have to be good at showing your own affect. This baseline capacity for self- disclosure—“show some emotion!”—is also, I have come to believe, an essential skill for therapists who work with relationally traumatized clients. The Boston Group supports therapist self-disclosure with the language of recognition and intention. “Intention” captures both emotion and the making of meaning together; shared consciousness is created by the mutual recognition of intentions. Speaking in this language, I wish I could have seen some moment-to-moment personal intentions in my therapist’s attempts to resolve the impasse with me. Then I might have sensed his real emotion, too—the emotion that mattered between us. I wish that my therapist had disclosed implicitly more of what he meant to be doing with me and more of what he saw me trying to do with him. But I could not see past the opacity of his empathy. I felt out on a limb with my own intentions. More transparency from him might have allowed me to trust our shared endeavor and stay inside it with him, following through on our shared intention to keep on understanding what it was all about. Instead I escaped Downloaded by [New York University] at 13:36 13 August 2016 into left-brain logic to make sense of my experience as best I could. In BCPSG terms, our impasse could be called a long “now moment,” sustained as I held out for a moment of meeting, a moment when he might meet my “being different” with something spontaneous and personal of his own. They say such moments make possible shifts in implicit relational knowing. I tried in every way I knew to make my tsunami experience transformative. But it was not to be; I could not transform our relationship on my own. I continued in analysis for another two years, and then in weekly therapy for three years more. Sometimes I felt close to finding what I was searching for, and yet it felt (he felt) so far away. As this feeling Twelve Years Later 197 became clearer to me, I knew I would just have to leave one day, content with what years of consistent empathy, no small gift, had done for me. That’s how I ended. Yet a while after ending, I noticed myself speaking of our work “ironically,” saying how I could never get him to talk to me. I realized I was angry, with that edge of contempt that wards off shame. I had some clues about my left- over shame: first, I had learned young the wrong of wanting to know either of my parents intimately, of saying, “Tell me what you’re thinking, what you’re feeling.” Also, although I had vetted Chapter 5 with my therapist, I still felt that in writing about us I had used a strange, back-door way to make him be with me. This sense of “wrong” was not entirely conscious. My internal prohi- bition against wanting too much personal connection was powerful enough to keep that dangerous longing self in not-me space, mostly. My shame about being my particular, embodied, emotional, relational self, though not so annihilating, was still mostly a mystery to me—even while I began to try to write a book about shame. Five years passed. One day my ex-therapist and I were both attending a psychoanalytic conference, as we had twice a year for many years, both during and after the time I was in therapy with him. I had always been careful to locate him in a conference room of a hundred people and then keep distance between us. This time I didn’t see him coming, and suddenly he was saying hello. He was smiling, his eyes lit with recognition and kindness. I don’t remember what we said. I do remember the shock of a profoundly good experience. If I had put words to it, I might have said, “I think he likes me!” In that moment I felt like a different self in a relationship with him I had never had before. A few months later I found myself alone in some pain, and I thought, “I could talk to him.” I was drawn by the memory of his consistent empathy, but perhaps what I wanted even more was to experience that different relationship with him in a sustained way. When I called, he suggested we use cancellation times, and so I saw him for another seventeen sessions over the course of another year. An epilogue, as it turned out. Downloaded by [New York University] at 13:36 13 August 2016 I began with what hurt. He knew the back-story well, more than twenty years in the making: my “coming out,” the breakup of my marriage and our family of five, the reconstruction of family with a woman partner, and all the complications of blended-extended family relationships, with kids moving between two houses and two sets of parents. As adolescents, my children had been remarkably accommodating and supportive of both their father and me. As adults, that summer they had created time and space to talk with us about those days and what those changes had cost them. I was feeling sad, guilty, and ashamed that I had missed the confusion and pain behind their “good kid” performances. These weren’t entirely 198 Twelve Years Later new feelings but I was facing them full-on. That was what I came to talk about. My analyst listened. And to my surprise, he talked. We had a conversation. It was the experience of empathy as I had remembered it, but inter- spersed with experiences of him sharing his own thoughts. I stopped to ask, “Have you changed how you do therapy?” He said he hadn’t. “But you’re talking to me!” I said. He shrugged and shook his head. I let it go. I tried to articulate my shame precisely: that I had been so distracted, so emotionally overdrawn, that I had not been able to see my children clearly. My own childhood story replicated, I said. The last thing I wanted to do to them. I knew that he knew my history, the relational trauma in it, the unmet need. I also suddenly understood that he had always known what I was telling him now. But I could see that he didn’t find it a reason for shame. Just a sad truth about how life goes, how trauma repeats itself down generations. “But with a difference,” he said. “Your kids can talk to you. They want to talk to you.” I saw warmth in his eyes for all of us. I felt Yes, and then tears, but not tears of shame. I made another appointment, wondering what would turn up. It was another piece of shame to out. I spoke of my partner of twenty years and the age difference between us. “My neediness is out there for all the world to see,” I said. My analyst seemed baffled. “A desperate need for parenting,” I explained. “My need for a mom—to think I’m wonderful, to just adore m e .” He thought for a moment. Then he said, “I guess you knew something important about what you needed. It seems you made a good choice for yourself—seeing as how this relationship has lasted for so long.” Was that a twinkle in his eye? This time I smiled. Yes. What else did we talk about for seventeen sessions? I kept coming back because it felt different to be with him—I felt different—and I wanted to see what would happen next. I told him about that conference moment when I felt that he knew me and liked me. I told him that I had been worried for years about putting him in my book, that maybe it had been some kind of underhanded move. He said he felt I had been fair and honest Downloaded by [New York University] at 13:36 13 August 2016 with him. I talked about my life and reflected on here-and-now moments between us, and as I talked, I felt him becoming more silent. He was not less present, but he was less forthcoming. He had told me the truth: he hadn’t changed the way he did therapy. As summer came around again, it happened that my parents came for a visit, the first in twenty years. Though I had kept in touch, it hadn’t been easy for them to accept the changes in my life or to visit me in my home. We spent a holiday week with them, sharing meals and chatting, and I noticed how my mother turned even a gentle compliment from my father into dismissive self-criticism. I saw the painful self-consciousness Twelve Years Later 199 behind her ways of disengaging, the deep self-doubt beneath her constant evaluations, with their slight odor of suspicion or contempt. She didn’t mean to be uncaring or disrespectful. She just couldn’t stop herself from stepping outside of every interaction, where thought would be a safe alternative to feeling. I thought about being a little kid with a mom who couldn’t be other than outside our relationship, evaluating me as a reflection of her worth. I remembered the stories I had heard about her anxiety to parent “by the book” with me, her first baby. This distancing, evaluative experience had been laid down in myriad networks of neural pathways; it was in my blood and bones. When I felt it there, I knew that this was what I had felt with my therapist, too. I brought this “Aha!” to him. Here, I said, was what had been so wrong for me between us: I experienced his silence as evaluation, which left me distanced, pathologized, and shamed. He got it in an instant, and in that instant the narrative we shared about us reorganized itself. I never thought to ask about what had been happening on his side of that silent, mostly unconscious interaction, and he didn’t speak of it either. We met twice more that summer, and in the fall he needed to cancel a session for illness. I intended to rebook, but I never got around to it. I guess I couldn’t think why I would, except to say good-bye, and I wasn’t ready for that. I think that this—my solo mentalization of implicit relational moments between us—is my good-bye. (I’ve since sent him a note about this new chapter, asking if he would like to read it and respond. He hasn’t replied, and I respect his consistency. But I’m sorry that I’ll never know his thoughts and feelings in response to what I’m saying here.) What happened in our epilogue to analysis? Here’s the story as it tells itself to me. My therapist and I sustained a now moment between us for ten years, a moment that slid into impasse early but was neither a missed now moment nor a failed now moment; rather, it was a now moment carried forward as “enduring.” It endured being spoken about, written about, and the end of the analysis. I had dared to ask, “Could you please read what I wrote?” meaning, “Could you engage with me fully and delight in my Downloaded by [New York University] at 13:36 13 August 2016 being?” I had not known what I meant or how fear and shame had masked the meaning of the question. But ten years later, “by accident,” my therapist surprised me with an answer, a moment of spontaneous engagement and delight in me. It was a moment of meeting. The long now moment could end at last, with an answer that fit. The moment of meeting also produced the “shift in affective perception” that allows dissociated enactment to end. A brand-new emotional realization let me make conscious contact with the not-me shame that had shaped my internal relationship with my therapist. Until I felt, “I think he likes me!” I had not been able to know that this was what I had wanted so 200 Twelve Years Later badly, so deeply. “Delight in me!”—Who asks for that? (How unbearable to feel wrong for wanting that.) Then I needed to know if what I felt was true—not the delight, as such, but his connection with my needing self beneath my shame. I needed to unwrap my shame with my therapist and feel whole and real in his presence for longer than two minutes. He intuited something of that, I think, and in opening sessions once again met me where I was, speaking what I felt to be his mind and heart. The moment of meeting was sustained long enough, right brain to right brain, for me to believe it. And then we went back to being who we were, though on my side, at least, I felt more freedom to be myself with him. As Interpersonal/Relational theory would have predicted, once the dissociated enactment of not-me shame began to resolve, a narrative of “what’s going on” became possible. A story of my mother and me became, belatedly and retroactively, part of the conscious story of our analysis. The insight matters, of course, but it is not the key. I agree with Stern; in these relational journeys, “It is not so much that we learn the truth, but that we become more than we were.”32 More than we were is not different than we were. I ended therapy a second time not because I had finally been able to achieve the relationship of mutual emotional connection I wanted to have with my therapist. I ended because I felt that he would not be different, nor would I, but that the understanding we had come to was as true and mutual as it could be, given our differences. Maybe we make peace with the therapists we’ve been given in the same way we come to accept the parents we’ve been given. It’s good to remember that our children and our clients are doing the same with us.

The Enactment of Showing Up

It could be argued that writing this epilogue to end this chapter is but Downloaded by [New York University] at 13:36 13 August 2016 another enactment of unresolved relational emotion. So be it, then. If the relational theory of the last twelve years tells us anything, it tells us that both life and therapy move forward as a never-ending series of enactments. We enact what we know of how to be with one another, a knowing laid down in implicit procedural memory, in right-brain nonverbal awareness not translatable to logic. Some of what we know, enacted, causes us endless pain. Some of what we know is too painful to bear, and so we enact not- knowing. This implicit world, enacted through intention, recognition, and felt meanings, a world of interpersonal emotion with the power to destroy or to sustain “self,” is the world where relational psychotherapy moves. Twelve Years Later 201 Therapy happens and change happens at this deep, moment-to- moment, local level where the implicit is enacted. Here interactions are as sloppy as everyday life. We lead with our best intentions, and we welcome clients into a shared process of going somewhere meaningful together, though we don’t know exactly where we are going or how we will get there. We invite clients to explore what’s on their minds as we share what’s on our minds about them. They have feelings, and we have feelings together, and we talk about these feelings. There are mutual misunderstandings to clarify, hurts to resolve, impasses to negotiate. In all of this, of course, we are making sense together—of our clients’ current struggles, life histories, and core beliefs, of the cotransference dynamics moving between us, of the unconscious patterns in our relationship that emerge as emotions and behaviors. Making sense with our clients is the project that guides our intentions; it’s the activity that clears a path to where we’re going. But the sense we make together is not what heals. Making sense is something we need to do with our clients, and the sense we make with them has to add up to something meaningful for them, but the enactment of making sense, with someone who is connected with them emotional self to emotional self—that’s what changes our clients’ right brains and their implicit relational knowing. When the implicit shifts, our clients can enact these new ways of knowing in relationship, with new freedom to be more than they were. That’s how relational therapy changes lives for the better. This, in a nutshell, is what new relational theorizing has to say, the direction of its trajectory. In other words, new theory underscores for us this fundamental principle: the practice of relational psychotherapy is most essentially the practice of showing up. We need to know about development and attachment, trauma and dissociation, organizing principles, transference, and the theory behind affect attunement and mentalizing. But when we sit down with our clients, what they need from us is not what we know. They don’t need us to be powerful, deeply insightful, or able Downloaded by [New York University] at 13:36 13 August 2016 to cure their pain. They don’t need a flawless expression of experience- near empathy. What our clients need from us is emotional connectedness, right-brain to right-brain. They need, as part of our empathy, our willingness to let them know who we are with them—what we feel, think, hope, and intend. They need us to welcome the sloppiness of not knowing, wondering, and being vulnerable together. If this here-and-now, moment-to-moment relationship is going to make a difference for them, what they need from us time and again, no matter what’s happening, is that we show up in the relationship— that we enact our emotional/relational being with them—for real. 202 Twelve Years Later The Ethics of Showing Up

But a commitment to interactive, transparent emotional presence with our clients raises complex ethical questions. If we perform a psychotherapy defined as “scientific” or “objective” to the best of our knowledge and ability, striving to do no harm and to take no advantage of clients for our own interests, we can, in a simple, straightforward way, lay claim to ethical professional practice. Another, more profound kind of ethic, however, is inherent in subjectively showing up. If relational therapy is our mode of practice, we know that when we show up for real in relationships with our clients, our hearts are involved. “Right-brain to right-brain” means “heart to heart.” Mentalizing, or accurate, articulate empathy, does our clients no good unless it’s expressed with felt compassion for their human struggle. A moment of meeting is as much a moment of mutual loving respect as it is a moment of understanding. When we hold ourselves to the task of living through mutual dissociated enactment with our clients, when for their sakes we meet them from within our own vulnerability, we are practicing not only the art and science of psychotherapy but also an ethic of care. Embedded in the first edition of this book, now the first sevenc hapters, is an ethic of compassion, care, and respect that gives purpose and meaning to our work with clients. Whether its roots are in the humanism of Carl Rogers, the relational feminism of the Stone Center, or the paren- talism of the baby-watcher psychoanalysts, relational psychotherapy, as I have outlined it, is about a deep sense of taking care; it enacts a profound sense of responsibility (response-ability) to others in need of such genuine, respectful presence in their lives. Twelve years ago, I felt that this implicit ethic of care needed no further articulation in order to be understood as fundamental to what we do. In the last twelve years, however, partly in response to demands for evidence-based practice, relational psychotherapy has come to speak a more scientific language. Mentalization theory, with origins in attachment

Downloaded by [New York University] at 13:36 13 August 2016 theory, has a long tradition of detailed research behind it. Boston baby- watchers have invoked the science of systems theory to explain change in therapy. Allan Schore has cited hundreds of brain studies to back up his account of the science behind the art of psychotherapy, and the I/R analyst Philip Bromberg has claimed that his own artful practice of psychoanalysis is undergirded by the science Schore explains. In this science-biased environment, certain relational theorists hold firm on the creative, constructivist art of relational psychotherapy, and from this perspective they develop new theory about the ethic embodied in a relational practice. Other relational theorists make a more developmental Twelve Years Later 203 argument for the place of compassion, affection, and love in the work of therapy. Such conversations about the ethics foundational to relational psychotherapy exist as counterpoint to scientific conversations, and together they can be seen as the fifth emergent theme of the last few years of relational psychotherapy theory. From a relational hermeneutic perspective, also implicit throughout this book, science is only one way humans interpret their existence to themselves. Science is a human creation alongside other human systems— the worlds of politics and economics, of art and religion, of cultural institutions and familial moralities. These meaning-making systems, bound by place and time in history, are secondary to the human beings who construct them, and what matters most is the effect these constructed systems have on their fellow beings for good or ill, for well-being or suffering. Humans create the science of psychotherapy, too, and that’s why it never has been and never will be “the truth,” but rather a powerful meta- phorical system that changes shape across cultures and with the passing of decades.33 New meanings will, indeed, continue to be formulated by theorists of psychotherapy, and what matters is how they will be used to support well-being and to relieve suffering. These ethical questions about what we do with our knowledge are more important than what, in any culture or generation, we believe we know. According to this worldview, meanings that create well-being are co- constructed in intersubjective cultural conversation; this is how they become embodied in technologies, institutions, theories and moralities. Well-being comes by way of our interpreting the world well to one another, with a passion for care, respect, and justice, and a passion against cruelty, indifference, and injustice. As therapists we invite clients into an intersubjective conversation that offers them a kind of interpersonal justice—a chance to reinterpret their lived experience with self-respect and compassion. This is the ethical context for the culturally constructed science of psychotherapy—not the ethics of its professional frame of practice, but the foundational ethics that give it life and meaning. Downloaded by [New York University] at 13:36 13 August 2016 Not all relational theorists who resist scientism with hermeneutic philosophy make their ethical positions explicit. Donna Orange does. She finds herself in the tradition of the relational analysts Ferenczi, Fromm-Reichmann, Winnicott, Kohut, and Brandchaft, who understood their patients within what she calls a hermeneutic of trust, an alternative to a “tough-minded” hermeneutic of suspicion that must be ever watchful for the dodges and lies of patients’ defenses and resistances. A hermeneutic of trust does not assume that patients deceive and manipulate us. Nor does it require that our patients trust us. Instead, a hermeneutic of trust defines our attitude toward them, our belief “that they are trying to communicate 204 Twelve Years Later their truth to us, by whatever they are saying or doing, and that it is up to us to try to understand.”34 Orange merges ethical hermeneutics—insistence that dialogue take place in a common world of inclusion, welcome, and respect—with the radical ethics of Emmanuel Lévinas, who saw in the face of the Other (or the Suffering Stranger) the unavoidable responsibility that gives meaning to our subjective lives and is the first question for philosophy. A therapist who practices within this ethic of trust, respect, and primary obligation is welcoming and nonjudgmental. She engages simply, humbly, and patiently, surrendering herself to the process of seeing, hearing, and responding to the other in his uniqueness. She keeps listening, refusing to reduce the other to something already said or known. Relief of suffering is her fundamental therapeutic vocation, and she offers care in therapeutic relationships of asymmetrical responsibility. But the care she offers is dialogic, informed by a hermeneutic of trust. On her side of the dialogue, most essentially she says and keeps on saying, “It’s me, here.”35 We might say that in both her listening and her speaking, she shows up for real with her heart. Orange describes and begins to theorize the ethics that ground and inspire her practice. Many relational theorists don’t speak the language of ethics—even when they write about the transformative power of love in analysis. In Thomas Ogden’s story of Ms. R, for example, transformation happens as fundamentally new emotional terms are created in the therapeutic relationship, terms that allow Ms. R to give and to receive a form of love that she never knew existed.36 What Ogden calls “transformative thinking” we might call a profound shift in implicit relational knowing. But what matters here is Ogden’s insistence that such transformation requires the minds of at least two people—alone, none of us can alter how we order our experience—and that this transformation may come by way of giving and receiving a specific form of love. Yet Ogden seems careful to speak of this love as something impersonal— as “new terms” in the therapy relationship—thus distancing himself from participating as either the giver or receiver of love. Daniel Shaw, by con- Downloaded by [New York University] at 13:36 13 August 2016 trast, puts the analyst’s participation at the center of his discussion of “the therapeutic action of analytic love.”37 He does not frame his discussion as ethical, but rather as a logical extension of developmental theory. He asks: If love is important in theories of human development, shouldn’t it be important in theories of treatment? Don’t we need to develop theory about how the analyst can love authentically and use his love therapeutically? Shaw distinguishes analytic love from erotic and countertransferential love, and he reviews how, in the history of psychoanalysis, analytic love has been both accepted and rejected as a valid therapeutic agent. Then he offers two defining principles of valid, useful analytic love. First, as with parental Twelve Years Later 205 love, analytic love cannot exist without respect for the individual loved and for his innate potential for development as a separate, inviolable being. Without such respect, parental or analytic “love” is a narcissism that threat- ens to subjugate. Second, analytic love cannot exist without the analyst’s commitment to the analysand’s safety. Our dedication to both the growth and the safety of those in our care is in essence a complex act of love. Shaw suggests that the crucial place of love in the history of psychoanalysis needs further articulation so that it can be better integrated into our theory and practice. He acknowledges that analytic love can be complicated, opening us up to hurt and disappointment. But this, he says, is no reason to ignore or cancel our love. This knowledge “seems instead a call to persist in loving, as authentically, deeply, respectfully, and responsibly as we can.”38 Clients experience a therapist’s enactment of analytic love as empathic understanding, but also as empathic compassion, an understanding expressed with interpersonal warmth and affection. Orange affirms that experiencing our therapist’s affectionate understanding “often does really shift something radically in our self and relational experience.” Neverthe- less, she notes, “It seems to me that therapists and analysts of all persuasions have been taught to be ashamed of their affection for their patients, and not to let on how much we care for them.”39 Dan Perlitz, who happened on the term affectionate understanding in clinical supervision with Orange, expands on the concept (which he finds more useful than analytic love) in a yet-to-be-published paper. As I do, he notes that current psychoanalytic theory has come to conceptualize our work as operating largely at an emotionally-based implicit level of dyadic mutual influence. And yet current theory is reluctant to speak about the analyst’s emotions. “The component of affection is left unspoken, to be gleaned as an implicit meaning, as if stating it is prohibited; the ‘don’t ask, don’t tell’ rule of emotional narrative in psychoanalysis.”40 Perlitz acknowledges the complexities of affectionate understanding: Since the analyst’s affection must emerge from within the analyst– Downloaded by [New York University] at 13:36 13 August 2016 patient relationship, it can be a hard-won achievement, especially when the patient challenges the analyst’s competence, confidence, and emotional well-being. Furthermore, those very patients who need help with their aversion to affection can experience the analyst’s expression of affection as threatening or shaming. Yet Perlitz offers a simple, straightforward summary of what he believes would be Kohut’s contemporary position: “that the analyst’s affection is an important factor for therapeutic action; and that self-psychology, with its grounding of hermeneutic trust and empathic process, optimizes the possibility of the emergence of affectionate understanding.”41 206 Twelve Years Later I have suggested that a fifth theme is emerging in the dynamic system of ongoing relational theory; we see it taking shape as these theorists from various relational viewpoints explore foundational clinical ethics, analytic love, and affectionate understanding. This theme also arises in relation to my case study. Why was I able to discover my therapist’s affection for me only by accident? How does his practice of offering empathy while with- holding personal emotion relate not only to emergent themes in the science of relational therapy but also to an emergent relational ethic of practice? I have no doubt that my analyst is faithful to deep, strong ethical commit- ments, and that he practices analysis in order to relieve emotional suffering by psychotherapeutic means, above all by means of empathic understanding. Further, I believe that when he chooses not to read my work or to respond to my note about a new chapter, he does so for what he believes are ethical reasons. He is holding the frame of analysis, keeping our relationship intact for any future work, and also protecting how I internalize the relationship in the present. That’s the sense I’m able to make of his reasons. When he sustains an affectively neutral presence, he is keeping space clear for me to find my own self-understanding without impingement. This, too, can be seen not only as a technical choice but as dedication to ethical principles of care and respect. Nevertheless, I also wonder whether the hermeneutic of trust implicit in self psychology has been able to override my analyst’s early formation within a more traditional psychoanalytic culture, one committed to a hermeneutic of suspicion. Detachment based on mistrust of relationship is a form of implicit relational knowing transmitted right brain to right brain down generations—not only of parents and children but also of analysts and analysands. Theory on its own cannot undo such knowing. And perhaps another reason for my analyst’s detachment lies with classic self psychology—in how it trusts its patients to express their necessary truths in therapy interactions, but does not include the emotions and intentions of its therapists within that circle of trust. If we apply a hermeneutic of suspicion to ourselves, we believe that our Downloaded by [New York University] at 13:36 13 August 2016 affection for our clients is likely something else, an unconscious intent to seduce or dominate them, or an unconscious collusion with their desire to escape the painful self-reflection therapy requires. This must be why we hide the affection we feel for our clients, even as we come to know them in their most open and vulnerable moments: we are ashamed of the danger our desires and emotions entail for them. We anticipate doing therapy “wrong.” Our affection will derail our clients’ true healing process, we believe. It will be a boundary-crossing impingement on their selfhood. Or perhaps, at least sometimes, we hold back more out of fear than shame, afraid of more reality than we can bear in a therapy relationship. A theory of Twelve Years Later 207 therapeutic detachment may let us escape realities that feel like too much to us, especially when the “too much” is powerful, affectionate love and we have no theory to help us understand how to work with that love in our clients’ best interests. Right now, in other words, a gap still exists between new relational theories about an emotionally transparent, “showing up” way of practicing therapy and a relational ethic commensurate with that practice, an ethic that both grounds such a practice philosophically and guides it concretely. Recently theorists have begun to close that gap, reaching for new coherence as they make certain implicit connections explicit, connections between mind and heart, understanding and affection, scientific knowledge and ethical responsibility. I am not making a case here for any specific answers to the ethical questions that our commitment to emotional availability raises, though I expect that my biases show. I’m saying that if we believe new relational theory asks us, above all, to show up in our therapy relationships, to enact our emotional/relational being with our clients, then we must also be open to the philosophical and ethical questions implicit in that demand. We need to talk about these questions with honesty, courage, and respect for one another’s situated differences and deeply held convictions. I offer my story and my thoughts in the spirit of such conversation, curious about where it might take us, and wondering what a coherent dynamic system of relational theory will look like twelve years from now.

Notes

1. First “operationalized” in the seminal work by Peter Fonagy et al., Affect Regulation, Mentalization, and the Development of the Self (New York: Other Press, 2002). For example, the authors define mentalized affectivity as the ultimate form of affect regulation and note that this notion comes very close to describing what happens in psychoanalysis and other kinds of psychotherapy, 96. 2. Jon Allen, Peter Fonagy, and Anthony Bateman, Mentalizing in Clinical Practice (Washington, DC: American Psychiatric Publishing, 2008), 99–105. 3. Ibid., 74, 80–81.

Downloaded by [New York University] at 13:36 13 August 2016 4. Ibid., 110. 5. Ibid., 67. 6. Ibid., 188–189. 7. Daniel Stern, The Present Moment in Psychotherapy and Everyday Life (New York: Norton, 2004), cited in Allen, Fonagy, and Bateman, 156. 8. Boston Change Process Study Group, Change in Psychotherapy: A Unifying Paradigm (New York: Norton, 2010). 9. BCPSG, Change in Psychotherapy, 149. 10. Philip Bromberg has written extensively on working with such dissociation and threat of overwhelming affect, most recently in The Shadow of the Tsunami and the Growth of the Relational Mind (New York: Routledge, 2011). 11. Donnel Stern, Partners in Thought: Working with Unformulated Experience, Dissociation, and Enactment. (New York: Routledge, 2010), 121. 208 Twelve Years Later

12. Ibid., 89. 13. Ibid., 124. 14. Bromberg, Shadow of the Tsunami, 59. 15. Stern, Partners in Thought, 128. 16. Bromberg, 104. 17. Allan Schore, “Therapeutic Enactments: Working in Right Brain Windows of Affect Tolerance,” The Science of the Art of Psychotherapy (New York: Norton, 2012), 164–165. 18. Ibid., xxxiii. 19. Ibid., xxxiv. 20. Louis Cozolino, The Neuroscience of Psychotherapy: Healing the Social Brain, 2nd ed. (New York: Norton, 2012). 21. Allen, Fonagy, and Bateman, 116–123. 22. Daniel Siegel, The Mindful Brain: Reflection and Attunement in the Cultivation of Well-Being(New York: Norton, 2007). 23. Daniel Siegel, The Mindful Therapist: A Clinician’s Guide to Mindsight and Neural Integration (New York: Norton, 2010). 24. Daniel Siegel, Mindsight: The New Science of Personal Transformation (New York: Bantam, 2010). 25. Bonnie Badenoch, Being a Brain-Wise Therapist: A Practical Guide to Interpersonal Neurobiology (New York: Norton, 2008), 152. 26. Allan Schore with Judith Schore, “Modern Attachment Theory: The Central Role of Affect Regula- tion in Development and Treatment,” in Science of the Art, 27–51; Allan Schore, “Relational Trauma and the Developing Right Brain: An Interface of Psychoanalytic Self Psychology and Neuroscience, in Science of the Art, 52–70; “Right Brain Affect Regulation: An Essential Mechanism of Develop- ment, Trauma, Dissociation, and Psychotherapy,” in Science of the Art, 71–117; “The Right Brain Implicit Self Lies at the Core of Psychoanalysis,” in Science of the Art, 118–151. 27. Bromberg, 70–71, 126, 136. 28. Stern, Partners in Thought, xv; and “The Embodiment of Meaning in Relatedness,” in Partners in Thought, 1–24. 29. Stern, “On Having to Find What You Don’t know How to Look For: Two Views of Reflective Function,” in Partners in Thought, 161–182. 30. Lewis Aron, “On Knowing and Being Known: Theoretical and Technical Considerations Regarding Self-Disclosure,” in A Meeting of Minds: Mutuality in Psychoanalysis (Hillsdale, NJ: Analytic Press, 1996), 221–253. 31. Patricia DeYoung, Understanding and Treating Chronic Shame: A Relational/Neurobiological Approach (New York: Routledge, in press). 32. Stern, Partners in Thought, 128. 33. Stern is one of those relational theorists who, from a hermeneutic perspective, holds firm on the creative, constructivist art of relational psychotherapy; see, for example, his argument against what he calls the objectivist epistemology of the Boston Change Process Study Group, in Partners in Thought, 202–205. 34. Donna Orange, The Suffering Stranger: Hermeneutics for Everyday Practice (New York: Routledge, 2011), 40. Downloaded by [New York University] at 13:36 13 August 2016 35. Ibid., 40–71. 36. Thomas Ogden, “On Three Forms of Thinking: Magical Thinking, Dream Thinking, and Transfor- mative Thinking,” Psychoanalytic Quarterly 79, no. 2 (2010): 343. 37. Daniel Shaw, “On the Therapeutic Action of Analytic Love, in Traumatic Narcissism: Relational Systems of Subjugation (New York: Routledge, 2014) 116–135. 38. Ibid., 134. 39. Orange, personal correspondence, June 2014. 40. Dan Perlitz, “Beyond Kohut: From Empathy to Affection,” (unpublished manuscript, Toronto, 2014), 11. 41. Perlitz, “From Empathy to Affection,” 23. Bibliography

Ainsworth, Mary. Patterns of Attachment: A Psychological Study of the Strange Situation. Hillsdale, NJ: Lawrence Erlbaum, 1978. Allen, Jon, Peter Fonagy, and Anthony Bateman, Mentalizing in Clinical Practice. Washington, DC: American Psychiatric Publishing, 2008. Altman, Neil. The Analyst in the Inner City: Race, Class, and Culture through a Psychoanalytic Lens. Hillsdale, NJ: Analytic Press, 1995. Aron, Lewis. A Meeting of Minds: Mutuality in Psychoanalysis. Hillsdale, NJ: Analytic Press, 1996. Atwood, George, and Robert Stolorow. Structures of Subjectivity: Explora- tions in Psychoanalytic Phenomenology. Hillsdale, NJ: Analytic Press, 1984. Bacal, Howard, ed. Optimal Responsiveness: How Therapists Heal Their Patients. Northvale, NJ: Jason Aronson, 1998. Bacal, Howard, and Kenneth Newman. Theories of Object Relations: Bridges to Self P sychology. New York: Columbia University Press, 1990. Badenoch, Bonnie. Being a Brain-Wise Therapist: A Practical Guide to Interpersonal Neurobiology. New York: Norton, 2008. Beebe, Beatrice, Joseph Jaffe, Frank Lachmann, Stanley Feldstein, Cynthia Crown, and Michael Jasnow. “Systems Models in Development and Psy- choanalysis: The Case of Vocal Rhythm Coordination and Attachment.” Infant Mental Health Journal 21 (2000): 99–122.

Downloaded by [New York University] at 13:36 13 August 2016 Benjamin, Jessica. The Bonds of Love: Psychoanalysis, Feminism, and the Problem of Domination. New York: Pantheon, 1988. ———. Like Subjects, Love Objects: Essays on Recognition and Sexual Difference. New Haven: Yale University Press, 1995. Boston Change Process Study Group: Nadia Bruschweiler-Stern, Alexandra Harrison, Karlen Lyons-Ruth, Alexander Morgan, Jeremy Nahum, Louis Sander, Daniel Stern, and Edward Tronick. Special issue of Infant Mental Health Journal 19, no. 3 (1998). Boston Change Process Study Group. Change in Psychotherapy: A Unifying Paradigm. New York: Norton, 2010. 210 Bibliography Bowlby, John. A Secure Base: Parent–Child Attachment and Healthy Human Development. New York: Basic Books, 1988. Bromberg, Philip. Standing in the Spaces: Clinical Process, Trauma and Dissociation. Hillsdale, NJ: Analytic Press, 1998. ———. The Shadow of the Tsunami and the Growth of the Relational Mind. New York: Routledge, 2011. Brown, Lauara. Subversive Dialogues: Theory in Feminist Therapy. New York: Basic Books, 1994. Chesler, Phyllis. Women and Madness. New York: Doubleday, 1972. Cozolino, Louis. The Neuroscience of Psychotherapy: Healing the Social Brain, 2nd ed. New York: Norton, 2012. Davies, Jody Messler, and Mary Gail Frawley. Treating the Adult Survivor of Childhood Sexual Abuse: A Psychoanalytic Perspective. New York: Basic Books, 1994. DeYoung, Patricia. Understanding and Treating Chronic Shame: A Relational/ Neurobiological Approach. New York: Routledge, in press. Ehrenberg, Darlene. The Intimate Edge: Extending the Reach of Psychoana- lytic Interaction. New York: Norton, 1992. Fonagy, Peter, Gyorgy Gergely, Elliot Jurist, and Mary Target. Affect Regu- lation, Mentalization, and the Development of the Self. New York: Other Press, 2002. Freud, Sigmund. The Standard Edition of the Complete Psychological Works of Sigmund Freud. Translated by James Strachey. London: Hogarth, 1953–1966. Herman, Judith Lewis. Trauma and Recovery. New York: Basic Books, 1992. Jordan, Judith, Alexandra Kaplan, Jean Baker Miller, Irene Stiver, and Janet Surrey. Women’s Growth in Connection: Writings from the Stone Center. New York: Guilford., 1991. Jung, Carl, and Marie-Louise von Franz, ed. Man and His Symbols. New York: Doubleday. Kohut, Heinz. How Does Analysis Cure? Chicago: University of Chicago Press, 1984. Lichtenberg, Joseph. Psychoanalysis and Motivation. Hillsdale, NJ: Analytic Downloaded by [New York University] at 13:36 13 August 2016 Press, 1989. Lichtenberg, Joseph, Frank Lachmann, and James Fosshage. Self and Moti- vational Systems: Toward a Theory of Psychoanalytic Technique. Hills- dale, NJ: Analytic Press, 1992. Main, Mary. “Recent Studies in Attachment: Overview with Selected Implications for Clinical Social Work.” In Attachment Theory: Social, Developmental, and Clinical Perspectives, edited by S. Goldberg, R. Muir and J. Kerr. Hillsdale, NJ: Analytic Press, 1995, 407–474. McNamee, Sheila, and Kenneth Gergen, ed. Therapy as SocialC onstruction. Newbury Park, CA: Sage, 1992. Bibliography 211 Miller, Jean Baker and Irene Stiver. The Healing Connection: How Women Form Relationships in Therapy and in Life. Boston: Beacon, 1997. Mitchell, Stephen. Relational Concepts in Psychoanalysis: An Integration. Cambridge, MA: Harvard University Press, 1988. ———. Hope and Dread in Psychoanalysis. New York: Basic Books, 1993. ———. Influence and Autonomy in Psychoanalysis. Hillsdale, NJ: Analytic Press, 1997. ———. Relationality: From Attachment to Intersubjectivity. Hillsdale, NJ: Analytic Press, 2000. Ogden, Thomas. “On Three Forms of Thinking: Magical Thinking, Dream Thinking, and Transformative Thinking.” Psychoanalytic Quarterly 79 (2010): 317–347. Orange, Donna. Emotional Understanding: Studies in Psychoanalytic Epistemology. New York: Guilford, 1995. ———. The Suffering Stranger: Hermeneutics for Everyday Practice. New York: Routledge, 2011. Pérez Foster, RoseMarie, Michael Moskowitz, and Rafael Javier, ed. Reach- ing Across Boundaries of Culture and Class: Widening the Scope of Psy- chotherapy. Northvale, NJ: Jason Aronson, 1996. Perlitz, Dan. “Beyond Kohut: From Empathy to Affection. Unpublished manuscript, Toronto, 2014. Renik, Owen. The Perils of Neutrality. Psychoanalytic Quarterly 65 (1966): 495–517. Rogers, Carl. Counseling and Psychotherapy. Boston: Houghton Mifflin, 1942. ———. On Becoming a Person. Boston: Houghton Mifflin, 1961. Schore, Allan. Forward to The Shadow of the Tsunami and the Growth of the Relational Mind, by Philip Bromberg. New York: Routledge, 2011. ———. The Science of the Art of Psychotherapy. New York: Norton, 2012. Shaw, Daniel. Traumatic Narcissism: Relational Systems of Subjugation. New York: Routledge, 2014. Siegel, Daniel. The Mindful Brain: Reflection and Attunement in the Culti- vation of Well-being. New York: Norton, 2007. Downloaded by [New York University] at 13:36 13 August 2016 ———. The Mindful Therapist: A Clinician’s Guide to Mindsight and Neural Integration. New York: N orton, 2010. ———. Mindsight: The New Science of Personal Transformation. New York: Bantam, 2010. Stern, Daniel. The Interpersonal World of the Infant: A View from Psychoanalysis and Developmental Psychology. New York: Basic Books, 1985. ———. The Present Moment in Psychotherapy and Everyday Life. New York: Norton, 2004. Stern, Donnel. Partners in Thought: Working with Unformulated Experi- ence, Dissociation, and Enactment. New York: Routledge, 2010. 212 Bibliography Stolorow, Robert, and George Atwood. Contexts of Being: The Intersubjec- tive Foundations of Psychological Life. Hillsdale, NJ: Analytic Press, 1992. Stolorow, Robert, George Atwood, and Bernard Brandchaft, ed. The Inter- subjective Perspective. Northvale, NJ: Jason Aronson, 1994. Sullivan, Harry Stack. The Interpersonal Theory of Psychiatry. New York: Norton, 1953. White, Michael and David Epston. Narrative Means to Therapeutic Ends. New York: Norton, 1990. Wolf, Ernest. Treating the Self: Elements of Clinical Self Psychology. New York: Guilford, 1988. Downloaded by [New York University] at 13:36 13 August 2016 Index

abuse survivors, relational work in 56 Bromberg, Philip 183, 188, 202 addictions, relational work in 56 Brown, Laura 26, 27, 28, 68, 71 adversarial transference 139 affectionate understanding 205 cause-and-effect thinking 16 affect regulation 182 change, model of 146–147 agape love 23 Chesler, Phyllis 67 Ainsworth, Mary 142, 174 childhood abuse, survivors of 85–90 alter ego transference 139 chronic dissatisfaction 61–62, 64 ambivalent attachment 142 client-centered therapy 2, 22–23 analytic love 204–205 cognitive-behavioral therapy 1, 21 animus 20 commitment to being present 45, 148, 155, anxious avoidant attachment 142 164, 171 anxious resistant attachment 142 communication of empathy 48–50 archetypes 19–20 “complex post-traumatic stress disorder Aron, Lewis 31, 34, 122, 148, 150, 170, (PTSD)” 85 190–191 connections/disconnections 29–30, 40, assessment of patterns in interactions 3, 72–73, 79–80, 87–90 70–73 constructive empathy 51 attachment theory 142–143, 173 “convictions” 80 Atwood, George 37, 137, 138, 149 core relatedness 143, 144–145, 156 authenticity in therapy 49–50 cotransference 123 countertransference 17, 23, 121–124 baby studies, interpersonal activities in 50, couples therapy, relational work in 57–58 52, 54, 79 Cozolino, Louis 184

Downloaded by [New York University] at 13:36 13 August 2016 Bacal, Howard 37, 39, 138 crying 74 Badenoch, Bonnie 184 bedtime story of a client 71–72 Davies, Jody Messler 101, 102 Benjamin, Jessica 34, 149–150, 170 deficits in self experience 139 bereavement therapy 55 dependency in therapy 46, 152–154, 157–158 Boston Change Process Study Group developmental aspect of theory 37 (BCPSG) 146–147, 177–180, 188, 189, disconnection, effects of 29, 69–71, 90–92 191, 196 dissatisfaction, feelings of 61–62 boundaries of therapy 3, 45–46, 51, 192 dissociated enactments 187–188, 190, 199 Bowlby, John 142, 143, 155 dissociated selves 181–182 Brandchaft, Bernard 80 dissociation: continuum of 103–105; British independent school of relational 101–103; response to trauma psychoanalytic therapy 31 with 85, 91–92; traumatic effects of 90–92 214 Index

dissociative identity disorder 100, 104–105 “go unconscious” 181 dissonance, relational 62, 64 grieving and relational therapy 56, 94, downward relational spirals 123 163–164 dreams, role in Jungian therapy of group therapy 2, 58 19–21, 28 dynamic systems theory 173, 177–180, 187 Herman, Judith Lewis 84, 94 hermeneutic of suspicion 206 eating disorders 2 “hermeneutic of trust” 203–204 efficacy in relationship 139 humanistic therapy 22–25, 28 ego 18 either/or thinking 15–16 idealizing transference 139 emancipatory political theories 26 implicit knowledge 179, 188 emergent relatedness 143, 144 “implicit relational knowing” 146, 177, 179 emotion 187–188; mentalizing 176 individualistic model of therapy 15, 20 emotional abandonment 53 infants, interpersonal world of 41, 49–50, emotional abuse 85 52, 66, 67, 78–79, 144, 145–146 emotional connectedness 201 insight 187–189 emotional intimacy in therapy 151–152 integration 90, 94, 104–105, 109, 114, 119, emotional takeover 53 124–125 empathy: benefits to the client of 3, intention and its importance in 51–52; communication of 48–50; psychotherapy 179, 188, 196 constructive 51; definition of 47–48; interactive system of self 63, 64–66 making connections in therapy with “internalized oppression” 71 135–137, 160, 162, 169; in relational interpersonalist theory 31–33, 34 therapy 41, 47–60; in self psychology interpersonal neurobiology 184 therapy 32, 36, 78; three stages of interpersonal process, system of 63–65 174–175 intersubjective relatedness 143, 144, 145 empowerment, components of 150 intersubjectivity: feminist definition of enactment of showing up 200–201 149–150 encounter groups 23 intersubjectivity theory 31, 37, 39, 189, 193 ending therapy 5, 160–171 intrapsychic reality 34 Enrenberg, Darlene 34 “isolated self” 12 “erotic transference” 151–152 isolating behaviors 71–74 ethical hermeneutics 204 ethics. See professional ethics “Jane” case of 17–18 experience: emotional 187–189; in Jordan, Judith 51 relational therapy 41 Jung, Carl 19 Jungian therapy 19–21, 28 falling in love in therapy 151–152, 164 family systems: disconnection to 70–71; “Kim” case of 154–158 model scenes of 106–107; relational kinds of doing 13–14 work in 57 Kohut, Heinz 31, 32, 36, 37, 47, 48, 139, 153 Downloaded by [New York University] at 13:36 13 August 2016 fear 24, 54; influences on therapy 59, 152 feeling bad 61–62, 64, 77 languages of attunement 184 feminist theory of psychotherapy 1, 26–28, Lévinas, Emmanuel 204 29, 34–35, 67–69, 71 Lichtenberg, Joseph 143, 145–146 Fonagy, Peter 173, 174, 176, 177 love in psychotherapy 204–205 Freud, Sigmund 15, 16, 74 “Lucy” case of 98–102, 104–105 Freudian therapy 16–19, 28, 74 Main, Mary 168 Gestalt therapy 23 Marxism 26 goal-oriented therapy 21, 28 medical model of therapy 14, 28 goodness of ordinary life 134–137, Meeting of Minds: Mutuality in 154–158, 165 Psychoanalysis, A (Aron) 191 Index 215

“Megan” case of 97–98, 104, 105 personality clash 59 memory/memories 91–102, 165–167; phobias 2 repressed 9 phobias, relational work in 56 mentalization theory 173–177, 182, physical abuse, relational work in 3, 187–188, 190, 194, 202 56–57, 85 mentalizing 173–177, 187, 190, 195; “play space” 123 emotion 176; the transference 176–177 positive transference 18 merger transference 139 procedural knowing 177 Miller, Jean Baker 70, 150 process memory, system of 63–64 mindfulness 184 professional ethics 2, 47, 151–152, mindsight 184 202–207 mirroring transference 139 pseudo-mentalizing 176 Mitchell, Stephen 34, 35, 122, 148, 150 Psychoanalytic Dialogues 32 “model scenes” 105–111, 113, 131, 135, psychoanalytic therapy 2, 17 145, 156 psychodrama therapy 23 “moments of meeting” 177, 191 psychodynamic theory of psychotherapy 1 motivation, systems of 145–146 psychological dissonance 62, 65–66, 69, “moving along” in therapy 147 71–72, 81 multiple personality disorder 104 mutuality in relationship 149–150, 170 radical feminism therapy 1, *26–28, 29 mutually dissociated enactments theory rationalism 15–16, 24 173, 180–183, 190–191 realization in psychotherapy 188 reflective-functioning scale 173–174 narrative therapy 25–26, 28, 71–72 relatedness, sequence of 143–145 negative transference 4, 18, 122–126, 128 relational brain 183–186, 187 neurobiological affect regulation theory relational dilemma 62 173, 183 relational dissociation 101–103 Newman, Kenneth 138 relational dissonance 62, 64 “not-me” dissociation 181–183, 195 relational failures 121–122 “now moments” in therapy 147, 156, 177, relational group therapy 58 196, 199 relational images of self-image 72–73 relational psychoanalysis 30–36 object relations theory 31, 33, 41, 73–76 relational ruptures in therapy 3, 120–122, obsessive-compulsive patterns, relational 128–132 work in 56 relational theorizing 186–187 Ogden, Thomas 204 relational theory of psychotherapy 2 “one-body” 34, 37 relational therapy: clients that can benefit oppression producing mental illness 68–69 from 5–8; definition and its contexts “optimal responsiveness” 37, 39, 138 with other psychotherapies 11–42 Orange, Donna 37, 80, 123, 149, 203, 205 relational trauma. See also trauma: “organizing principles” system of 63–65, continuum of 86–88; definition 78, 79–81, 96, 98 of 84; effects of 3, 84–86, 90–92; Downloaded by [New York University] at 13:36 13 August 2016 outside-inside interface 66–69, 74–79 factors contributing to 89–90; role of remembering in 92–103, 163–164 parent-child mentalizing interactions 174 remembering, relational work with “parentification” 70 92–102 parents, exchanges with infants 144, Renik, Owen 34 145–146 repetitive transference 137–138, 193 “pathological accommodation” 80–81, 90 “resistance” 22 patriarchal power 27 right-brain emotional/relational performative therapy 13–14, 82 connection 173, 183–185, 189 Perlitz, Dan 205 right-brain integration as response to personal change and/or systemic change trauma 183, 185 189–190 right-brain vertical integration 184 216 Index

RIGs (Representation of Interactions which in therapy 153; on dissonance in have been Generalized) 63–64, 66, 74, family systems 69, 70; on empathy 156, 179 in therapy 51, 69; on mutuality Rogers, Carl 22–23, 47, 48, 49, 202 in relationships 150–151, 170; on romantic interests in therapy 151–152 psychological problems 72–73; theory of psychotherapy of 29–33, 35, 37, 40; on saying good-bye to therapy 163–165 the zest in connections 150, 157, 167 Schore, Allan 183, 184–185, 189, 190, 202 strategic therapy 21 secrecy 70 strategies of connection/disconnection secure attachment 142, 174 72–73 self: interaction with others 3; symbolic Subversive Dialogues (Brown) 26 view of 20–21 “Sue” case of 68–69 self-actualization 23 Sullivan, Harry Stack 31, 32, 33, 76 self-delination 140–141 survivor health 18 self-delineating selfobject transference synchronous affect communication 185 139–140 systemic change and/or personal change self-disclosure 190–192, 196 189–190 self-experience 32–33 systems of “self” 62–65 “self-in-relation” 29, 72, 150, 170, 189 “selfobject” 31, 32, 36, 77–78, 194 “Tale of Two Hospitals, A” 98–102 “selfobject transference” 138–142 talk therapy 16 self psychology: on defining a client’s terminating therapy 160–171 problem 77–79; empathy as a tool in therapeutic alliance 16 32, 36; influence on relational therapy therapeutic detachment 206–207 by 31–33, 36–39, 40; on “repetitive therapists: qualities of a good relational one transference” 137–138 9–10; quality relationship with client self-state systems 62–63, 67 180; in therapy 109–120, 122, 193–200 self-sustaining selfobject ambience therapy: boundaries of relationship 44–47 139–140 transactional analysis 23 self-with-other, focus of 5–6, 11–14, 62, 95, transference: definition of 17; in relational 147–151, 172 therapy 4, 23, 103, 107, 122–126, sexual abuse, relational work with 3, 56, 70, 151–152; in self psychology therapy 85, 101 137–142 Shadow of the Tsunami and the Growth of transformative thinking 204 the Relational Mind, The (Bromberg) 183 trauma. See also relational trauma: shame, feelings and effects of 65–67, 77, 92, continuum and effects of 86–92, 183 94–95, 111, 113–114, 182 Trudeau, Justin 163 Shaw, Daniel 204 Trudeau, Pierre 163 short-term therapy 21–22, 28 twinship transference 139 Siegel, Daniel 184 social-construction therapy 71 unconscious, understanding of 8 social disconnection 70–71 Downloaded by [New York University] at 13:36 13 August 2016 social location, influence in therapy by 69 verbal-reflective knowledge 179, 188 social power 27 verbal relatedness 143, 144, 145 solution-focused theory 1, 21–22 vicarious introspection 47 spiritual-medical model of therapy 19–21 spiritual work in relational therapy 56 we-ness of the therapy relationship Stern, Daniel 50, 63, 79, 143–145, 146, 189–190 156, 177 William Alanson White Institute 32 Stern, Donnel 188, 190, 192, 200 Wolf, Ernest 139 Stiver, Irene 70, 150, 153 Women and Madness (Chesler) 67 Stolorow, Robert 37, 137, 138, 149 “working models of parents and self” 142 Stone Center for Developmental Services and Studies: on dependence zest in-relation 150