A Rumor of Empathy: Resistance, Narrative and Recovery in Psychoanalysis and Psychotherapy 9781138795372, 9781138795365

Table of contents :
Cover......Page 1
Title......Page 10
Copyright......Page 11
Dedication......Page 14
Contents......Page 16
Acknowledgements......Page 20
List of figures......Page 21
Preface......Page 22
Fact or psychic reality......Page 28
Truth and construction......Page 30
Self-knowledge and cognitive impenetrability......Page 32
Hermeneutics and interpretation......Page 34
Suffering and psychotherapy......Page 37
Empathy and its inauthenticities......Page 41
The literature on “resistance to empathy”......Page 43
A unified multidimensional definition of the process of empathy......Page 49
One person’s empathy is another’s countertransference......Page 54
The resistance to empathy in the organization......Page 56
Clinical vignette: the Freud of psychiatric diagnosis—oops, I mean “fraud”......Page 59
Clinical vignette: speaking truth to power......Page 62
Clinical vignette: crashing the bike......Page 65
The therapist’s resistance to empathy......Page 69
Clinical vignette: dynamics of idealization......Page 74
The patient’s resistance to empathy......Page 78
Clinical vignette: a bother instead of a belonging......Page 83
Empathy and its discontents......Page 87
Language and speech acts......Page 92
Narrative and interpretation......Page 94
Description and redescription......Page 97
Interpretation and micro-narratives......Page 101
Micro-narratives and a rumor of empathy......Page 103
A rumor of empathy in Freud......Page 109
Narrative truth and historical truth revisited......Page 121
Kris’s personal myth as narrative truth and historical truth......Page 126
Narrative truth and historical truth in Pierre Janet......Page 127
The Oedipus complex and the original trauma = X......Page 130
From empathic narrative to optimal responsiveness......Page 132
Plato not prozac......Page 136
Examining the unexamined life......Page 137
The micro-narrative of a chemical imbalance......Page 141
From a rumor to a scandal of empathy in psychopharmacology......Page 149
A rumor of empathy on the inpatient unit......Page 155
Clinical vignette: redescribing youthful indiscretion......Page 156
Clinical vignette: redescribing saying “good bye”......Page 159
Clinical vignette: cultivating the tree of one’s sorrows......Page 162
Clinical vignette: a noticeable absence of trauma......Page 163
Prelude......Page 168
Why do men abuse and what to do about it......Page 173
Escape......Page 178
Safety......Page 180
The facts are fragile......Page 182
Acknowledgment of what happened......Page 184
Acknowledgment of what the survivor made it mean......Page 189
Clinical vignette: redescribing the skeleton in the closet: it’s crowded in there......Page 192
Boundaries: confrontation with shame, guilt, rage, negative emotions......Page 196
Clinical vignette: redescribing honor......Page 199
Expectation (realistic and otherwise) of compensation for suffering......Page 202
Clinical vignette: redescribing emotional balance......Page 206
Access to emotional resources, aspirations, ambitions, ideals......Page 209
Re-engage with the developmental process......Page 211
Risks: retraumatization, stuckness, endless looping, isolation......Page 216
Conclusion......Page 222
References......Page 225
Index......Page 236

Citation preview

“Always equally challenging and accessible, Dr Lou Agosta’s text, A Rumor of Empathy, succeeds in presenting empathy from the unified perspective of cognition and affect. In doing so, our understanding of, and feeling for, empathy is both substantially enhanced and transformed. A Rumor of Empathy is a major contribution to the debates surrounding empathy, as well as to its uses and mis-uses, within psychotherapy.” —Professor Ernesto Spinelli, Ph.D., ES Associates, London, UK “Having defined and explicated the ‘deep history’ of empathy in earlier work, Agosta in the present book draws out the clinical yield of his earlier studies by tracking empathy and its failures, and the resistances to empathy, as these show up on in both participants in the psychoanalytic encounter. In this Insurance-Company-Driven Age of Scientism and the Quick Fix, he seeks nothing less that the restoration of empathy to its rightful place as the foundation of authentic human relationships. In so doing, he offers a much needed, philosophically informed, non-pathologizing approach to emotional disturbances and human suffering guided by humanist values. I recommend A Rumor of Empathy to psychoanalytic therapists at all levels of training and experience.” —Robert D. Stolorow, Ph.D., author, World, Affectivity, Trauma: Post-Cartesian Psychoanalysis (Routledge, 2011) “A Rumor of Empathy by Lou Agosta melds philosophy, psychology, and psychoanalysis together in a remarkable inquiry into empathy as a multidimensional process extending from empathic receptivity, through empathic understanding, to empathic interpretation and responsiveness in empathic language and listening. Agosta demonstrates that the innovations of Freud and Kohut in psychoanalysis and Paul Ricoeur in Philosophy come alive and enliven in Agosta’s provocative and penetrating engagement with empathy as the foundation of human relatedness. The author surfaces a subtle resistance to empathy that has previously not been engaged and shows how to overcome it through engagement with countertransference, micro-narrative, and introspection, thus validating a rumor of empathy. Working his way through resistance to empathy the author surfaces a rumor of empathy, which he applies as a stalking horse in a diversity of psychodynamically relevant contexts to demonstrate that empathy lives. As Agosta writes at the end of his Preface, empathy means that ‘after all the diagnostic labels have been applied, all the prescriptions written, all the cognitive behavioral scripts implemented, all the distinctions of meaning between manifest and latent fantasies called out, all the id made ego, all the transference and countertransference explored, every hermeneutic circle spun out, all the narratives and micro-narratives transformed, one is simply and unavoidably

in the presence of another human being.’ Focusing on empathy, Dr. Agosta explores the resistances to empathy in a personally risky and ultimately productive fashion.” —Paul C. Holinger, M.D., M.P.H. “The value of Lou Agosta’s A Rumor of Empathy lies not only in its academic and theoretic contribution, which, as might be expected from a scholar such as Agosta, is top notch. For a clinical psychologist such as myself, running a multidisciplinary clinic, the value lies in the lesson that when all the diagnostic categories are applied, all the cognitive behavior methods deployed, all the transferences and countertransferences analyzed, all the medications prescribed, in empathy, one is simply in the presence of another human being. Remarkably enough, Agosta succeeds in making empathy present, in bringing it to life, amidst the struggle for wholeness, integrity and completeness and in the face of human emotional pain, empathy LIVES.” —Aarnon Rolnick, Ph.D., Clinical Director, Ramat Gan Psychotherapy Center

A Rumor of Empathy

Empathy is an essential component of the psychoanalyst’s ability to listen and treat their patients. It is key to the achievement of therapeutic understanding and change. A Rumor of Empathy explores the psychodynamic resistances to empathy, from the analyst themselves, the patient, from wider culture, and seeks to explore those factors which represent resistance to empathic engagement, and to show how these can be overcome in the psychoanalytic context. Lou Agosta shows that classic interventions can themselves represent resistances to empathy, such as the unexamined life; over-medication, and the application of devaluing diagnostic labels to expressions of suffering. Drawing on Freud, Kohut, Spence, and other major thinkers, Agosta explores how empathy is distinguished as a unified multidimensional clinical engagement, encompassing receptivity, understanding, interpretation and narrative. In this way, he sets out a new way of understanding and using empathy in psychoanalytic theory and clinical practice. When all the resistances have been engaged, defenses analyzed, diagnostic categories applied, prescriptions written, and interpretive circles spun out, in empathy one is quite simply in the presence of another human being. Agosta depicts the unconscious forms of resistance and raises our understanding of the fears of merger that lead a therapist to take a step back from the experience of their patients, using ideas such as “altruistic surrender” and “compassion fatigue” which are highlighted in a number of clinical vignettes. Empathy itself is not self-contained. It is embedded in social and cultural values, and Agosta highlights the mental health culture and its expectations of professional organizations. This outstanding text will be relevant to psychoanalysts, psychotherapists who wish to make a contribution to reducing the suffering and emotional distress of their clients, and also to trainees who are vulnerable to the professional demands on their capacity for empathic listening. Lou Agosta, Ph.D. teaches empathy in systems and the history of psychology at the Illinois School of Professional Psychology at Argosy University. He is the author of numerous articles on empathy in human relations, aesthetics, altruism, and film. He is a psychotherapist in private practice in Chicago, USA. See www.aRumorOfEmpathy.com

PSYCHOANALYTIC INQUIRY BOOK SERIES JOSEPH D. LICHTENBERG SERIES EDITOR

Like its counterpart, Psychoanalytic Inquiry: A Topical Journal for Mental Health Professionals, the Psychoanalytic Inquiry Book Series presents a diversity of subjects within a diversity of approaches to those subjects. Under the editorship of Joseph Lichtenberg, in collaboration with Melvin Bornstein and the editorial board of Psychoanalytic Inquiry, the volumes in this series strike a balance between research, theory, and clinical application. We are honored to have published the works of various innovators in psychoanalysis, such as Frank Lachmann, James Fosshage, Robert Stolorow, Donna Orange, Louis Sander, Léon Wurmser, James Grotstein, Joseph Jones, Doris Brothers, Fredric Busch, and Joseph Lichtenberg, among others. The series includes books and monographs on mainline psychoanalytic topics, such as sexuality, narcissism, trauma, homosexuality, jealousy, envy, and varied aspects of analytic process and technique. In our efforts to broaden the field of analytic interest, the series has incorporated and embraced innovative discoveries in infant research, self psychology, intersubjectivity, motivational systems, affects as process, responses to cancer, borderline states, contextualism, postmodernism, attachment research and theory, medication, and mentalization. As further investigations in psychoanalysis come to fruition, we seek to present them in readable, easily comprehensible writing. After 25 years, the core vision of this series remains the investigation, analysis and discussion of developments on the cutting edge of the psychoanalytic field, inspired by a boundless spirit of inquiry.

PSYCHOANALYTIC INQUIRY BOOK SERIES JOSEPH D. LICHTENBERG SERIES EDITOR

Vol. 2 Psychoanalysis and Infant Research Joseph D. Lichtenberg Vol. 8 Psychoanalytic Treatment: An Intersubjective Approach Robert D. Stolorow, Bernard Brandchaft, & George E. Atwood Vol. 10 Psychoanalysis and Motivation Joseph D. Lichtenberg Vol. 12 Contexts of Being: The Intersubjective Foundations of Psychological Life Robert D. Stolorow & George E. Atwood Vol. 13 Self and Motivational Systems: Toward a Theory of Psychoanalytic Technique Joseph D. Lichtenberg, Frank M. Lachmann, & James L. Fosshage Vol. 14 Affects as Process: An Inquiry into the Centrality of Affect in Psychological Life Joseph M. Jones Vol. 16 The Clinical Exchange: Techniques Derived from Self and Motivational Systems Joseph D. Lichtenberg, Frank M. Lachmann, & James L. Fosshage Vol. 17 Working Intersubjectively: Contextualism in Psychoanalytic Practice Donna M. Orange, George E. Atwood, & Robert D. Stolorow

Vol. 18 Kohut, Loewald, and the Postmoderns: A Comparative Study of Self and Relationship Judith Guss Teicholz Vol. 19 A Spirit of Inquiry: Communication in Psychoanalysis Joseph D. Lichtenberg, Frank M. Lachmann, & James L. Fosshage Vol. 20 Craft and Spirit: A Guide to Exploratory Psychotherapies Joseph D. Lichtenberg Vol. 21 Attachment and Sexuality Diana Diamond, Sidney J. Blatt, & Joseph D. Lichtenberg (eds) Vol. 22 Psychotherapy and Medication: The Challenge of Integration Fredric N. Busch & Larry S. Sandberg Vol. 23 Trauma and Human Existence: Autobiographical, Psychoanalytic, and Philosophical Reflections Robert D. Stolorow Vol. 24 Jealousy and Envy: New Views about Two Powerful Feelings Léon Wurmser & Heidrun Jarass (eds) Vol. 25 Sensuality and Sexuality across the Divide of Shame Joseph D. Lichtenberg

Vol. 26 Living Systems, Evolving Consciousness, and the Emerging Person: A Selection of Papers from the Life Work of Louis Sander Gherardo Amadei & Ilaria Bianchi (eds) Vol. 27 Toward a Psychology of Uncertainty: Trauma-Centered Psychoanalysis Doris Brothers Vol. 28 Transforming Narcissism: Reflections on Empathy, Humor, and Expectations Frank M. Lachmann Vol. 29 Mentalization: Theoretical Considerations, Research Findings, and Clinical Implications Fredric N. Busch (ed.) Vol. 30 From Psychoanalytic Narrative to Empirical Single Case Research: Implications for Psychoanalytic Practice Horst Kächele, Joseph Schachter, Helmut Thomä & the Ulm Psychoanalytic Process Research Study Group Vol. 31 Toward an Emancipatory Psychoanalysis: Brandchaft’s Intersubjective Vision Bernard Brandchaft, Shelley Doctors, & Dorienne Sorter Vol. 32 Persons in Context: The Challenge of Individuality in Theory and Practice Roger Frie & William J. Coburn (eds) Vol. 33 Psychoanalysis and Motivational Systems: A New Look Joseph D. Lichtenberg, Frank M. Lachmann, & James L. Fosshage

Vol. 34 Change in Psychoanalysis: An Analyst’s Reflections on the Therapeutic Relationship Chris Jaenicke Vol. 35 World, Affectivity, Trauma: Heidegger and Post-Cartesian Psychoanalysis Robert D. Stolorow Vol. 36 Manual of Panic Focused Psychodynamic Psychotherapy—Extended Range Fredric N. Busch, Barbara L. Milrod, Meriamne B. Singer, & Andrew C. Aronson Vol. 37 The Abyss of Madness George E. Atwood Vol. 38 Self Experiences in Group, Revisited: Affective Attachments, Intersubjective Regulations, and Human Understanding Irene Harwood, Walter Stone, & Malcolm Pines (eds) Vol. 39 Nothing Good Is Allowed to Stand: An Integrative View of the Negative Therapeutic Reaction Léon Wurmser & Heidrun Jarass (eds) Vol. 40 Growth and Turbulence in the Container/ Contained: Bion’s Continuing Legacy Howard B. Levine & Lawrence J. Brown (eds) Vol. 41 Metaphor and Fields: Common Ground, Common Language and the Future of Psychoanalysis S. Montana Katz (ed.) Vol. 42 Psychoanalytic Complexity: Clinical Attitudes for Therapeutic Change William J. Coburn

Vol. 43 Structures of Subjectivity: Explorations in Psychoanalytic Phenomenology and Contextualism, 2nd Edition George E. Atwood and Robert D. Stolorow Vol. 44 The Search for a Relational Home: An intersubjective view of therapeutic action Chris Jaenicke Vol. 45 Creative Analysis: Art, Creativity and Clinical Process George Hagman Vol. 46 A Rumor of Empathy: Resistance, narrative and recovery in psychoanalysis and psychotherapy Lou Agosta

Out of Print titles in the PI Series

Vol. 4 Structures of Subjectivity: Explorations in Psychoanalytic Phenomenology George E. Atwood & Robert D. Stolorow Vol. 5 Toward a Comprehensive Model for Schizophrenic Disorders: Psychoanalytic Essays in Memory of Ping-Nie Pao David B. Feinsilver Vol. 6 The Borderline Patient: Emerging Concepts in Diagnosis, Psychodynamics, and Treatment, Vol. 1 James S. Grotstein, Marion F. Solomon, & Joan A. Lang (eds) Vol. 7 The Borderline Patient: Emerging Concepts in Diagnosis, Psychodynamics, and Treatment, Vol. 2 James S. Grotstein, Marion F. Solomon, & Joan A. Lang (eds) Vol. 9 Female Homosexuality: Choice without Volition Elaine V. Siegel

Vol. 1 Reflections on Self Psychology Joseph D. Lichtenberg & Samuel Kaplan (eds)

Vol. 11 Cancer Stories: Creativity and Self-Repair Esther Dreifuss-Kattan

Vol. 3 Empathy, Volumes I & II Joseph D. Lichtenberg, Melvin Bornstein, & Donald Silver (eds)

Vol. 15 Understanding Therapeutic Action: Psychodynamic Concepts of Cure Lawrence E. Lifson (ed.)

This page intentionally left blank

A Rumor of Empathy

Resistance, narrative and recovery in psychoanalysis and psychotherapy

Lou Agosta

First published 2015 by Routledge 27 Church Road, Hove, East Sussex, BN3 2FA and by Routledge 711 Third Avenue, New York, NY 10017 Routledge is an imprint of the Taylor & Francis Group, an Informa business © 2015 Lou Agosta The right of Lou Agosta to be identified as author of this work has been asserted by him 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 utilized in any form or by any electronic, mechanical, or other means, now known or hereafter invented, including photocopying 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. British Library Cataloguing in Publication Data A catalogue record for this book is available from the British Library Library of Congress Cataloging in Publication Data Agosta, Louis, 1950– A rumor of empathy: resistance, narrative and recovery in psychoanalysis and psychotherapy/Lou Agosta. pages cm Includes index. 1. Empathy. 2. Psychoanalysis. 3. Psychotherapy. I. Title. BF575.E55A36 2015 152.4⬘1—dc23 2014046589 ISBN: 978-1-138-79536-5 (hbk) ISBN: 978-1-138-79537-2 (pbk) ISBN: 978-1-315-73897-0 (ebk) Typeset in Times New Roman and Gill Sans by Florence Production Ltd, Stoodleigh, Devon, UK

Disclaimer No book can substitute for individualized professional guidance. However, finding guidance that is consistent with one’s own values and philosophy is important. The aim of this book is to present a position on a rumor of empathy. It cannot be used as a treatment handbook. It cannot be used as a practical handbook. It is not a reference manual. The discussion in this book aims at psychodynamic inquiry and speculation, social commentary, cultural history, hermeneutic explication, and, occasionally a sustained polemic against a pendulum that has arguably swung too far in one direction or another. This work contains no medical advice, legal advice, software advice, cooking advice, or, for that matter, any advice, professional or otherwise. All the usual disclaimers apply. Common sense applies: Follow the guidance of one’s trusted professional advisers.

Also by Lou Agosta A Rumor of Empathy in the Context of Philosophy: Rewriting Empathy in the History of Philosophy

This page intentionally left blank

To the memory of my teachers TC, SET, PR, for whom empathy was no rumor but an enlivening presence, inspiring inquiry and fulfilling relatedness

This page intentionally left blank

Contents

Acknowledgements List of figures Preface Introduction: basic distinctions

1

xix xx xxi 1

Introducing the introduction Fact or psychic reality Truth and construction Self-knowledge and cognitive impenetrability Hermeneutics and interpretation Suffering and psychotherapy

1 1 3 5 7 10

Empathy and its resistances

14

Empathy and its inauthenticities Types of resistance to empathy The literature on “resistance to empathy”

14 16 16

A unified multidimensional definition of the process of empathy 22 One person’s empathy is another’s countertransference 27 The resistance to empathy in the organization

29

Clinical vignette: the Freud of psychiatric diagnosis—oops, I mean “fraud” 32 Clinical vignette: speaking truth to power 35 Clinical vignette: crashing the bike 38 The therapist’s resistance to empathy

42

Clinical vignette: dynamics of idealization 47 The patient’s resistance to empathy

51

xvi

Contents

Clinical vignette: a bother instead of a belonging 56

2

Empathy and its discontents

60

A rumor of empathy . . .

65

Language and speech acts Narrative and interpretation Description and redescription Interpretation and micro-narratives Micro-narratives and a rumor of empathy A rumor of empathy in Freud Narrative truth and historical truth revisited

65 67 70 74 76 82 94

Kris’s personal myth as narrative truth and historical truth 99 Narrative truth and historical truth in Pierre Janet 100 The Oedipus complex and the original trauma = X 103

3

From empathic narrative to optimal responsiveness

105

Plato not prozac!

109

Plato not prozac Examining the unexamined life The micro-narrative of a chemical imbalance From a rumor to a scandal of empathy in psychopharmacology A rumor of empathy on the inpatient unit

109 110 114 122 128

Clinical vignette: redescribing youthful indiscretion 129 Clinical vignette: redescribing saying “good bye” 132 Clinical vignette: cultivating the tree of one’s sorrows 135 Clinical vignette: a noticeable absence of trauma 136 4

Treatment of domestic violence

141

Prelude Why do men abuse and what to do about it Escape Safety

141 146 151 153

The facts are fragile 155 Acknowledgment of what happened Acknowledgment of what the survivor made it mean Clinical vignette: redescribing the skeleton in the closet: it’s crowded in there 165

157 162

Contents

Boundaries: confrontation with shame, guilt, rage, negative emotions

xvii

169

Clinical vignette: redescribing honor 172 Expectation (realistic and otherwise) of compensation for suffering Abuse survived and worked through as a resource

175 179

Clinical vignette: redescribing emotional balance 179 Access to emotional resources, aspirations, ambitions, ideals Re-engage with the developmental process Risks: retraumatization, stuckness, endless looping, isolation

182 184 189

Conclusion References Index

195 198 209

This page intentionally left blank

Acknowledgements

A number of people read an early version of this work, or parts of it, and provided useful feedback to me: Dennis Beedle, Paul Holinger, Meghan M. Kennedy, Ron Kimberling, Joe Lichtenberg, Ernesto Spinelli, Robert Stolorow, Molly Romer Witten. I thank them again. I write this in the present tense because it lives on in me in the present, and years ago I send the late Dr Michael Franz Basch Chapter One of my dissertation on Empathy and Interpretation (University of Chicago 1977) in the Philosophy Department. Basch writes back to me with a six-page type written response. A relationship is born. Empathy is made present—albeit in scholarly form. The work commences. “Dear Mike—sorry it took so long. I believe this is what we had in mind.” Many people provided inspiration by agreeing with me; others, by disagreeing with me. In several cases, I disagreed so strongly with the assertions that I was inspired to use my disagreement to articulate an alternative point of view. Thus, they contributed indirectly to my education without appreciating how. I acknowledge all, and, express my gratitude to all including, Jim Anderson, Claude Barbre, Todd Dubose, Ben Garber, Michael Hoit, Leah Horvath, Susan Lanzoni, Judith Newman, Kenneth Newman, William Richardson, Erika Schmidt, AnneMarie Slobig, Neil Spira, Nathan Szajnberg, Fredrik Svenaeus, Richard Telingator, Barbara Rocah, Leo Weinstein. Thanks also to Kate Hawes at Routledge for her publishing guidance and expertise. My wife and daughter, Alex and Michelle, contributed in ways beyond measure by lovingly schooling me in the practice of empathy. I acknowledge Serena Low and Neha Gill, former and current executive directors, respectively, at Apna Ghar, Our Home, and all the colleagues serving there, whose stand against domestic violence is an implementation of empathy in the best, engaged sense of the word.

Figures

1.1 The hermeneutic circle of empathy 4.1 Recovery cloud: transforming domestic violence Cover artwork: © Alex Zonis, E is for empathy, 2014, oil on panel, www.AlexandraZonis.com

23 152

Preface

One person’s empathy is another’s countertransference. I will not confess my weaknesses, since they will be obvious to the reader in any case. As Freud famously noted, betrayal oozes at every pore. That sometimes applies to psychotherapists too. Breakdowns in empathy occur. Defensiveness happens. Secrets are withheld or revealed. And if there is empathy, can narcissistic rage be far behind? That too occurs, albeit in an aim-inhibited form. When a person gets angry enough, the person finds that being selfexpressed is worth the risk of being vulnerable and exposed. In this book, I have attempted to reach back into my own training as a dynamic psychotherapist, and, retaining the sense of a naive beginner, capture clinical “lessons learned.” While I aim to address a wide audience of experienced clinicians, this work also addresses the dynamic psychotherapist in training. I try to express with empathy and humor what are the dynamic “take-aways” for the starting practitioner, based on my own experiences in the “college of hard knocks.” However, here is the distinctive feature: no one knows better than the advanced practitioner, we are all always beginners. Therefore, there are “lessons learned” liberally intermixed for the seasoned veteran too. Thus, instead of a confession, I offer a bold statement of the obvious: the individual writing a book on empathy—in this case, myself—struggles to be empathic, has to give an account of his own empathy, and indeed on occasion—gasp!—lacks empathy. If this be defensiveness, make the most of it. Anyone promising empathy has to take a stand on his own empathy. On a good day, one gets there. One is “in the zone,” delivering empathy— making empathy present in the conversation. On a less good day, one struggles to relate—to be in touch. This is my ultimate inauthenticity. One discovers one lacks empathy, in the fundamental sense of resistance to empathy. One works on expanding the empathy that one does have, removing the obstacles to empathy. If empathy were so easy, there would be more of it in the world. Cynical readers may say that the author did not get enough empathy. “That must be why the author is so engaged by the subject.” Point granted. Yet

xxii

Preface

such an assertion lacks nuance. It overlooks what “enough” would even mean here. Enough to give empathy away to others who may not have enough? The minimum sufficient to flourish and thrive? What would a world look like in which there was enough empathy, much less related but distinct phenomena such as compassion, flourishing, altruism, or love? Okay, I did not get enough empathy. This is because the task is not increasing the quantity, but rather expanding the quality of the empathy in relatedness to self and others. The task is developing the empathy in which we already live—to make empathy present in the moment of relatedness. The empathic narrative, the good read—like D. W. Winnicott’s “good feed”—has its source in the reactions and countertransferences of the narrator —and of the author. Empathic failures—optimal and non-optimal failures— are the genetic explanation of the motivation behind this project of expanding the presence and effectiveness of empathy in a clinical context and in the world. The goal is to create a context for the natural unfolding of empathy— in others and myself. Paradoxically, empathy is like the oxygen we breathe, yet it is all-tooscarce in the market. A subtle shortness of breath overtakes one. The market for psychotherapy services is filled with professional schools granting diverse credentials at an accelerating rate. Yet the natural unfolding of empathy seems like a high bar in today’s marketing mix of mental health services, which are characterized by a dizzying diversity of talk therapies, varieties of psychotropic medications, and pretexts for prescribing them, and social justice agendas (e.g. Solomon 2012). In such a context, the proposal that empathy is at the foundation of human relationships can seem out-of-date. Does anyone still believe in empathy? An enthusiastic advocate of empathy can sound like a lone voice crying in the wilderness—and an echo of the cry “Empathy!” is the source of the title of “A Rumor of Empathy . . .” Empathy has disappeared behind rules and regulations of confidentiality and is never spoken about. Empathy has disappeared behind the institutional framework. Empathy has disappeared into “the circle of caring,” but many are still outside the circle. Yet empathy lives. It lives as communicability of affect—empathic receptivity. It lives as empathic understanding of the possibilities of clarifying misunderstandings and restoring relationships. It lives as empathic interpretation in human responsiveness to the vicarious experience of the other person’s suffering and happiness. It lives in empathic listening as a paradoxical use of language in providing a gracious and generous listening to the other person’s narrative and struggle. Empathy lives as a multistep process encompassing and unifying the diverse aspects of human relatedness. Now another bold statement of the obvious: psychoanalysis—like most talk therapies—is an embattled discipline in a challenging market. The number of psychoanalytic patients who are not otherwise psychiatry residents, behavioral health professionals pursuing psychoanalytic training, or low-fee

Preface

xxiii

supervised cases in psychoanalytic clinics, can be counted on the fingers of one hand in any given class year. It is just that I personally benefited— benefited greatly—from a generous listening in the process of psychoanalysis at a time when I was the deeply wounded refugee from a heavy-handed, authoritarian father. Okay, so there is some confession after all. I would not get a formal definition of “domestic violence” until years later, but the psychoanalysis I received enabled me to begin distinguishing what happened from what I made it mean. It reinforced the validity of my own experience, perception, and reality testing. It distinguished the psychic creation of meaning from pathogenic fantasies that I was unworthy, broken, or wounded beyond repair, which themselves took time to disentangle and transform. I encountered such meaning creating first in psychoanalysis and psychoanalytically oriented talk therapy. So, as befits a Preface, I honor psychoanalysis first and foremost, no matter what are the current struggles of its all-toohuman practitioners. I actually make no exceptions, since all are embattled. Having circled the wagons, we are set about, limited in the ability to innovate, think outside the proverbial box, or contribute to the community. Finding oneself in a hole, one does not always realize that digging faster and harder does not raise one out of it. Yet there is hope. Innovation happens. In running for election as the President of the American Psychoanalytic Association, Mark Smaller, Ph.D., reportedly said, “If you want to build your practice, get out of your office”—that is, get out and contribute to the community. Dr. Smaller is known in the community for being a driving force behind using psychoanalytic methods with high-risk adolescents at a local alternative high school. Get out and engage in making a difference in the community. Get out and get involved. Get out and be the change you want to see. The current approach to training and preparing psychodynamic psychotherapists is caught in a dilemma. Most training in clinical psychology and psychiatric residency starts with a traversal of the Diagnostic and Statistical Manual (DSM-V). Nothing wrong with that as such. The categories and labels are then applied to the suffering humanity that presents itself from the community. First put these 500 categories—many objectifying and dehumanizing—between oneself and the other person, then try to relate to her or him. Hmmm. It is hard to conceptualize an approach more lacking in empathy than the imposition of so many labels as a context for a conversation about human possibility and recovery of suffering. From the perspective of the DSM, psychology is an observational science dealing with the facts of behavior. Still, the availability of a diagnostic label invites the transition from the frying pan of behavioral labels to the fire of medication—a psychiatrist prescribing a psychotropic intervention. As the Chief Psychiatric Resident of a training program with which I was familiar said: “It is mighty satisfying at the end of a conversation to take out that prescription pad and write one.” Once again, nothing wrong with that as such; and if a person is considering

xxiv

Preface

harming himself or another, the availability of mood altering interventions— especially sedatives—is useful as a measure of harm reduction. Still, the neurochemical reshaping of personality has had many unanticipated consequences. I acknowledge that the debate is not ended by Chapter 3, “Plato Not Prozac!,” the name of which is hereby acknowledged to be from Professor Lou Marinoff’s penetrating and incisive book of the same title. Resistance to empathy and the prescribing of psychotropic medications intersect. Indeed the battle is just joined. I have identified and referenced scientific papers that argue that such medications increase “rapid cycling,” not just in bipolar symptoms, but across a diversity of DSM disorders from anxiety to psychosis. If there is a polemical part of this work, then the debate about medication is it. All in. There is simply no empathic way to bury the hatchet—even metaphorically—in the head of the overprescriber. This is where empathy gives way to a response resembling narcissistic rage—or at least righteous indignation. A rumor of empathy gives way to the scandal of empathy. Years before DSM-I appeared and pharmacologists announced that chlorpromazine had antidepressant effects, Aldous Huxley was prophetic: “The need for frequent chemical vacations from intolerable selfhood and repulsive surroundings will undoubtedly remain” (1954: 64; see also Lane 2007: 170). Plato’s teacher, Socrates, noted, “The unexamined life is not worth living” (Plato Apology 38a). The examined life strikes back. It just might be a timely counter-attack as Stephen Stahl (2008: 383), one of America’s eminent psycho-pharmacologists, has for some time been publishing on the “life-shortening” effects of second generation antipsychotics. Life-shortening indeed. No half measures. To be sure, Sigmund Freud was engaged by biology and chemistry, but he was also interested in myths, stories, and narratives. Freud bemoans the fact that the physiology and anatomy that one learns in medical school is inadequate to the explanations of such clinically relevant phenomena as neurotic symptoms, acting out sexually or aggressively, self-defeating actions, or infantile sexuality. Freud then points out in a neglected text that needs to be better known: But a familiarity with the history of civilization and with mythology is equally indispensable [. . . .] As a “depth psychology”, a theory of mental unconscious, it can become indispensable to all the sciences that are concerned with the evolution of human civilization and its major institutions such as art, religion, and the social order. (Freud 1927: 40, 96) A Rumor of Empathy starts from this single statement by Freud, applicable to dynamic psychotherapy writ large. Three final thoughts. First, this work is not a series of separate essays clipped together. Not that there would be anything wrong with a book of

Preface

xxv

separate essays—just this is not one of those. It is a coherent, integrated, unified argument. Second, while working on this project to expand empathy in the world, I have occasionally felt like a voice crying in the wilderness. Indeed, two voices. The first, a conversational one telling a story of what happened; the second, a clinical one reflecting on the meaning of what happened. I look forward to diverse voices calling out “empathy” so that empathy becomes less of a rumor and becomes instead an expanded presence in the community. Regarding the case histories, clinical vignettes, and anecdotes, I am either in possession of written permission to use the material, have disguised the material so as to render identification impossible, or all of the above. In every instance, the reader is advised: This narrative is based on a true story. I will not repeat the phrase “psychoanalytic therapy or psychoanalytically oriented psychotherapy,” but will simply say “psychotherapy” or “dynamic psychotherapy” unless “psychoanalysis” is specifically appropriate. Third, I emphasize—and empathize—this work is first and last guided by empathy, not what some celebrated thought leader—Freud, Kohut, Ricoeur, Socrates, etc.—did or did not say about empathy. The commitment is to be true to the text of any thinker’s or clinician’s ideas as quoted and intended— exactly what was said or not said. However, the ultimate commitment is to empathy, not Freud; empathy, not Kohut; empathy, not narrative; empathy, not Prozac; empathy, not a host of other thinkers and psychoanalytic clinicians and their ideas. In empathy one assimilates the experience of the other person, processes it as a possibility, and gives it back to the other in such a way that it is useable by the other to expand his or her humanity. Finally, the position of this book is that, after all the diagnostic labels have been applied, all the prescriptions written, all the cognitive behavioral scripts implemented, all the distinctions of meaning between manifest and latent fantasies called out, all the id made ego, all the transference and countertransference explored, every hermeneutic circle spun out, all the narratives and micro-narratives transformed, in empathy, one is simply and unavoidably in the presence of another human being.

This page intentionally left blank

Introduction Basic distinctions

Introducing the introduction A clinical work on a rumor of empathy has to take a position—take a stand— on the relevance and significance of such distinctions as fact, psychic reality, truth, self-knowledge, etc., even if the ultimate justifications for such distinctions remain issues of debate in science, whether as a natural or hermeneutic discipline.

Fact or psychic reality Paul Ricoeur (1977) asserted that a fact in psychoanalysis is constituted by four criteria. First, a psychoanalytic fact is something that can be said. It is part of a conversation. Freud’s guidance about free associating and responding on the basis of evenly hovering listening is not an ordinary conversation, but it is a conversation nonetheless. Second, it is something that is said to another person. The other individual and relatedness to the other are part of the process of communication. Third, a psychoanalytic fact engages psychic reality. This invites numerous paradoxes but is of the essence. Symptoms and fantasies may not correspond to material reality, and, in that sense, are fictional from a common sense perspective. Infantile scenes, lost love objects (persons), and substitute objects (persons) open up a world of imaginary meanings and relationships. The work of mourning is an exemplary case for Freud—and Ricoeur. Material reality is diminished by the departure or death of a loved one, and the imaginary world of psychic reality is proportionately expanded. The psychoanalytic recovery of well-being is closely related to the work of mourning. Fourth, the human experiences that emerge in psychoanalysis are captured and formulated as stories or narratives—case histories. Indeed, Freud compared himself to a writer of short stories (Freud 1893: 160). The famous declaration that “hysterical patients suffer principally from reminiscences” (Breuer and Freud 1893: 221) establishes a relationship to memory that requires filling in the gaps between isolated events to form a meaningful narrative that opens up future possibilities for satisfying love and productive work.

2

Introduction: basic distinctions

To any clinician, the one thing that is arguably missing from Ricoeur’s four criteria is—empathy. For Heinz Kohut empathy is defined as “vicarious introspection,” which provides a form of data gathering specific to psychoanalysis (1959: 461). Without empathy, the mental and emotional life of other human beings is unthinkable (Kohut 1977: 306). The one person is humanized by the other. Not just by the other individual’s receptivity, understanding, interpretation, and responsiveness, but by the other’s very presence. For Kohut, writing in 1959, psychoanalysis is the science of empathy wrapped in positive science (where “positive science” is modeled on natural science). Having first encountered Kohut’s work in 1974, Ricoeur’s commitment becomes replacing the caricature of positive science with a robust application of hermeneutics, the theory of interpretation. Without empathy, the individual human being—with whom the psychoanalytic conversation occurs in Ricoeur’s criteria two—gets lost and is unavailable. Without the other person, one is left lacking in vitality, lifeless, apathetic, lethargic, in short, depressed. A detailed definition of empathy as a unified multidimensional process is provided in Chapter 1, “Empathy and its Resistances.” However, initially empathy functions as “vicarious introspection” and as a rumor of empathy. In addition, something that is present in Ricoeur but invites elaboration is how narrative functions in relation to the psychoanalytic transference. Those in training as dynamic psychotherapists are routinely cautioned not to be distracted by the patient’s story—the narrative. Yet the narrative is essential. It provides access to the relatedness in the transference. Without relatedness, the narrative lacks direction, point, plot; but without the narrative, the transference relationship is an empty, over-intellectualization without context. Both are required. Thus, Ricoeur argues that there are facts in psychoanalysis. The short definition of a fact, whether in material or psychic reality, is that which stands fast. It is just that our contribution to the constitution of the “standing fast” is more expansive and regulative than models of positive science would lead us to believe. Psychic reality emerges from a background of facts. Factual reality emerges from a background of psychic beliefs, desires, feelings, and intentions. Intentions are intrinsically psychic and create a context of psychic reality that give meaning to the facts, which would otherwise be pointless. Again, both are required. For example, when the patient comes in and says that she was driving in her car to her psychotherapy session and she was rear-ended by another driver, then that is a fact about urban traffic. But if the patient then says that her partner was driving and she and her partner have a “big argument” after the crash about who was or was not paying attention and who was to blame, then we have access to psychological dynamics—psychic reality—that is relevant to therapy. What the patient and her partner intend, feel, and own as motivations, emerge as psychic reality.

Introduction: basic distinctions

3

The process of therapy can seem like learning to live with ambiguity. Where do material facts end and psychic realities begin? What time was that appointment supposed to be? Did he or didn’t he? She said; he said. Therapy requires firm boundaries, and much work needs to be done to determine and maintain boundaries in the conversation in therapy and in life itself. Boundaries issues between a person and the others in significant relationships are pervasive and often require investigation as to what the patient—and therapist—made them mean. Notwithstanding debates about narrative truth and historical truth (Spence 1982), many therapists find that it makes a difference both to their patients and to themselves to have a working hypothesis (subject to revision) as to where the boundary stands between fact and psychic reality. The distinction persists and shall engage us in detail.

Truth and construction Truth is truth as constructed under an interpretation. It is easy to say what “construct” does not mean. “Construct” does not mean “subject to a vote.” Above all, “construction” does not mean “relative” or “relative” to a consensus. The majority would be no more justified in imposing its interpretation on an individual than an individual would be justified in imposing his interpretation on the majority, if he had the power to do so. “Construct” does not mean merely “form a consensus” or “agree,” though agreements and disagreements occur in any struggle for consensus. What, then, does “construct” mean? It means subject to a process of constitution that maps inputs to outputs in a rule-governed way to which the participants contribute and that allows for inquiry and counter-examples. Such rules include the therapeutic agreement and diverse methods of interpretation (to be engaged shortly). This Introduction asserts that there is such a thing as truth, not just as mere consistency or narrative fact, but as that which stands fast in the face of attempts to question it or refute it. How the truth stands fast is a function of how well it is constructed. This standing fast requires a context against which to lay out a network of distinctions. The network of distinctions enables a conversation about possibilities of relatedness, recovery, wellbeing. Conversation, in turn, indicates a background of language within which to construct an interpretation of what happened, referring to the world of human beings and what the participants made it mean. One’s grasp of the truth—especially in the matter of all things psychodynamic—is much rarer and exceptional than we would like to hope and believe. The struggle to seek and sometimes succeed in finding the truth may seem abstract but is clinically relevant as soon as we get to the difficult cases. Thus, this book is not proposing an asceticism of truth—to give up the possibility of truth or give up the struggle to arrive at truth. Rather the authentic asceticism of truth is to learn to live with ambiguity. Developing

4

Introduction: basic distinctions

one’s introspective and empathic abilities correlates with the tension increase that accompanies living with ambiguity. Not knowing increases the tension to which the clinical process is subjected. The task is to learn to live with uncertainty, ambiguity, and not knowing. However, be open to finding out. For example, Freud’s (1896: 199) first 18 patients experienced boundary violations—in Freud’s day euphemistically called “seductions”—among the defining causes of their neuroses. Freud had scientific aspirations to determine a single cause of hysteria analogous to the tubercule bacillus (the cause of tuberculosis). This required a condition contrary to fact cause, enabling a definitive cure: “If there had been no X (bacillus or sexual trauma), then there would have been no resulting Y (tuberculosis or hysteria); whereby the removal of the X, also causes the Y to disappear.” Thus, Freud argued that a sexual trauma was the cause of all cases of hysteria. However, Freud was at least firm in his commitment to the Truth, and when compelling counter-examples occurred, he gave up his account of a single cause. In some cases at least, the trauma was nothing like a straightforward description that an adult might give. Rather, an admixture of fantasy was incorporated, as when children of a tender age accidently witness adults having sexual intercourse, their description is not of an expression of love, but one of violence, the larger individual overpowering the smaller one (Freud 1908: 220). Multiple variables confound one another—and confounded the hope of a single curative treatment. Freud’s position evolved in the direction of studied ambiguity (see below “A Rumor of Empathy in Freud” (Freud 1917: 370)), pp. 82–93, while allowing room for real-world abuse and pathogenic fantasies. In our own times, bitter public controversies around recovered memories of boundary violations, secret satanic rituals, and celebrated literary memoirs that turned out to be hoaxes (e.g. Maechler 2001) have tended to drive therapists in the direction of a relativistic interpretation of co-constructing the truth with the patient (e.g. Hacking 1995, 1999; Young 2007). Given that one has constructed a world of facts, one can line up statements with facts—construct a correspondence. This gives us a correspondence theory of truth. Truth is the agreement between a statement and a state of affairs— facts—in the world. This applies to simple and complex cases. Yet the correspondence never quite relinquishes its comet’s tail, which it drags after it, like the return of the repressed. A factual truth that stands fast is a construction that has in effect thrown away and deleted—“repressed”—the process of construction. The correspondence theory of truth has many uses once facts have been constructed, detached from their context of formulation, and are left standing fast and freely unrelated to the context. This works in a positivistic context of natural science such as Galileo dropping weighted objects off the Leaning Tower of Pisa. But in a clinical context the process of construction itself is often what is significant and engaging. What makes

Introduction: basic distinctions

5

the clinical conversation into an inquiry into truth is the condition that human self-knowledge and self-understanding are self-referential and looping. We contribute to constructing situations, conversations, and the “facts” therein, whose consequences then come back—loop back—to surprise, inform, delight, frustrate, or haunt us. Freud’s commitment—and ours—to the truth is raised to another level as one inquires into self-knowledge.

Self-knowledge and cognitive impenetrability Self-knowledge intersects with the boundaries between factual and psychic reality. Freud’s (1905) case history of Dora is so engaging as a rumor of empathy precisely because the boundary between everyday factual reality and psychic reality is rendered problematic by the questionable behavior of the so-called adults in Dora’s life. What is fact and what is rumor? Did Herr K “make a pass”—try to kiss—Dora down by the lake as she asserts? Did he press his erect penis up against her as Freud interpretively reconstructs? Or is Dora’s adolescent imagination “over-active” and confusing a kiss with fellatio as Herr K asserts? Is Freud’s countertransference activated by Dora as he tries to find an alternative to his discarded “seduction theory”? (see below “A Rumor of Empathy in Freud,” pp. 82–93.) Taking a step back, much work is engaged in psychotherapy that results in enhanced self-knowledge. However, strictly speaking, “knowledge” is not the best word. This is because the therapist cannot simply tell the patient: “You claim to love your father without qualification, but you actually hate him, too.” Psychodynamic psychotherapy explores the bounds of the inexpressible and unformulated (Stern 2003). It performs a raid on the inarticulate. This not only includes the possibility of enhanced self-knowledge of one’s own motives but more importantly, for those who are suffering emotionally, access to interrupting self-defeating blind spots and limitations of self-understanding. This enables one to transform constraints into possibilities of rewarding relationships. The therapeutic process confronts “cognitive impenetrability” as one of the blind spots of self-knowledge. Everyday examples abound. Flying in commercial airliners is much safer than getting behind the wheel of an auto. Yet, in spite of all the statistics, as the airplane is accelerating down the runway for take off, many people find their palms sweaty. They have to make an effort to visualize in the mind a “safe spot by the lake” and not think too deeply about what is bothering them—the remote possibility of a crash. One has the knowledge, but, without the emotional work and affective engagement, the knowledge does not make a difference. That is cognitive impenetrability. Having the conceptual distinction does not make a difference: This disconcerting ability in patients to combine conscious knowledge with ignorance remains unexplained by what is called normal

6

Introduction: basic distinctions

psychology. By reason of the recognition of the unconscious, psychoanalysis finds no difficulty in it [. . .] The patients are aware, in thought, of the repressed experience, but the connection between the thought and the point where the repressed recollection is in some way imprisoned is lacking. No change is possible until the conscious thought-process has penetrated to this point and has overcome the resistances of the repression there. (Freud 1913: 154–155) Instead of “patients” Freud might have said “all humans, including myself.” Things that made no sense become intelligible once the repressed ideas and affects are added back. Dramatic displays of hysteria have indeed disappeared from the presenting symptoms with which patients seek help, as Freud puts it, like the disappearance in “fairy-tales” of “evil spirits whose power is broken when you can tell them their name which they have kept secret” (Freud 1910: 148). Today, “normal psychology” has explored cognitive impenetrability, but still struggles to explain it without deploying a distinction such as that of the dynamic unconscious. By the year 1913, Freud is clear about the doubtful value of attempting to communicate knowledge to the patient directly. Educating the analysand, telling the patient that the behavior is inconsistent, using the power of suggestion to implant counter-cognition, may be palliative or educational, but is dubious psychotherapy. Responses to a patient’s free associations extend along a continuum from empathic mirroring and recognition all the way to confrontational assertions. Misguided approaches such as moral condemnation, reparenting, or intellectual debates are non-starters. Until empathically informed interpretations have created freedom around the patient’s censorship of himself or related vulnerabilities, the unexpressed commitments underwritten by conformity and avoidance of shaming will win out over logic, information, and knowledge. Clinical inquiry is a process in which the possibility of self-knowledge— primarily but not exclusively for the patient—emerges from a conversation between the participants. A bold statement of the obvious: no natural science —neither relativity, quantum mechanics, chaos theory, or neuroscience— engages in a conversation with its objects the way two human beings—in this case, a therapist and a patient—engage in a conversation. Instead of trying to wrestle secrets from nature as classical physics and brain science of today, the commitment of dynamic psychotherapy is to discover the secrets about oneself and how one fools oneself about one’s own motives, desires, and vulnerabilities—and how one (and one’s community) suffers as a result. Human beings unwittingly keep secrets from themselves—and then are amazed when their lives do not work. Lack of self-knowledge includes self-deception. No one wants to be told that he is fooling himself,

Introduction: basic distinctions

7

especially if it is accurate. It seems confrontational and like bitter medicine. Yet self-deception lives. Language is required for self-deception. Language is required to say what is not the case. Prior to language, deception—misrepresentation— cannot exist. Granted, nature knows about camouflage, the caterpillar does not deceive itself with its own camouflage. The caterpillar does not use camouflage against itself. Lack of access to self-knowledge and barely formulated early experiences have a crucial role to play in keeping defenses in place. Staying within the comfort zone of familiar emotional suffering is preferred to asking tough questions and taking risks. People have selfprotective strategies—often called “defenses”—that occur not only because of external dangers, but also because the mind is overwhelmed by painful deformities, traumas, or isolation that occur during development: “Emotional pain cannot find a relational home in which it can be held” (Stolorow 2007: 10). But without that “relational home”—the psychodynamic encounter— the emotional pain lives on. When the traumatic experience is pre-verbal, the sense in which there is a lack of self-knowledge is further attenuated. The task truly becomes a raid on the inarticulate; and, as in any raid, matters get chaotic. Expanded empathy is required. The conversation that discloses what is hidden from oneself is no ordinary one. When undertaken in the context of a humane, empathic listening, it does not have to be retraumatizing. And, yes, it is facilitated by free association, saying what is present to one’s awareness as directly as possible. What is distinctive about psychodynamic therapy is its commitment to deliver something to which no other discipline is quite so committed—self-knowledge.

Hermeneutics and interpretation The thinker who is most responsible for formulating psychoanalysis as a hermeneutic discipline such as history rather than a positive science like physics is Paul Ricoeur (1965). Simply stated, “hermeneutic” means “method of interpretation.” Ricoeur argues that Freud’s contribution encompasses two tension-laden tendencies—hermeneutics and energetics— that are fated to be in inevitable, dramatic conflict. The trajectory of Freud’s writings enacts this conflict. The hermeneutic tendency is established in Freud’s Interpretation of Dreams. A well-defined interpretive method maps manifest to latent content. Meaning and significance are decoded amid the apparent absurdity of the dream. This model of interpreting manifest and latent contents is progressively extended to hysterical, obsessive, and pathological symptoms. The model is then extended again to culture and works of art, which, though not pathological, disclose a deep structure that expresses the darker side of humanity, our libidinous and aggressive tendencies. This points to the second indispensable tendency, humans are subject to conflicts of forces over which we have limited control. Humans

8

Introduction: basic distinctions

are born into a world in which there is suffering due to sexual and aggressive forces that demand satisfaction but which conflict with the moral standards of civilization required by living in community. Material scarcity persists. Deprivations abound. Not enough empathy. Double binds. Natural and manmade disasters. The struggles and efforts of human relations with parents, neighbors, competitors, etc., result in developmental deformities that people try to rectify through compensations and enactments, creating further misunderstandings and suffering. For Freud, hermeneutics and energetics are both essential to understanding human dynamics. Freud’s lasting methodological innovation is an essentially hermeneutic one. But energetics is never far away. Both understanding of meaning and explanation of forces in conflict are found in Freud, and, according to Ricoeur, are essential to appropriating Freud’s contribution. The attempt to dispense with the so-called “economic perspective,” for example, by discarding metapsychology as a totality (e.g. George Klein 1976), ends up mutilating and disfiguring Freud’s contribution. The economic point of view is indispensable and lives on as the energetics of tension regulation, introspection of affects, and emotional equilibrium, enabling relatedness to others and oneself. For example, Kohut’s economic vocabulary of narcissistic investment, equilibrium and disequilibrium, resources and assets engaged with archaic structures seems indispensable to describing the experience of the relatedness to oneself and the other. Empathy is soothing when one is in distress. Yet everyday life does not readily embrace introspection and empathy. If empathy and introspection were so easy, they would be less scarce in the world. Engaging in empathy and introspection requires effort and correlates with tension increase, and, as such, arouses pain, which, in turn, stimulates resistance. Today, in our pharmacologically conscious age, instead of “hermeneutics and energetics,” we might say “hermeneutics and chemical imbalance.” Alternative attempts to build an expanded “experience near” theory to support clinical practice do not seem to be subject to the same damaging distortions as Klein’s wholesale jettisoning of metapsychology (e.g. Kohut 1959; Basch 1976; Stolorow and Atwood 1992; Atwood and Stolorow 2014). However, an approach to a hermeneutic psychoanalysis that does not acknowledge and embrace the finitude of the whole human being as a biological and social being is incomplete. (For more on hermeneutics and psychoanalysis, see Edelson 1985; Hanly 1996; Steele 1979; Saks 1999; for background in hermeneutics, see Ricoeur 1973 and Palmer 1969, also Herder (1772/1792)). The cynics say that the advantage of hermeneutics is that few readers have any idea of what hermeneutics is so that the clinician can define it opportunistically. However, a brief history of hermeneutics distinguishes it as a “theory of interpretation.” Its intellectual provenance is deep. Aristotle’s treatise on language, Peri Hermeneias (“On Interpretation”),

Introduction: basic distinctions

9

discusses the possibilities of truth and falsity, given basic logic and ordinary nouns and verbs. During the Christian era, hermeneutics specialized in the interpretation of the Christian Bible. Goethe’s colleague Johann von Gottfried von Herder and, following Herder, Friedrich Schleiermacher built a generalized theory of hermeneutics according to which to understand the unknown was to translate it from a foreign into a familiar language. Freud independently arrived at the same idea (1913: 176): “Interpretations made by psycho-analysis are first and foremost translations made from a foreign method of expression into one which is familiar to us.” Hermeneutics was generalized from an approach to translation into a method of human understanding at large. Wilhelm Dilthey developed a hermeneutics based on language and phenomenology into the foundation of an entire discipline of the human sciences (Geisteswissenschaften) over against the positive, natural sciences (Naturwissenschaften). Dilthey emphasized understanding as opposed to causal explanation. Unlike Ricoeur’s interpretation of Freud, where both understanding and explanation are required, Dilthey came squarely down on the side of understanding in the human sciences with explanation cast out and assigned to the natural sciences. At the end of the twentieth century, Hans Georg Gadamer (1960) brought together the work of traditional hermeneutic thinkers such as Dilthey with his own interpretation of method in the human sciences in a synthesis that attempted to reconcile truth with method. In virtually every real-world clinical vignette a point occurs at which understanding and interpretation collide with a social or biological contingency, inviting an explanation in terms of forces in conflict. A redescription of the meaning of the clinical dynamics erupts that requires a language of forces in conflict, emotional equilibrium, tension regulation, and a literal absence or excess of energy on the part of the person (or the therapeutic dyad) in life’s challenges. Thus, energetics represents human contingencies and constraints in the face of which hermeneutics points the way forward through understanding. Understanding emerges from misunderstanding, distortions, and miscommunications through interpretation. This hermeneutic situation includes the idea that people already live in an interpretation of what is possible in and for their lives, whether they know it or not. The value of hermeneutic inquiry is to shift the interpretation in the direction of human possibility and back again. The “hermeneutic circle” is the method by which a phenomenal whole—a text, a dream, a symptom, a person’s life—is understood through its component parts, which, in turn, make sense in the context of the whole. The circular, reciprocal relation between part and whole, dimension and totality, element and unity, component and system, generate an interpretation in an ongoing process that maps to a conversation, which, in turn, opens up possibilities for human understanding and flourishing. Empathy itself has the structure of the hermeneutic circle in which empathic receptivity, empathic understanding, empathic interpretation, and empathic responsiveness in

10

Introduction: basic distinctions

language form a coherent unified multidimensional process (see below “A Unified Multidimensional Definition of the Process of Empathy,” pp. 22–27). These component dimensions and the whole mutually inform one another in the process of cycling through them in relating to another individual.

Suffering and psychotherapy The narratives of suffering are diverse. Though ethno-centric, “The Book of Genesis” of the Hebrew Bible makes a narrative out of the three paradigms of pain—earning one’s bread by the sweat of one’s brow, the pain of giving birth, and death itself. At first, the world and life were perfect, then something went terribly wrong. According to the narrative, humans are to blame for their own misfortune. It seems inevitable that the survivors—in this case, all of mankind—blame themselves for their own misfortune. So instead of just physical pain, physical pain plus psychic pain—guilt—at causing one’s own physical pain emerges. Aggression and sexuality are already given as factors that disrupt our relationships with one another and raise the bar on cooperating for the common good. The fall from grace of the golden age is the original trauma. We are thrown into a world with suffering and pain. It gets worse. We are to blame for it. Human history begins. Many other forms of trauma, pain, and suffering follow. Fast forward. The narrative of the redescription of trauma is intimately linked with the emergence of the rail roads in England in the 1840s. Train accidents were a new kind of disaster. As train accidents occurred, the psychical damage to the bodies of ordinary civilians was unlike anything seen up until that time outside of exploding artillery shells and coalmine accidents. Litigation, torts at law, and liabilities were debated in court and attempts made to assess negligence, liability, and responsibility. Sometimes the injuries were definitely physical. But not always. Victims of “railway spine” had no anatomical lesion. Many of the survivors of the wrecks were formerly vigorous men, seemingly transformed into psychological wrecks (see Trimble 1981). Enter Mesmer, Charcot, Bernheim, Janet—and Freud (see Ellenberger 1970). Freud inquired into three sources of suffering. First, persons suffer due to the infirmities of human bodies. We get physically ill. We experience bodily pain. If we live long enough, our bodies fail. This is often (though not always) accompanied by physical pain. Though Freud (1923: 58) has his own interpretation of death (the unconscious does not admit the distinction), many people find the very thought of dying and being thrust into the unknown to be anxiety-arousing, stressful, and, therefore, painful. Second, persons suffer due to the constraints of the community. If one does not live up to community standards, then other members of the community impose sanctions including shaming and devaluing descriptions of the person in question. This implies

Introduction: basic distinctions

11

that human beings are social and value the feedback received from fellow humans. The imposition or threat of isolation or exile from the community are sources of suffering. Finally, persons internalize the standards and judgments of parents, mentors, teachers, and neighbors, and experience suffering in the form of a guilty conscience when one does not live up to one’s owned, internalized standards. The stolen cookie just does not taste right. The taste of guilt? The more desire and aggression that humans renounce to become civilized, the more humans suffer from unsatisfied desires and aggressions turned inward against themselves as guilt. Thus, Freud saw a feedback loop that made him pessimistic about human prospects for flourishing. Freud could psychoanalyze individuals and interpret their self-punishing superegos or work to replace narcissism with object love, but it was not possible to put an entire community on the couch to interrupt the cycle of frustration, aggression, and guilt. One arguably innovative form of suffering is the empty psyche. Kohut (1971) has written eloquently about individuals who present themselves for therapy with empty affect and a sense that life is passing them by. Neither classic melancholy nor moral masochism, the emptiness is the key here. The lack of feeling is itself a source of suffering. The suffering of emptiness— nothing matters—is the suffering of one’s energy being tied up elsewhere— engaged in the archaic exhibitionism or grandiosity of the self, fighting a battle with a parental imago or hostile introject from the past. It is not that one lacks energy; rather one’s lack of action—one’s procrastination—is due to one’s energy being entangled elsewhere. Thus, the language of energy seems to be ineliminable. One depressed individual lacks the energy literally to pull himself out of bed. Another’s emotional disequilibrium, apathy and lethargy, give rise to diverse forms of risky behavior, enactments, and acting out, as the person tries to invoke a feeling of aliveness and vitality. In extreme cases, inflicting and self-inflecting pain in the form of sadomasochism is the preferred method to overcome the feeling of emotional emptiness or deadness of affect (Goldberg 1995: 139). The individual in an extreme situation, devoid of feeling, in emotional disequilibrium, painfully experiencing a loss of meaning and satisfaction, comes to represent the predicament of post-modern man contemplating the inhumanity of the horrors of the twentieth century. The suffering of emotional emptiness is the suffering of dehumanization. The fragmenting and crumbling sense of self-esteem expressed in Kafka’s Metamorphosis, where Gregory Samsa is transformed into a giant insect, represents a world in which human warmth and empathy are inaccessible (Kohut 1977: 287–288). The individual is inscribed in the social; and Franz Kafka’s reallife relationship with his bullying, bigger than life father is documented in his unpublished “Letter to the Father” (1919). This document provides ample evidence that he felt crushed like an insect in this relationship. The

12

Introduction: basic distinctions

individual and the social amplify and dampen one another reciprocally. The result is that the individual is ground down in a process of depersonalization that drains away all emotional and vitality—that is, all life and humanity. For Kohut, empathy becomes the symbolic equivalent of Freud’s sexual libido, now generalized to the level of the gendered self of the whole person (Terman 1984). Deprived of the responsiveness, recognition, and mirroring (i.e. empathy) of the parents, deformities of the self occur. When the gendered self fragments due to life’s traumas and deprivations, the fragments are sexualized drive derivatives that, in turn, rejoin the classic Freudian libidinal-aggressive line of development. If individuals such as Dora, the Rat Man, and the Wolf Man—and do not overlook Freud himself—had not been suffering psychically and emotionally, then psychoanalytic therapy would not exist. Yet it is common place to distinguish goals of psychotherapy from goals of psychoanalysis. Overlap and distinctions exist. The goals of psychotherapy include reducing suffering, providing symptom relief (symptoms being a source of suffering), and promoting adaptation to the environment. The goals of psychoanalysis include the exploration of meaning of human actions in a diverse array of contexts, enhanced self-understanding (“self-knowledge”), building psychic structure in such a way as to enhance self-esteem and emotional equilibrium, and (as Freud famously noted) expanding one’s ability to love and work. The latter two items, in particular, are arguably psychotherapeutic results, sending us looping back to the initial question of the distinction. Kohut (1966) has added developing such abilities as humor, empathy, creativity, artistic refinement, and even wisdom, as results, making a compelling case that the release of productive energies tied up in archaic narcissistic structures of the psyche expand such capabilities. These overlap with the abilities to love and work, but add substantially to specific capacities for human relatedness and community. What transforms pain into suffering is the repetitiveness, automaticity, and awareness of the experience of loss of control and freedom in the face of it. To be driven in this way by pain is precisely to suffer in the original sense of the word—to experience passively, to undergo, to be constrained to allow to happen. It is like a toothache which one cannot help but test with the tongue, finding out, “Yes, it still hurts.” “You already knew that—why did you push on it?” “Well, I was hoping it would magically get better?” Psychic suffering takes diverse forms. Yet they have in common an individual overtaken by disorder. Freedom is lost and replaced by a sense of being at the effect of something alien. The automaticity of obsession and compulsion is missing in most affective disorders, but the person still experiences a loss of a sense of well-being in the face of out-of-control moods. In that sense, the language of mechanism, process, and causality better describes the presenting symptoms than intention, purpose, aim, or motivation. The suffering is the experience of emotional fragmentation, undifferentiated and free-

Introduction: basic distinctions

13

floating anxiety, and, once again, overwhelming helplessness, or annihilation. The wolves or bogey man may be imaginary but the fear is real enough. How to recover in the face of such distress? This points to the commitment of dynamic psychotherapy in its diverse forms to minister to the disordered mind, pluck from the emotions the rooted sorrow, raise out the troubles of the brain, and with an empowering conversation, cleanse the choked affects of those perilous troubles that weigh upon the heart. This points to empathy.

Chapter 1

Empathy and its resistances

Empathy and its inauthenticities Empathy, like motherhood and apple pie, is something everyone endorses. How could anyone be against them? Yet when it comes to my mother or your mother or this tasty calorie-laden dessert totally at odds with optimal nutrition, maybe it is not such a good idea. One thinks of Thomas Ogden’s patient, who, at the start, associates to misadventures, suggesting maybe this process of psychoanalysis is not such a great idea after all (Ogden 1992: 228). Or the therapist who is not afraid that the patient will leave, but afraid that he will stay. Though Ogden’s examples are richly humorous, more painful ambivalence about empathy exists than initially meets the eye. In turn, the ambivalence recruits enactments—confrontations, canonical advice, prescribing medications, affixing devaluing diagnostic labels (“borderline” comes to mind) when the patient is merely “reactive” and “difficult,” or the therapist’s speaking ex cathedra as the authoritative decoder of meaning instead of the empathic inquirer. The challenge is to bring forth empathy and make it present. For example, one is not listening to what the other said. One is listening to one’s own opinion of what the other person has said. One is listening to one’s opinion of whether one agrees, disagrees, values, devalues, judges and evaluates, etc. Opinions happen. They are inevitable. They are then recruited by narcissism to form resistances to empathy. The resistance is subtle. It is pervasive. It is rarely acknowledged. One key to overcoming—or at least managing —this recalcitrant inauthenticity is to take the focus off oneself. Empathy lives in relatedness—as the foundation of the community of interrelated individuals, as the dynamic duo of the psychotherapeutic conversation. This is my ultimate inauthenticity. The author of a book on empathy struggles with his empathy (Agosta 2010). Introducing myself saying, “I am the author of a book on empathy, and you can count on mine” gets people annoyed. It sounds like “empathy lives over here by the author of this work.” Over there—“over there by you, the audience” is lack of empathy. It sounds like arrogance. It lands like grandiosity. It is. Make no small plans. Instead,

Empathy and its resistances

15

I might usefully have said: “I acknowledge your empathy.” I might have said: “You’ve got empathy. I’ve got empathy. All God’s children got empathy.” The commitment in engaging empathy and its resistances is to expand the possibility of empathy and the empathy in the world. On a good day, one succeeds in being empathic—delivering a gracious and generous listening. Then one has to close the loop, complete the circle. One engages the other person, and, in conversation, one recognizes the other’s humanity. One relates to the other and acknowledges the other’s humanity, as a possibility, in the struggles and accomplishments the other has expressed. On a less good day, one struggles. One is subject to the grandiosities of empathy—that one is a wonderful listener, that others admire and idealize one, that one’s guidance is golden. If there is self-deception about the extent and depth of one’s empathy, then can resistance be far behind? Yet as a transformation of narcissism (Kohut 1966) empathy is consistent with healthy exhibitionism, productivity, ambition to contribute to humanity, and aspirations to build a community of neighbors. Nor should we forget that when we speak of “resistance to empathy,” “resistance” has a long history of being a blessing in disguise. Transference emerges in Freud’s most spectacular failed case, Dora, and starts out like a nearly insurmountable obstacle—resistance—to treatment. However, this obstacle and the accompanying breakdown becomes a method of getting traction through interpretations that advance treatment. Transference resistance becomes “transference neurosis,” which is “an artificial illness which is at every point accessible to our intervention” (Freud 1914: 154). Likewise, resistance to empathy emerges in parallel to the analyst’s countertransference. At first it seems an obstacle and a source of breakdown. Freud stresses the need to overcome the countertransference (as an unanalyzed personal complex). No therapist can get further in his work with patients than allowed by his own complexes and countertransference. Thus, the need for the therapist’s personal psychoanalysis, training analysis, and on-going self-analysis (Freud 1910a: 144). But then a surprising reversal occurs. The obstacle of countertransference becomes a source of progress and insight in the treatment. Breakdown provides access to and becomes the source of breakthrough. Instead of being the cause of breakdown, countertransference becomes an opportunity for a breakthrough. Heinrich Racker (1957, 1968) speaks truth to power: “The first distortion of truth in ‘the myth of the analytic situation’ is that analysis is an interaction between a sick person and a healthy one” (1957 [2007]: 731). Analysis is an interaction between two personalities, both of whom are set upon by the id, superego, and external world. Racker quotes the German sage Gotthold Lessing approvingly: “He who does not occasionally lose his sanity has none to lose.” The analyst’s “objectivity” is a function of the relationship he has with himself that enables self-observation. Another way of redescribing this relationship with himself is “countertransference.” Far from being

16

Empathy and its resistances

dispassionate, the neutral, anonymous, abstinent therapist experiences anxiety, aggression, guilt, etc. (Racker 1968: 169). Racker does not use the word “introspection,” but his approach to examining his reactions to the patient is highly introspective. When made the focus of introspective inquiry, such countertransference reactions are the source of a breakthrough in the therapist’s relatedness to the patient. Distorted and deficient understanding emerges in the countertransference. When processed introspectivelyempathically, countertransference becomes the basis of integrating interpretations benefiting the treatment (1968: 153). Obstacles and breakdowns point to breakthroughs in interpretation and treatment. “Resistance to empathy” sounds like an obstacle, but it becomes the source of a breakthrough in relatedness when handled deftly. Furthermore, unless engaged and made the target of analytic inquiry, resistance to empathy foils treatment. Once engaged, resistance to empathy provides access to the possibility of using empathy to create well-being and flourishing where these had previously not been envisioned. However, the forms of resistance are diverse, to which we now turn.

Types of resistance to empathy Resistance to empathy includes those factors coming from the therapist, those from the patient, including those emerging in the interaction, and those from the background such as the “culture” and what Racker calls “countertransference to the psychoanalytic organization,” especially by those in training. These are ideal types and mixed cases are common. Individuals often come to therapy expressing positions endorsed by some segment of the community, taken over from professional organizations with mixed agendas. These positions can show up in therapy as authentic worry about health and well-being, defense transference, negative therapeutic reaction, or all of the above.

The literature on “resistance to empathy” The references to “empathy” in the literature are many. The references to “resistance” are very many. However, the intersection of the two terms “empathy” and “resistance” is virtually the null set—very limited. I am unapologetic that this literature is dominated by the contribution of selfpsychology. The review of the literature indicates that precisely the selfpsychologists and their fellow travelers have engaged with empathy and its resistances most extensively. In his celebrated 1959 essay, Kohut refers to “resistance against introspection” (1959: 465) on the part of the psychoanalyst. Kohut calls out a professional and scientific reluctance to engage with phenomena that might be “mystical,” but the main focus is the ego strength—“self cohesion”—required to engage in vicarious introspection, i.e. empathy. Both

Empathy and its resistances

17

introspection and empathy arouse resistances because the individual is “helpless in the face of tension increase” (1959: 465). Fast forward to Kohut’s last paper, published posthumously (1982), in which, in a rhetorical flourish, he says that he is not engaging with resistance to empathy. Instead, he engages in a redescription of the deep structure of the Oedipus complex. Nevertheless, Kohut does engage with resistance to empathy. Publishing at about the same time as Kohut’s (1959) initial statement on empathy, Greenson (1960) delicately balances inhibitions of empathy with over-identifying with the patient. Greenson notes resistance to empathy on the part of some patients: “One’s capacity for empathy can be influenced by the other person’s resistance or readiness for empathic understanding. There are patients who consciously or unconsciously want to remain misunderstood; they dread being understood” (Greenson 1960: 422). Greenson builds a working model of the other person that can be deployed to reestablish empathic contact when, for whatever reason, the patient and analyst have experienced a breakdown in empathic communication. This “working model” is a valuable—and usable—aspect of Greenson’s definition of empathy, and is a powerful device in informing one’s listening. Publishing after Kohut’s innovations have disrupted the complacency of the psychoanalytic community, Lichtenberg (1981) distinguishes empathy as a process (e.g. vicarious introspection) from an empathic vantage point within which to position one’s listening within the patient’s experiences. Lichtenberg takes issue with Kohut’s distinction between intuition and empathy (Kohut excludes intuition from empathic data gathering) in order to defend Kohut against the accusation of “transference mutualization,” by which is understood emotional merger and perhaps a corrective emotional experience. Resistance to empathy takes the form of juxtaposing unresolved conflicts with the requirements for self-soothing, self-regulation, and maintenance of emotional equilibrium through the responsiveness of the therapist. Intrapsychic conflict and the need for emotional regulation are two sides of the same coin. When the therapist takes the perspective of the outside observer, offering the canonical description of who the patient is, or when the analyst undertakes an inquiry with iterated requests for clarification, then the risk of a breakdown in empathy and retraumatization looms large as the patient defensively mobilizes a “counteraggression”—narcissistic rage in reaction to real or imagined injuries. Even if the therapist takes the role of an interested, sympathetic inquirer, pursuing clarifying answers, the need for emotional regulation is neglected. The commitments of scientific observer or sympathetic inquirer are useful. Nothing is wrong with them, but something is missing—empathy. In contrast, as the intrapsychic conflicts are interpreted from within the patient’s experience by the empathic vantage point, then developmental failures are able to be reengaged and development restarted. Acknowledging Kohut’s and Greenson’s contributions, Kulka explicitly calls out “resistance to empathy” (1988). Kulka states that empathy can

18

Empathy and its resistances

generate anxiety about dependency and regression, presumably in the context of merger with the archaic aspects of the selfobject. (A “selfobject” is defined as the way one’s psychic representation of another person functions in and contributes to one’s own psychology, especially affect regulation and psychic equilibrium.) In turn, this anxiety generates resistance to empathy. Kulka focuses on the agenda of building a bridge between self psychology and the structural approach of ego psychology. But resistance to empathy gets lost and remains undeveloped. Leonard Fagin (2001) calls out the example of resistance to empathy in the context of inpatient admissions, where stressed psychiatric staff react defensively to the transference relatedness and enactments of the patients. Resistance extends from “offhand,” flat affective responses to explicit discourtesies. Compassion fatigue and emotional burnout are common. Empathy as a sample, trace, and signal affect of the other person’s experience devolves into projective identification and collapses into over-identification. The inpatient staff are dedicated professionals in difficult and even extreme situations. However, exploring their own resistance to empathy is not on the agenda. Indeed, one comes away from Fain’s discussion appreciating that survival, not thinking too deeply, and, as Winnicott might have put it, “coming out alive” is the main agenda. Richard Tuch (1997) appreciates the importance of resistance to empathy, and makes the patient’s self-protective measures (“resistances”) the topic of sustained inquiry. Working with a rich definition of “empathy” that allows for both bottom-up, affective, and top-down, cognitive empathy, Tuch allows that his definition may be incomplete. What is missing? “[E]mpathy as a mode of relating to others” (1997: 262), that is, a responsiveness that is demonstrated in interpretations and actions. Thus, Tuch (1997: 260) distinguishes between selfobject failures where idealization or grandiosity are deformed or missing, and failures of empathy in which one’s vicarious introspection is inaccurate. Such a distinction is useful in conceptualizing empathy as experience-near whereas deprivations in archaic objects and structures are experience-distant. Tuch makes the significant point that failures of empathy are not limited to resistance, which would yield to timely, accurate interpretations. Failures of empathy are complex, deep, and due to deformations in the areas of idealization and grandiosity. Failures of empathy are due to limitations in underlying capabilities for establishing and maintaining relatedness, emotional equilibrium, and productivity. Tuch asserts that the need for empathy is distinct from the needs for mirroring and idealization. His analysis subtly shifts from the analyst to the patient’s resistance, which, in Tuch’s view, is where the discussion really belongs. Empathy fails to unfold in the relationship because the patient is unable to use the analyst’s empathy. Tuch (1997: 262) comes to the view that like love, empathy is not enough, especially on the part of the analyst, and that the patient must develop the ability to use the therapist’s empathy.

Empathy and its resistances

19

Tuch builds a strong but implicit case that the definition of “empathy” must conceptualize empathy not just as a conceptual distinction but as a multistep process. David Beres and Jacob Arlow’s (1974) juxtaposition of “Identification and fantasy” in the title of their article suggests the one word redescription: “empathy.” They are engaged by the way in which unconscious fantasies are communicated from the patient’s unconscious to the analyst’s, ultimately being accessible to the consciousness of either individual, though usually to the analyst due to her or his superior understanding. This juxtaposition recalls Freud’s (1912b: 115) metaphor of the latest technology of his day, the telephone: [The analyst] “must turn his own unconscious like a receptive organ toward the transmitting unconscious of the patient.” Even if the analyst is not listening, his unconscious is. Beres and Arlow invoke the tradition of debunking magical thinking initiated by Helene Deutsch (1926). Unlike Tuch (1997), whose approach is arguably debunking of empathy, Beres and Arlow are exploring the deep structure of empathy as implemented in the organism and unconscious fantasy, admittedly prior to the discovery of a hypothetical mirror neuron system—“hypothetical” because the implementation mechanism may or may not actually be mirror neurons (see Decety et al. 2013; Hickok 2014 for an alternative view; for more scientific scepticism, also see Vul et al. 2009; and Satel and Lilienfeld 2013: 166ftnt. 34). Empathy is not an occult process—or is it? What remains unexplained is how the verbal content gets communicated. Beres and Arlow situate the work done by vicarious introspection in three dimensions: temporary identification, signal affect, and emergent sensations that lie just below the threshold of conscious awareness. The process of transient identification maps closely to that of vicarious experience —it includes the distinction between self and other, excluding merger with the other that would be a breakdown of empathy. In turn, the transient nature of the identification with the anxiety, depression, or rage of the patient is a sample affect—a signal—and leaves the recipient of the affective communication free to use the signal for further empathic processing. Finally, Beres and Arlow address how various sensations—including physical postures, non-verbal motor discharges, and what is sometimes called “muscle mimicry”—provide delicate, fine-grained experiences of the other person’s emotional micro-expressions. A precursor of the mirror neurons and, therefore, of empathy? That is the suggestion. Finally, Beres and Arlow call out “resistance and empathy” (1974: 43), but they mean empathizing with the patient’s resistances rather than getting inside the way empathy itself is resisted. Beres and Arlow then change the topic and invoke the work of T. Shapiro on “The development and distortion of empathy” (1974). Shapiro starts with Freud’s comment that identification is the psychological mechanism underlying empathy: “A path leads from identification by way of imitation to empathy” (1921a: 110ftnt.). Shapiro cites both Fliess

20

Empathy and its resistances

(1942) and Schafer (1959), elaborating on transient identification as the metapsychology of empathy. Shapiro makes Kohut sound like he is out of touch with the mainstream (and perhaps that was so at the time (1972)) by quoting Kohut accurately but out of context as focusing on the cognitive as opposed to the affective aspects of empathy: “[Empathy is] a mode of cognition which is specifically attuned to the perception of complex psychological configurations” (Kohut 1971: 300). Shapiro then emphasizes—and empathizes with—the affective aspects of vicarious introspection. Kohut’s strategic commitment to making empathy a form of data gathering about the complex mental states of persons means that empathy becomes the foundation and necessary condition for psychoanalytic psychology as a rigorous discipline. Sliding between the clinical and the metapsychological contexts, Shapiro makes a compelling case that as a form of perception— communication of affect—empathy suffers from the same distortions as any form of perception. Shapiro presents a “model of empathy as a defense” (1974: 20). The surface structure of the patient’s statement (e.g. expressing appreciation of the analyst’s experience) expresses the patient’s empathy. However, the underlying mechanism points to a drive fragment. Wherever there is fragmentation, there is anxiety. Wherever there is anxiety, there is defense against anxiety. Instead of “I feel fear as a vicarious signal of your fear” empathy can be deformed into a defense “I feel fear because I am afraid of past wishes.” Empathy has misfired. Empathy has been distorted. But empathy can be improved with practice and training. That is precisely the purpose of personal and training psychoanalyses. A really interesting question would be if there are “in principle,” cognitively impenetrable distortions of empathy (and no knowledge enables one to see them otherwise), analogous to optical illusions such as the straight straw that looks like a bent straw in the glass of water, the way the moon appears larger at the horizon than at its zenith, etc. A suggestion for future work: deformations of empathy are a function of egocentrism, narcissism, confabulation, and overly active elaboration and meaning making. As such these are arguably in principle distortions of relatedness, self-cohesion, and emotional equilibrium, capable of being transformed into such positive personality traits as humor, creativity, and empathy itself (Kohut 1966). A charitable reading of Shapiro’s contribution indicates that he is trying to point to an appreciation of the distortions of empathy. However, the “in principle” distortions of empathy—optical illusions, as it were—remain undeveloped. Dan Buie’s (1981) contribution is to offer a critique of empathy that documents a theoretic position made obsolete by the identification of an underlying implementation mechanism for empathy such as a hypothetical mirror neuron system. Yet Buie has a singular contribution and represents a bridge within the limits of the science of his time. Buie starts with “obstacles that stand in the way of empathy.” Buie properly cites Kohut that, like all human beings, psychoanalysts must rely on sensory perception to

Empathy and its resistances

21

relate to other human beings (Kohut 1977: 144; see also Olden 1953). But what is the mechanism underlying empathy? “The only alternatives would be physiological means of perception not yet known to us or extrasensory perception” (Buie 1981: 282). Admittedly, the operation of empathy can seem like extrasensory perception (ESP). Today we believe that the mechanism that might substitute for ESP forms the basis of emotional microexpressions. Darwin (1872) and Ekman (2003) have provided the basis for comprehending the expression of emotional micro-expressions without necessarily grasping the underlying implementation (debated as mirror neurons (e.g. Decety and Jackson 2004; Iacoboni 2005, 2007; Gallese 2001, 2007; Rizzolatti and Gentilucci 1998; but see Decety et al. 2013 and Hickok 2014 for an alternative view) or as a neural network of opaque but powerful causal thickness (e.g. Clark 1989; Wimsatt 2007: 193)). Mammalian organisms resonate together and are capable of a kind of “affective action at a distance,” which, admittedly, is distinct from full-blown, adult empathy, and rather like emotional contagion. We are all connected biologically. Such resonant phenomena as emotional infection are on a continuum with fullblown empathy. They are input to a multistep empathic process. Taken up a level, the idea of joint intentionality enables one individual to grasp the intentional mindedness of another (e.g. Tomasello 1999: 56). Ultimately, brains and neurons do not empathize; human beings do. The myth is that we are unrelated. Buie presciently anticipates many aspects of empathy without, however, appreciating the essential unity of empathic receptivity, understanding, interpretation, and responsiveness that the approach of a multidimensional process of empathy attains (to be discussed in the next section). We do indeed make inferences as to the experiences of other people. But rarely do we infer that the other person is happy because she or he is smiling. We experience the happiness directly in the smile. Rarely do we infer that the person is sad because they are crying. We immediately experience the sadness in the tearstained face. Such an inference (from a smile to an inner state of happiness) would be an over-intellectualization and (as such) an obstacle to empathy. Secondary processes—including inference but more accurately understanding of possibilities and interpretations of patterns (which Buie does not engage)—are the cognitive functions that are applied “downstream” to the communicability of affect to develop full-blown, adult empathy. Buie’s account is distinct from the multistep process of empathy that regards communicability of affect (empathic receptivity), understanding of possibility (empathic understanding), interpretive responsiveness (empathic interpretation), and the expression of empathy in language (empathic listening) as four steps in a unified process of empathy. Notwithstanding Buie’s significant contribution, these remain undeveloped in Buie’s work. A robust, coherent definition of empathy would have been useful. To that we now turn.

22

Empathy and its resistances

A unified multidimensional definition of the process of empathy

Empathy is a defining feature of our humanity, and without empathy a person is missing an essential part of his or her humanity. Clinicians and researchers have engaged with the task of defining empathy in both a controversial and rewarding struggle. What is new here is the appreciation of empathy as a unified multidimensional process that traverses our humanity from receptivity through understanding to interpretation and responsiveness. Now we narrow our focus from resistance to empathy to defining empathy itself. Diverse definitions of empathy in the literature include both an affective and a cognitive dimension. This continuum between diverse dimensions of the process of empathy—an emotional (affective) and an understanding (cognitive) one—is prominent in the clinical literature in psychoanalysis and psychotherapy (e.g. Fliess 1942; Kohut 1959; Greenson 1960; Basch 1983; Goldberg 2011). The following definition of empathy as a unified multidimensional process is an original synthesis of ideas of previous work with the appreciation of just how well the two dimensions of affect and cognition map to a unified, coherent, multidimensional process that includes communicability of affect (receptivity), understanding, interpretation, and responsive speech. In particular, the minimal essential constituents of the unified, multidimensional definition of the process of empathy include: (1) empathic receptivity: a receptivity (“openness”) to the communicability of the affect of other people in face-to-face encounter or as artifacts of human imagination (e.g. the novel), the paradigm case of which is vicarious feeling; (2) empathic understanding: an understanding of the other individual in which the other is acknowledged in relatedness as a possibility of human flourishing—a possibility of choosing autonomously, making commitments, and implementing them, the paradigm case of which is recognition of the other; (3) empathic interpretation: an interpretation of the other person that identifies patterns of adaptation and templates of survival and development from first-, second-, and third-person perspectives, the paradigm case of which is a transference-like, transient identification “as if ” one were the other in the other’s situation; and (4) empathic responsiveness: an articulation in optimal responsiveness in language of the previously noted receptivity, understanding and interpretation, that enables the other to appreciate that he or she has been the beneficiary of a gracious and generous listening, the paradigm case of which is the speech act of narrative, story telling (see Figure 1.1). Let us look at these four minimal essential dimensions in more detail. We trace the multidimensional process through the four steps. The process advances (1) by being vicariously receptive to the other’s experience; (2) through an empathic understanding of what is possible in the experience; (3) to articulating and integrating the structure of what is understood in empathic interpretation; and, finally, (4) through expressing explicitly what

Empathy and its resistances

Empathic understanding

23

Possibilities

Vicarious experience Empathic narrative (responsiveness)

Empathic listening

Empathic interpretation

Empathic receptivity Point of view: 1st, 2nd, 3rd person Aspects of a multi-dimensional definition of empathy

Figure 1.1 The hermeneutic circle of empathy

is given in the relatedness between self and other in empathic responsiveness in listening and speech. The following account occurs in stepwise sequence, but in relating to another person, all aspects of empathy are present simultaneously in the conversation. (1) Empathic receptivity is an act directed at the expression of affect (emotion, sensation, experience) of the other. Empathy is not reducible to emotional contagion, gut reactions, contagious yawning, animal magnetism, the reciprocal activation of mirror neurons, or prereflective fellow feeling; but empathy draws on the same function of communicability of affect that occurs in emotional contagion, etc. Empathy recruits the same function of affectivity that occurs in vicarious experience as a form of receptivity to the other. It is preconsciously receptive as a kind of empathic data gathering. But if one interrupted and stopped the process of empathy at this point it would remain mere infectious feeling, emotional contagion, just an affective reaction. Empathic receptivity (1) is the basis of “bottom-up” empathy, working at the level of the communicability of affect, emotional contagion, etc. The “vicarious” in Kohut’s “vicarious introspection” belongs here as a form of empathic receptivity. Likewise, Freud’s recommendation that the analyst “must turn his own unconscious like a receptive organ toward the transmitting unconscious of the patient” (1912b: 115) belongs here. In another

24

Empathy and its resistances

example, Dr. Ernest S. Wolf empathically picks up on the experience of playfulness where the patient’s presentation was a mournful one. Wolf’s receptivity is input to his interpreting the leading edge of new possibilities for his patient’s completing her relationship with her difficult mother. Wolf’s vicarious sensation of the patient’s playfulness captures her communicability of affect (1988: 20–21). A different yet parallel example occurs for E. James Anthony (1961) in his evocation of an entire world of meaning in the sensation of a cookie dipped in Coca-Cola. Empathic receptivity is the openness to the world that humans enjoy as embodied, sensing, experiencing creatures. Vicarious experience is what we encounter in theater, in film, or in a novel. It is the experience of listening to a narrative or story. It is experience once removed from directly being in the events in the story oneself. The innovation of Kohut’s 1959 paper was to conceptualize empathic data gathering as introducing a distanced-relatedness at the core of empathic receptivity. This approach creates a significance distinction between empathy and merger-like phenomena, the latter becoming a source of compassion fatigue, emotional burnout, or mystical merger based in over-identification with suffering. If one experiences these latter as a result of being empathic, then one needs to expand or contract one’s empathy. One is over-identifying. One is over-intellectualizing. In short, one is doing it wrong. In other words, empathy is a protection—one might say “defense”—against such burnout and compassion fatigue because empathy takes a sample of the suffering of the other without merging or over-identifying with the suffering. As a form of relatedness to the other individual, empathic receptivity is a filter—a semi-permeable membrane—that preserves a disinterested distance between self and other while nevertheless enabling a communicability of affect, feeling, and emotion. Empathic receptivity provides a trace affect of the other’s experience. Empathic receptivity filters out the overwhelming presence of a totality of a tidal wave of affect, emotion, or (often negative) feeling. Yes, the empathizer is open to the negative experience that the other individual is enduring, but as a trace sample, a signal affect, not the full weight of the suffering. Yes, one suffers; but, unconventional as it may sound, one suffers only a little bit. (2) Empathic understanding is a recognition of the other individual that encompasses what is possible for the other. Empathic understanding is an acknowledgment of the other, given the constraints and undeclared commitments in which the other is living and engaged. According to this definition, understanding is grasping of possibility—possibility of relatedness to the other. The term “understanding” is not used in the narrow sense where understanding is a secondary process according to rules of logic or association such as resemblance, consistency, and causality in consciousness, resulting in mental contents. Rather “understanding” is used here writ large as a form of life. We live in possibilities that we allow to define our opportunities and limitations. Understanding is understanding of relatedness. For example, a

Empathy and its resistances

25

person lives in an understanding, acquired through experience and temperament, that love is not possible with this person, e.g. a family member. But with an expanded understanding of possibility, the person just has a different way of showing love and the possibility of developing a relationship shows up. Empathic understanding (2) is an example of “top-down” empathy, activated by putting oneself in the other’s place, for example, deploying Greenson’s “working model” of the patient (1960). This may include explicit perspective taking, distinguishing observing and participating sectors of the self. In particular, relating to the patient as a possibility for developmental progress (2) is exemplified in Basch’s (1983) use of empathic understanding. Also relevant is Wolf’s (1988) example of parlaying his vicarious sensation of the patient’s playfulness into a new possibility of adult womanly relatedness that does not require “girlish” seductiveness. The example provided by Goldberg (2011) of the patient who periodically jumps up and literally leaves analysis, only to return after a short hiatus, maps to a pattern of the (for him) quasi-traumatic births of siblings that left this analysand in empathic isolation. This dynamic was reenacted in analysis. The psychoanalysis unfolds as engaging in understanding who the patient is as a possibility in the transference and to interpret what is going on “in the room” in relation to that possibility. (3) Empathic interpretation articulates and integrates what is the experience of the other person. When the empathic interpretation hits home, then the other person recognizes the experience as his own. The “as if” quality of empathic interpretation connects it with the psychoanalytic transference, which also has an “as if” quality to it, enabling empathy and transference to inform one another mutually. This includes imaginative variations that cycle through first-, second-, third-person interpretations “as if” one were the other. Circumstances create the understanding of possibility, but ongoing interpretations, usually implicit and unacknowledged, sustain the engagement with possibility as an existing template, pattern, or form of life. Empathic interpretation (3) extends empathic understanding of possibility into an explicit articulation of meaning. The “as if” of this articulation opens up new opportunities for the future out of the interpretation of the transference: “This struggle between the doctor and the patient, between intellect and instinctual life, between understanding and seeking to act, is played out almost exclusively in the phenomena of transference” (Freud 1912a: 108). Empathic interpretation is definitively exemplified in Loewald (1957: 238–239) in how interpretation captures and expresses what the patient experiences: “If an interpretation of unconscious meaning is timely, the words by which this meaning is expressed are recognizable to the patient as expressions of what he experiences.” That’s the empathic moment. The interpretation enables the patient to organize, experience first-hand, put into

26

Empathy and its resistances

words, and, therefore, integrate what was previously intangible, invisible, or unspeakable. Loewald’s moment of empathy is when the patient is presented with “what he experiences” in and through the interpretation and the patient then recognizes it as his experience. That’s it. In turn, this points in the direction of integrating the experience in and through language. (4) Empathic speech is a form of optimal responsiveness that includes both listening and replying. If the therapist is accurate in his empathy but does not respond, then the empathy is at risk of being the proverbial tree that falls in the forest without anyone being present. It may or may not make a sound, but it definitely does not make a difference—unless a listener is there to “get it.” Empathy without a response is still empathy, but the other person with whom one is empathizing may not know about it. Paradoxically, unexpressed empathy has a specific way of coming into speech. It does so as listening. Listening is the primary form of empathic speech. In order to listen, one has to be silent. One has to make still the busy, inner chatter of opinions and evaluations just below the threshold of expression. Listening occurs at the beginning of the multidimensional process as a form of receptivity, and at the end as listening is expressed as empathically responsive speech—an interpretation, a micro-narrative, a communicative facial gesture. This occurs as the listener formulates and expresses empathic responsiveness to the other person. Empathic speech (4) is a method of access both to top-down and bottomup empathic responsiveness. Paradoxically, the form of speech specific to empathic receptivity is listening, which maps to Freud’s recommendation to maintain the same “evenly-suspended attention” in relation to the patient’s communications (1912b). Schwaber (1981) associates empathic listening with Kohut’s emphasis on empathic-introspective data gathering as the form of observation specific to psychoanalysis. Ultimately, empathic speech—whether as a form of quiet listening or as a narrative—aims at being a response that advances the treatment, including a reply as “optimal frustration” (Kohut 1971) or “optimal responsiveness” (e.g. Bacal 1985, 1998; Terman 1988). Empathic responsiveness demonstrates the listener’s empathic receptivity, empathic understanding, and empathic interpretation of the patient’s struggles. Such empathic responsiveness includes the paradigm case of the speech act of story telling (Agosta 1980, 2010, 2014). Consider the example of Jesus of Nazareth as psychodynamic story teller. Jesus answers the question “Who is my neighbor?” by telling a story. The Good Samaritan in the story of the same name empathically experienced—“heard”—the survivor’s suffering. The “hearing” is the empathic moment; the binding up of the wounds, etc., is the altruistic, compassionate moment. These are distinct, though related. Empathy told the Samaritan what the victim was experiencing, whereas morality told him what to do about it. He decided to act altruistically and intervene compassionately, stopping, helping, and carrying the survivor to

Empathy and its resistances

27

the inn for further treatment. Granted, the boundary between empathy and altruism is controversial (e.g. Batson 2012; de Waal 2009; Baron-Cohen 1995, 2011; Agosta 2011; Kohut 1971). Though Frans de Waal’s (2009: 204–209) approach to empathy was developed separately with different components and with a different view of the prosocial aspects of empathy (with de Waal aligning empathy with the prosocial), he envisions a multidimensional approach to empathy similar to that described here with emotional contagion embedded in concern for others, in turn, embedded in perspective taking in the manner of nested Russian dolls. At one level, the story of the Good Samaritan contains an example of the use of empathy. At another level, telling the story provides an example of how to expand the community of neighbors through the empathic responsiveness of story telling. The minimalist interpretation of the Samaritan is that empathy conveyed information to him—as data gathering—that the victim was suffering. Empathy also conveyed similar data to the priest and the Levite. But they processed it differently than the Samaritan. They experienced empathic distress and passed by. In contrast, the Samaritan was not flooded by his empathic sample of the victim’s suffering, and he further consulted his sense of right and wrong to decide what to do about it. The debate, still ongoing, that transformed Kohut’s “non-traumatic, optimal frustration” into “optimal responsiveness” (Bacal 1998; Terman 1988) had as one of its consequences the position that empathic interpretation requires timing, tact, finesse, narrative skill, and, well, optimal responsiveness. Empathy emerges into speech as listening—a paradox of listening as speech—the quiet stillness of the one that enables the other individual to be self-expressed and appreciated for who the other is as a possibility. The multiple dimensions of relatedness map to gathering interpretation and speech into empathy as a multidimensional process embedded as components of vicarious introspection. A single, additional step is required to gather these distinctions together into empathy as a multidimensional process. It encompasses a unified whole with integrated parts: empathic receptivity, empathic understanding, empathic interpretation, and empathically responsive listening and speech. A multidimensional definition of empathy clarifies many of the disagreements in the literature, which are really differences in emphasis, grasping a different dimension of the whole and misleadingly making it into the totality. These multidimensional relationships form what is in effect a hermeneutic circle, and one can enter the circle at any point and come around in many-to-many interconnections to the other dimensions simultaneously or in sequence. One person’s empathy is another’s countertransference

Robert L. Tyson cites Jacob Arlow’s memorable comment from a panel discussion in 1983 (Tyson 1986: 259): “One analyst’s empathy is another’s

28

Empathy and its resistances

countertransference.” What, then, is the relationship between empathy and countertransference? Under one description, countertransference refers to the analyst’s unanalyzed distortion of the analysand’s transference. Under another description, countertransference refers to the totality of the relationship with the analysand. Wherever transference happens countertransference also occurs. Enter Heinrich Racker (1957 [2007], 1968): The “total countertransference” results from the wholesale “concordant identification” of the analyst’s id, ego, and superego, respectively, with those of the patient. The alignment of the two personalities provides Racker’s definition of empathy: [T]he concordant identifications—those psychological contents that arise in the analyst by reason of the empathy with the patient [. . . .] [T]he disposition to empathy—that is, to concordant identification—springs largely from the sublimated positive countertransference, which likewise relates empathy with countertransference in the wider sense. (1957 [2007]: 734, 735) “Concordant identification” is synonymous with “empathy” here. But countertransference also refers to the unacknowledged anxiety, aggression, and conflicts that arise in the analyst through identification with the patient’s aggressive impulses, rejecting objects, and unresolved conflicts. When concordant identification fails, the analyst’s ego may identify with the patient’s id, superego, or related hostile introjects, resulting in complementary identification. “Complimentary identification” is countertransference in the negative sense as a distortion to analyze: Current usage applies the term “countertransference” to the complementary identifications only; that is to say, to those psychological processes in the analyst by which, because he feels treated as and partially identifies him with an internal object of the patient, the patient becomes an internal (projected) object of the analyst. (1957 [2007]: 734) The results are those conditions of partially analyzed anxiety, desire, or aggression that most often get the analyst into trouble by influencing the analyst without his appreciating how or why. After having stipulated the uses and misuses of countertransference, Racker encounters a semantic issue with his own stipulation. The totality of the psychological attitude of the analyst towards the patient yields an intersection between Racker’s use of “countertransference” and “empathy”: [I]t is mainly through the countertransference that we feel and can understand what the patient feels and does in relation to the analyst, and what he feels and does in face of his instincts and feelings toward the analyst. (Racker 1968: 60)

Empathy and its resistances

29

If this does not describe empathy, then I would not know what does. Racker does not use the word “introspection,” but relating “empathy” and “introspection” would have been useful to him. He may not use the word, but he is introspecting—turning his attention to his personally experienced reactions—his awareness of how the other individual may be impacting his immediate experience. In spite of defining “empathy” by means of the mechanism of “concordant identification,” empathy is not reducible without remainder to a form of countertransference. “Empathy” and “countertransference” have trajectories at right angles to one another, even as they intersect significantly with one another. Empathy is available prior to the establishment of the transference in any technical sense; and empathy is available even after a transference neurosis has been worked through in a narrower sense. Whether transference is total, partial, or temporarily in abeyance, empathic receptivity provides a vicarious experience of what the other individual is experiencing that cuts across transference and countertransference. Contra Racker, empathy is sui generis and is not derivative from countertransference. Empathy does indeed overlap with countertransference, and we can learn much about what the other person means to the therapist by examining the therapist’s reactions, i.e. the therapist’s countertransference. For example, the communicability of affect undistorted by the analyst’s own issues occurs in empathic receptivity, and may usefully be acknowledged. Presumably in such an instance we would be dealing with concordant identification— defined as a form of countertransference but not formulated as a negative countertransference to be analyzed away. Analogous to Winnicott’s “there is no such thing as a baby”—an infant in isolation without a caretaker does not exist—empathy in isolation makes no sense. Empathy is not the possession of any one individual. It resides in the relatedness between individuals. Empathy belongs to the community, even if only the community of the analytic duo. Patient and therapist encounter resistance to empathy (and we shall engage with these in detail in the sections after next), but that is not all. Resistance to empathy is a function of community standards or lack thereof that exist in the background. Resistance to empathy occurs not only in the psychotherapist or patient, but in the way these are inscribed in the social order, in the way they dwell in the community. Racker’s discussion of transference and countertransference to the psychoanalytic institution and training analysis in the background looms large here (e.g. Racker 1968: 130).

The resistance to empathy in the organization Resistance to empathy is subtle, and it deploys institutional mechanisms, usually unwittingly, to disrupt empathy. The psychosocial dimension complicates resistance to empathy on the part of therapists and patients.

30

Empathy and its resistances

Resistance to empathy uses organizational rules and regulations to build protective walls, preventing individuals from being fully present with one another by interposing rules and regulations that consume the energies required to relate. In response, an individual pushes back, disagreeing and speaking truth to power. Empathy speaks truth to power. “Power,” whether institutional or otherwise, does not respond empathically, but urges the individual to conform. The individual asks for an accommodation. “Power” exhorts the individual to comply. “Power” says “I did not make up the rules—I just enforce them.” The individual argues that the institution exists to serve the people, not to perpetuate its own rule-making. The individual then does whatever he or she decides to do. “Power” imposes sanctions to force compliance and tries to increase the cost to the individual. Empathy struggles to be heard. This is the age of compliance. There are so many “shoulds”—so many rules—that doing one’s job is a challenge. “Compliance” includes conforming with acceptable boundaries and limits, so this is clinically relevant. Highly relevant. No one is saying disregard boundaries. No one is saying break the rules. Rather one is saying relate to rules and boundaries empathically. But what does that mean? Empathy is about transiently and temporarily traversing boundaries. These include not only boundaries between the self and the other, but between those in a position of authority and subordinates, between insiders and outsiders in communities, and between those who feel left out of an organization. Even those who define and redefine boundaries—think of Kohut innovating about the boundaries of self psychology—often end up feeling like they are outsiders. A case in point follows. A defining document of engaging and overcoming resistance to empathy— organizationally and individually—is Kohut’s posthumously published “Introspection, Empathy and the Semi-Circle of Mental Health” (1982). Towards the end of his career, Kohut returns to the topic and title where he started and from which he rarely strayed. In precipitously declining health in 1981, Kohut was no longer as cautious in speaking truth to power as he was in his initial article (1959). In his 1982 statement, Kohut explicitly names those in power, who, in his original 1959 presentation, did not get the point or, arguably in denial, pretended not to get it while “back channeling” organizationally to ignore and devalue his innovations (i.e. panelists, Rudolph Loewenstein, Helen McLean, Maxwell Gitelson, and Franz Alexander). Strozier (2001: 145) writes: Such resistance at the individual level has much broader points of reference in the culture, which explains why psychoanalysis has so strongly resisted acknowledging wholeheartedly that introspection and empathy constitute its unique epistemology, that is, its very own mode of observation. [Kohut says:] “It seems we are ashamed of it and do not

Empathy and its resistances

31

want to mention it directly,” for it evokes the mystical and non-Western [. . . .] irrational resistances to introspection. Innovation is disruptive and confronting, and Kohut was an innovator, even if a sometimes a reluctant one. Kohut does not lose his self-depreciating sense of humor—or his empathy. He is fully self-expressed, and he is angry. If this is not an example of a transformation of narcissistic rage into aiminhibited assertiveness, I would not know one (Kohut 1972: 390). Kohut cites the example from Tristam Shandy where the young protagonist, in the process of urinating out of the window (for reasons not engaged here), gets his penis badly bruised as the window falls on it due to the counter-weights having been removed by his Uncle Toby for his military miniature war games behind the manor house. It’s a picture of narcissistic imbalance—not to mention castration anxiety and, especially for the men, a vicarious sensation of wincing pain. We get a picture of “speaking truth to power,” power being the psychoanalytic establishment. We also get a picture of the “war games” in psychoanalysis as a battle between ego psychology, self psychology, and other approaches such as object-relational. Yet, like Kohut himself as a whole person, not a part object, the self remains intact, maintains its integrity, and is ever again available as whole and complete. Kohut’s own innovations and initiatives have alternatingly struggled and flourished in the marketplace of ideas. Even as Kohut personally suffers “tragic man’s” (Kohut 1977) incompleteness and unfinished business, self psychology lives. Kohut denies that his paper is going to interpret the resistance to empathy. However, he does so in spite of himself. Where empathy is required, can narcissistic rage be far away? A constantly reiterated theme in Kohut’s work is that narcissistic rage is reactive to injuries and slights endured by the self in the face of unempathic others—the technical term “selfobject” defines the “other” as psychodynamically engaged and performing a function (especially affect regulation and emotional equilibrium) for one’s self yet remaining “otherly.” A close reading of Kohut’s paper (1972) show it as debunking the symptoms of the Oedipus complex as a derailment of the standard development of the self, whether gendered or otherwise. The Oedipal age child enters with “a warm glow of joy” (Kohut 1977: 229; see especially Terman 1984) into the Oedipal phase, and it is only if the father becomes overly aggressive instead of empathically competitive and the mother overly seductive instead of empathically affectionate that drive derivative fragments appear as neurotic symptoms of Oedipal guilt and acting out. Kohut is undercutting the standard, canonical core of psychoanalysis as a conflictoriented treatment method (and profession) that engages with the defining narrative of the Oedipus myth (which, however, is retained). In case after case, after a suitably long process of analysis, which has yielded many benefits, it turns out that the patient’s anger and aggression is

32

Empathy and its resistances

seemingly cycling upwards, and the therapist cannot understand why. Negative therapeutic response? Unacknowledged defense transference? Unanalyzable patient? Is this due to mutative interpretations having removed the defenses (resistance) holding down primal aggression, which then explodes in a destructive eruption? Or is it due to the patient’s experiencing the interpretations as being inconsiderate, condescending, patronizing, arrogant (this list is not complete), and responding with rage at being retraumatized in the area of her or his vulnerability? This is in principle a solvable problem. Prior to The Analysis of the Self (1971), one did not have a systematic way of describing what came to be called “narcissistic rage,” sourced in vulnerabilities of the self and an artifact of misinterpretation. After 1971 narcissistic rage emerges as a reaction evocative of not being in control of one’s own mind or body, a child’s temper tantrum, minor slights occasioning rage reactions all out of proportion to the realistic content as the self’s deep, archaic vulnerabilities are unwittingly probed (Kohut 1984: 385–388) rather like a dentist hitting an exposed nerve with a sharp mental instrument. Hints did indeed exist, but mostly indirect ones, such as Ferenczi’s (1949)—and Ferenczi was a notorious “wild man”—nor was Kohut’s interest in Ferenczi sufficiently appreciated in the self psychology community (see Lunbeck 2011 for an eye-opening discussion of Ferenczi’s influence on Kohut). Clinical vignette: the Freud of psychiatric diagnosis— oops, I mean “fraud”

A 20-something young man, Mr. D, is referred for psychotherapy and comes in denouncing the “Freud of psychiatric diagnosis.” I think to myself, “Good news. I am not a psychiatrist.” I do not correct the slip. The denunciation is repeated as the “fraud of psychiatric diagnosis.” This individual is selfexpressed. The presentation continues with a high-energy intensity, “What makes these people think that they have the ‘canonical interpretation’ of who I am?” I think: “This is material that I can use. ‘Canonical interpretation’ indeed.” It is a low bar for me to provide standard humane responsiveness that “applying labels to people rarely makes a positive difference,” and it does sounds like the individual was not treated well at student mental health services. First, the would-be patient is given a devaluing label and then when the individual reacts angrily, the anger is interpreted as part of pathological process confirming the initial assessment and the label. A classic double bind is in the offing. Still, there is a long and complex history unfolding. I mostly keep my peace, though, listening to the person, I am now frequently associating to Erikson’s treatment of youth, identity, and crisis. But then I get a phone call from student mental health services, who assure me that the person had given them my name as being the therapist. By the way, this was the

Empathy and its resistances

33

first time I had heard about it. The individual is required to get therapy. Then I get the confirming question from the psychology intern at student services (and I am not making this up): “What is wrong with this person?” This is followed by a suggested list of devaluing labels; prominent among them is “thought disorder.” I do not see disordered thought, though I do see flashes of brilliance and a formidable list of associations to complex readings in literature, the social sciences, and humanities with which I am just barely able to keep up. The fact that the prospect gives out my name as the therapist in a moment of need and without my permission—how did the person get it anyway?—indicates that personal issues are to be engaged; there is little point in “taking the bait” and being provoked. The issues are not available until the reactive rage is contained and worked through. There is nothing wrong with the professionals at student services. Their dedication, commitment, and simple hard work is an inspiration to me, and I am constantly moved by their example. Yet this time student mental health services had done almost exactly what Kohut advised not to do: It is erroneous to tell the patient that his demands are unrealistic but that, on the contrary, he must demonstrate to the patient that they are appropriate within the context of the total early phase that is being revived and that they have to be expressed, then the patient will gradually reveal the urges and fantasies of the grandiose self . . . to the integration of the grandiose self into the structure of the reality ego and transform its energies adaptively. (Kohut 1971: 176) While I may struggle with being empathic on any given day, this is not one of them. The recommendation is to put the feelings and behavior in the context of the patient’s valid experiences. The patient has an admittedly ambitious entrepreneurial project in the offing. But who am I to say that the person is not the next Sheryl Sandberg or Mark Zuckerberg? Anyway, the family has significant wealth and might provide the capital for the projected enterprise. It bears repeating: There is nothing wrong with the professionals at student services. These are dedicated and hard-working professionals. The intentions are good, but there is something missing—empathy. Yet how can an individual be empathic when the system is set up to require filling out a check list of behavioral traits by the end of which the individual has been reduced—you guessed it—to a checklist of behavioral traits—and moreover has caused the applicant to feel like it? The empathic individual is inscribed in an unempathic system. Diagnostic categories do not provide access to empathic relatedness. The alternative? “Instead, the task of diagnosis shifts to the identification of recurrent patterns of disturbance or disequilibrium in complex intersubjective systems” (Atwood and Stolorow 1984 [2014]).

34

Empathy and its resistances

Kohut identified another aspect of the resistance to empathy in his work on the semicircle of mental health (1982). When in The Odyssey, Odysseus does not want to leave his wife and child and go off to the insane slaughter of the Trojan War, he feigns madness, plowing his field with an oxen yoked to a donkey. His would-be comrades at arms already know that Odysseus is, at any rate, “sane enough,” and, they confirm his sanity by putting his new son in the path of the plow. Odysseus steers around, plowing a semicircle that demonstrates to him and all present that he is not insane. Does he pass the test? He keeps plowing, yet changes his mind, conforms, and goes off to war. The lesson? Much of what passes for “insanity” and disordered emotions is reactive rage to the process of being devalued, misunderstood, and otherwise dehumanized by a mental health system that has no shortage of opportunities to enforce conformity by push down, alienation, or just plain rudeness (and not only to patients). Likewise, Kohut. He declines to conform to the canonical interpretation of inborn aggression inevitably in conflict with libido. Kohut stays the course, navigating, like Odysseus between the Scylla of retraumatizing interpretation and the Charybdis of indulgent, corrective emotional experience. Homer was not required reading at student services. Perhaps it ought to have been. Without empathic receptivity, one loses touch with the other person, devolving into detached professional concern, a euphemism for the careful application of diagnostic categories, in which one is at risk of drawing distorted conclusions about the other’s experiences (Halpern 2001; Hojat et al. 2009). The person is treated as a mere bundle of neurons, a potentially interesting case, or an association of symptoms, instead of a struggling human being. This is not to say that humans are not bundles of neurons. We are. However, these neurons generate meaning, possibility, and conscious experiences; and these latter are what arouse and call forth the process of empathy as a multidimensional method of data gathering, not further reducible to neurology without the loss of humanity. Neurons and the amygdala do not empathize; human beings do. Yet all-too-often, in clinics staffed by harried professionals, empathy is not a priority. Empathy gets paid lip service. Indeed—and pardon the double negative—one dare not not pay empathy lip service. But, truth be told, empathy takes too long. It is too messy. It is too painful. It is too much like a corrective emotional experience. It provokes countertransference. There is no time. There is no money. We are not even sure what it is. We need results now. Get over it. Conform! Not that there is anything wrong with conforming. Conforming is a valid choice. The patient comes in and takes the position that he wants to feel better right away. Even he wants to conform. Even if the therapist does not prescribe, he or she will need to have a position on prescribing. An easy way out? Medication will just cause a person to put on weight. You do not need a psychotherapist. You need a nutritionist! With that point, the institutional resistance of the background becomes individual, even if not nutritional.

Empathy and its resistances

35

Clinical vignette: speaking truth to power

Empathic receptivity discloses that Mr. D’s inner experience was that he was lonely and reaching out for human warmth, whereas a series of authority figures had a difference description of the behavior. For example, the description of the experience by the Pastor at Aquinas House was that Mr. D was talking loud and overstaying his welcome after closing time. Mr. D was reactively enraged at being thrown out. Mr. D spoke angrily— but also humorously and provocatively—about being excommunicated from the traditional Catholic worship by the Aquinas pastor as had occurred with the Renaissance philosopher, Giordano Bruno. Bruno ended up being burned at the stake for heresy, but Mr. D was just plain burned up. At times Mr. D felt life a lost puppy; other times, like an enraged pit bull. In a towering rage, Mr. D’s experience was that he was engaging the pastor in a spirited debate, whereas the pastor redescribed the experience as Mr. D’s having stolen a scooter and dishonored the congregation. Mr. D’s experience was that he was speaking truth to power, whereas the Dean’s redescription of the experience was that Mr. D was behaving like a “sophomoric” undergraduate. Mr. D’s experience was that his professor had given him permission to drop by the professor’s home at 8 pm, whereas the professor had not agreed and was concerned that Mr. D was enacting a boundary violations at 9 pm. Mr. D experienced classes at the university as stimulating, enriching, and engaging, whereas his teachers were concerned that he was not completing his work. All these events added up to the experiences of an individual who frequently needed to test boundaries in a provocative way. Why? In the background is the boundary between the young Mr. D and his remote, intermittently idealized, occasionally hyper-critical and nearly always inaccessible father. Mr. D struggled with an archaic grandiosity testing the limits of an over-stimulated narcissism. In addition, one could perceive a hunger for relatedness in which Mr. D’s own greatness—his “contribution” to use a more neutral term—was acknowledged by the admired authority figures, whether teacher, parent, or mentor. Intermittent disappointments on the part of idealized mentors would send him into an energetic state of overstimulated, confrontation-like verbal and intellectual self-aggrandizement, only a fraction of which was able to be engaged for productive purposes of school work or relationships. Mr. D’s experience of “speaking truth to power” is of an exhilarating, stimulating, and engaging challenge to the powers that be. Such a description —one might say, “micro-narrative”—encapsulates both story and relationship. The relatedness emerges in life—and eventually in the transference— as a challenge to those in authority to acknowledge Mr. D as an articulate innovator. The micro-narrative of “truth to power” unfolds further. “Power” speaks back. Sometimes “power”—the would-be idealized authority figure—

36

Empathy and its resistances

is not amused—whether as his father from high school days or the dean in graduate school—and Mr. D is left feeling put down, devalued, defeated, and, above all, misunderstood. His productivity is diminished. His emotional resources—energy—available for projects through the empathic understanding and responsiveness of admired mentors remain inaccessible or is undone. He is left depleted. Under one empathic interpretation, Mr. D compensates for the depletion and tries to recover by revving up his anger at the powers that be. How dare they? A pattern emerges. The narrative provides access to a form of relatedness that speaks truth to power, where, however, “truth” is a struggle for recognition, self-esteem, and a towering rage that the world is not in touch with his “greatness,” with his “contribution,” to use a more neutral word. The story unfolds. Mr. D signs up for a prestigious program in law at a notable university to try to help him complete his bachelor’s thesis. Mr. D tells me that he ended up “feeling terrible, feeling worthless.” Mr. D hints at a subtle prejudice among the mostly Catholic colleagues. The issue? These senior colleagues ask his opinion and give the young man D recognition and acknowledgement—mirroring. Mr. D likes it. He is honored. He is flattered by the attention and the positive feedback. But all of a sudden Mr. D realizes that these would-be mentors are relating to a version of Mr. D whose values he does not share. They are relating to Mr. D as a possibility to which he does not really aspire. Mr. D is not conservative like them. Mr. D is not a traditionalist as they are. Mr. D is not persuaded, and he feels like a fake in tentatively going along and not openly arguing back. Their comments get inside him and “blow up” in a devaluing way. There is conflict aplenty, not primarily between the id and superego, but between Mr. D’s aspirations and his self-presentation and emotional energies. The senior colleagues are into St. Thomas and natural law; Mr. D is into Paulo Freire and liberation theology. They are into virtue ethics; Mr. D is into the pedagogy of the oppressed. They are into Martin Luther King; and Mr. D is into Malcolm X. Mr. D is prematurely “overcommitted” to what he does not believe in, and it occurs as if it were something out of Martin Luther’s break with the Church. Even if the bloom is off of Erik Erikson’s distinctions in Young Man Luther, his contribution in this case resonates with incomparable accuracy and eloquence in (1958: 42): “The crisis in such a young man’s life may be reached exactly when he halfrealizes that he is fatally overcommitted to what he is not.” This academic excursion ends up as yet another prematurely (“traumatically”) wrecked attempt at idealization, all-too-similar to the situation with father. The social is also inscribed in the individual. Harmony was missing in the relatedness to the authority of the father. Mr. D’s aspirations may indeed be world shaking if he gets his way with his project, establishing and promoting a social justice “Think Tank,” the agenda of which is political harmony. Unfortunately, so far, Mr. D’s behavior is mostly self-defeating and only succeeds in plunging his own small world into crisis in a confusing and

Empathy and its resistances

37

frustrating way. Speaking truth to power was also undertaken by Young Man Luther (Erikson1958). Luther’s challenges to authority—especially the father of fathers, the pope of the Roman Catholic Church—resulted in world historical conflict, the Protestant Reformation. Mr. D’s conflict is also world shaking, though only his personal world gets shaken up. Mr. D states that he enjoyed life as a student at Stone Valley College (not the real name). Life there was “welcoming.” Mr. D describes the institutional setting as an empathic one without using the word. Teachers would have him over to the house for tea. As part of the role of professor, the teachers reached out to students. This was the kind of affinity that was missing from his relationship with his father. In contrast, the celebrity academics at the university that Mr. D was attending—all of whom have written multiple books—have presented Mr. D with a less welcoming experience. This is similar to his experience with his “celebrity” father. Mr. D acknowledges that he has struggled. Mr. D has energy for his pet project–the video, “The Education of D,” but his formal course work languishes. The cinema project flourishes. Mr. D struggles to complete his writing assignments. Throughout numerous sessions, I was the one exception to the angry denunciations of the fraud of psychiatry, psychotherapy, etc. I had hoped that the deidealization would occur gradually. It did not. I stumbled into the commoditization of the relationship with the father. As agreed in advance with Mr. D, I sent the invoice for my services to the father. This works for a while. I am generous—to a fault. I bill for only some of the time of Mr. D’s late and missed sessions. I am not firm enough about the framework. I am a good enough psychotherapist, just not a very good businessman. It is more important for the treatment to keep the conversation going than to split hairs over every detail. My mistake. A loving parent does not bill for the affection and affinity that the parent devotes to the child of tender age. Mr. D is looking for unconditional love. Mr. D is looking for someone to be genuinely thrilled and delighted by his accomplishments. While I am indeed impressed and engaged by Mr. D’s innovative thinking, I find that the authentically responsive “glimmer in my eye,” for which he so hungers, is consistent with billing for my time. The personal chemistry between us is good—perhaps even better than good—but it is not unconditional. I have billed for my services. I learn that Mr. D is not comfortable with this, and I receive a multipage communication that he is not comfortable with the relationship. The relationship has been commoditized. It is common and unexceptional. The psychotherapist is inscribed in the social order of commoditization. A pretext? My clumsiness? Resistance to look at my own countertransference about money—and mess? Belated attempts to work it out—to talk about how it all relates—are not timely. Attempts to repair and invitations to “talk about it” are a work in progress. Perhaps I too need to review my Homer.

38

Empathy and its resistances

Clinical vignette: crashing the bike

The individual and the community are inextricably intertwined. Individual issues are recruited by institutions to enact resistance to empathy and community issues are engaged by the individual to realize resistance to empathy. Inexplicable coincidences also occur. Another example. First, the following instance of the organizational resistance to empathy and transference to it begins as the would-be psychoanalytic candidate and applicant says what is in fact the case: “I am the author of a book on empathy, and you can count on mine.” He would have done better to say: “I acknowledge your empathy.” Second, notwithstanding Strozier’s dramatic, well-argued conclusion that Heinz Kohut really was Mr. Z in Kohut’s “The Two Analyses of Mr Z” (1979), we will never be sure (Strozier 2001: 308–316). In the following case, we can be sure. The author of this book is Mr. A. This material is worked out in the course of his psychoanalysis. Let us take a step back. The background is complex, dark, difficult and requires set up. Mr. A, a 30-something male with a Ph.D. in philosophy, presents himself for psychodynamic therapy, wanting to work on his relationships with women, with lack of self-confidence around them, social awkwardness, emotional disequilibrium, and a smoldering anger. He is struggling with a teaching career, and is unsure if the issue is lack of his ability or economically depressed opportunities in the teaching market in philosophy or both. Mr. A describes his father as “heavy-handed,” a bully who explodes with fierce anger and physical aggression in unpredictable ways, all out of proportion to the real or imagined trigger. For example, the father and son went out to teach the eight-year-old Mr. A to learn how to ride his new bike. Mr. A could not get his balance—could not get his equilibrium—a common issue in learning to ride. Mr. A crashed the bike. When one is learning to ride, one has a crash or two. However, the father was not supportive. He was not even clumsily unsupportive—“buck up, young fellow—be a man—big boys don’t cry!” No, the father took it personally—as what seemed to be a narcissistic injury—became enraged, spoke abusively to the boy, and gave him something to cry about—slapped him. Repeatedly. It was the ultimate unempathic moment. A parent is supposed to help one empathically to regain one’s emotional equilibrium when, for whatever reason, it had been upset. Matters got worse. As the years went on and the boy was not sufficiently responsive to the slap and verbal abuse, the punishments escalated. Several times when Mr. A had committed some breach of conduct and the father was in a particularly ugly mood, he took away Mr. A’s clothes, and threw him outside. This recalls Kafka’s “Letter to the Father” where the boy asked for a glass of water at night and the father picked him up bodily and put him outside, however, with his pajamas on. Bad enough. This was worse. Perhaps the father detected in the son an element of defiance of which the son was unaware. According to some “logic” of the father, this needed to be crushed. This reduced the

Empathy and its resistances

39

young Mr. A to a state of fear and deep distress. Why did Mr. A comply? He did not see how he could avoid an even worse outcome by resisting. The father started ripping off Mr. A’s shirt, and the buttons were popping left and right. Mr. A thought, hoping against hope, that if he complied, the father might remit, deescalate, and Mr. A would somehow survive. Mr. A was pushed down into survival mode. Being thrown out naked started happening when Mr. A was about 10 years old and would occur about once a year. The last time this ever happened Mr. A showed evidence of puberty, so he must have been about 13. It did not happen again. This was the last time Mr. A can recall being ordered to take off his clothes and ordered outside occurring, so the father seems to have come to his senses temporarily, or perhaps his Mom succeeded for once in putting her foot down, not that she didn’t often try, but only after he had calmed down. When she tried to interrupt the father’s rages while they were occurring, then she received the same treatment both verbally and physically. However, she was not required to remove her clothes. Further engagement with the example of crashing the bike will occur in the context of transforming traumatic upsets into emotional resources as part of the process of recovery from abuse (see “Abuse Survived and Worked Through as a Resource,” pp. 179–182). Fast forward a couple of decades. Hindsight is 20–20. Analogical thinking is one of the powerful approaches taught by the psychoanalytic method. Keep it in mind: Thrown out naked. This trauma is paralleled by the action of the local psychoanalytic institute. Mr. A had an academic background and as part of his transition into a career in psychotherapy, he was required to engage and make progress with two psychotherapy cases. For a variety of reasons, and partly because the local market for psychoanalytic therapy was not flourishing and the local clinic had no referrals to send his way, Mr. A was late in getting started with his cases. He was making progress, but the clock was ticking. The autumn semester was about to start. Mr. A reasoned he was doing well and would get the letters of progress from the supervisors by late October, which, however, would be eight weeks late. Mr. A made an empowering request—he tried speaking truth to power: “I acknowledge I am late, but things are going well. Bring me along. Let me begin, and the letters will be forthcoming. If they are not forthcoming, you can terminate my participation in due course.” There was no response. The clock continued to tick. Mr. A escalated: “May I speak with whoever is in charge?” An unfortunate choice of words? A meeting was arranged. The response? “You are minor league. You must be hypomanic!” The decision was made. We are not going to wait for the letters to terminate participation. We are going to do it now. Dismissed! Terminated with extreme prejudice. A poor choice of words: “May I speak with whoever is in charge?” This was not appreciated and the public humiliation was scheduled—and enacted. Without making excuses for the common and petty behavior of the decision makers, who became known as the Gang of Four, they had put their foot

40

Empathy and its resistances

in it. One supervisor, who had expressed the view that Mr. A was doing excellent work, immediately stopped working with him because “an institutional framework is now missing.” Evocative of the previous personal trauma, crashing the bike? In short, Mr. A was thrown out without clothes, without an institutional framework. Empathy is a high bar, and rare is the individual who gets over the bar everyday. However, we are not talking about empathy or lack of empathy here. We are talking about simple courtesy and its absence. Even though the Gang of Four was not listening, their unconscious was. The amazing thing is that without knowing Mr. A or anything about him, the colleagues and Mr. A managed unwittingly—I almost said “half wittingly”—to respond to Mr. A’s naive over-confidence in such a way as to call forth Mr. A’s personal trauma of being literally thrown out of the house without clothes. Then they implemented the response. The unconscious was running the show, and the amazing coincidence was unwitting. If ever there was an “occult process” (Deutsch 1926), this was it. I hasten to add that Mr. A did not then (nor does he now) find that being thrown out naked was a blessing in disguise. There was nothing good about it either then or earlier when it happened at the hands of Mr. A’s so-called father, for proper parents do not treat their children that way. Mr. A did not find anything good about it when it (i.e. being expelled) happened symbolically to him at the hands of local institute colleagues, who, of course, had other pretexts for perpetrating the unwitting enactment. A recurring theme of this exploration of countertransference and response is: These people are supposed to be well analyzed? The admission committee and anyone else who bothered to read Mr. A’s file had a concise two-page statement from him as part of the application process that his father had been “heavy handed.” This was juxtaposed with his discovery of Kohut’s account of narcissistic rage. The statement continued that he had an “Ah ha!” moment when in a truly defining moment Mr. A had first read Kohut’s account of narcissistic rage in The Analysis of the Self (1971). Kohut’s work seemed immediately to describe his father’s reaction when Mr. A committed some minor misdemeanor or whatever Dad perceived to be such. This was experienced as a narcissistic slight by the father with volatile consequences. No reading between the lines was required. In contrast, the behavior of the colleagues on this occasion was not really mean. It was definitely not enraged. Yet it may have been defensive in that they were troubled by what Marian Tolpin would have called “naive over-confidence” instead of “grandiosity.” Empathy was so important to Mr. A (already the author of a book on it) that he wanted further training in it. Arguably they were reluctant —one might say, “resistant”—to the challenge of introspecting about their own relatedness to empathy. If they had inspected the personal statement, they may have preconsciously been confronted about their own relatedness to domestic (“gender”) violence either in their own lives or the lives

Empathy and its resistances

41

of patients who they had tried to help. However, the introspection (and empathy) about the latter possibility were limited. No one was interested. The vote had been taken even before the meeting had occurred, and Mr. A was in effect voted off the island. Mr. A’s relationship with the local institute reenacted the meaning of his boyhood crashing the bike. Mr. A had indeed crashed the bike. However, the problem was not so much crashing the bike. It was being punished for it afterwards. Mr. A had made mistakes. He was late getting started with his psychotherapy cases because he had to go out and find them on his own instead of getting some support by way of clinic referrals. Mr. A had spoken truth to power. He had asked to speak with whoever was in charge, implying that maybe no one was. That didn’t work. However, the treatment seemed harsh and punitive all out of proportion to his misdemeanors. Crashing the bike was not the main issue. Being sanctioned for it was. Then—as in his youth—all the self-doubts emerge. With apologies to Melanie Klein, in spite of Mr. A’s denying the applicability of the paranoid position, he went there. He is caught by it. The “it” of the paranoid position and the “it” of the unconscious. Even as the paranoid position asks, “Why are they out to get me?” Mr. A ends up there. The still quiet voice inside his head, hardly recognizable as that of his father whispers instead of shouting: “There must be something wrong here. What is wrong with you?” Mr. A asks himself: “What is wrong with me? Why do I seem to call forth unfair treatment—one might say ‘abuse’—from others?” Mr. A asks himself: “Am I wearing a sign that says: ‘Abuse me’”? At this point, Mr. A also has a conversation with his psychoanalyst. He also gest a moment of grace. Two insights interrupt the predictable. “You know, when wouldbe teachers apply diagnostic categories unprofessionally to you personally, that is an expression of hostility. It is not a diagnosis. It is not guidance. People are not trying to give you useful feedback. It is confrontational whether or not you choose to respond.” This triggers another idea in Mr. A. “Heck, this so called ‘hostility’ is not abuse; it is common. It is petty. It is pettifogging. It is small. Petty behavior.” In reflecting on the matter with his psychoanalyst, both laughed and decided that if Mr. A really had such powers of projective identification, then he ought to be promoted on that basis alone. He managed to rub a couple of uninformed people the wrong way by being the author of a book on empathy. He managed to get a couple of decision-makers angry at him, and then they went and enrolled others in his many “failings” that seemed to grow as in the game of telephone with every communication in the network. The steady drum beat of “What’s the rumor of Mr. A?” grew with every exchange. Yet Mr. A was deeply disappointed and the idealization he might have had of his experienced colleagues at the local institute was broken, fragmented, kaput. Mr. A was disappointed that he was not going to be welcomed, albeit as a junior colleague. In spite of an amazing romp

42

Empathy and its resistances

through his personal history, he was disillusioned. Could not the experienced colleagues have identified an opportunity for personal growth or expanded empathy rather than being summarily terminated? Thrown out without clothes—retraumatized. It kept occurring to Mr. A: “These people are well analyzed? Yet they went directly to the paranoid position: there must be something wrong here.” Obviously more work was required. The possibility of Mr. A realizing his aspiration looked dubious, but was less hopeless than it seemed. Before a month had passed, there was a changing of the guard. The new chairman was the most inclusive man Mr. A had ever met. Mr. A told the new man about crashing the bike. He did not tell him about being thrown out naked. The new chairman was enrolled. He never really understood it, since crashing the bike was not the real issue. It was being punished for it. Yet as a micro-narrative, it was good enough. Never was it truer: change the context, change the conversation. He went to bat for Mr. A. Next, the head of Academics was replaced. In this case, it was not a rumor of empathy, but a rumor of an unspecified issue affecting performance. As with the NSA and other large governmental organizations, one cannot comment, and one cannot even comment that one cannot comment. The result was a new head of Academics. Sadly, another of the individuals passed away and may already have been “not fully present” at the time of the meeting. Just as significantly, Mr. A engaged in more work, and completed his psychotherapy cases and the reports were favorable—albeit paying retail for supervision. Perhaps that was the agenda all along—maximize revenue. We will never know. Yet a set-up for success was created. Mr. A applied for readmission and was accepted.

The therapist’s resistance to empathy People become psychotherapists for many reasons. The person wants to make a difference. The person wants to contribute to transforming emotional suffering, whether another’s or one’s own, into relatedness and productivity. The person wants to expand self-knowledge. The person wants to expand healing in the world. The person wants to expand empathy in the world. The person wants to work on and complete issues by vicariously experiencing the issues as reflected in the experiences of the other person. Rarely does one say that one wants to become a psychotherapist in order to confront one’s personal demons. Rarely does one say that one wants to engage one’s countertransference. Rarely does one say that, like in the fairy tale, one wants to descend to one’s own worst emotional hell and grapple with the anxiety, depression, devaluing judgments, real and imagined traumas, ghosts of the past, fragmentation, and dehumanization lurking there. Rarely does one say it, but that is what happens. That is what one is in for. An element of “boot camp” is not to be avoided. It seemed like a good idea at the time. But it seems like a less good idea when one is isolated, uncertain

Empathy and its resistances

43

and colleagues are making ambiguous—devaluing?—comments. By the time the person has worked on and worked through the difficult issues in the person’s own psychology, the person finds that what has been learned can be used as a resource to make a difference to other individuals who are struggling with their own issues. On any given day, the therapist’s partially analyzed narcissism—diplomas, publications, licenses, certifications, prescription pads, professional honors and credentials—present an obstacle to empathy and empathic interrelating. I hasten to add that professional credentials and accomplishments are a proper source of pride and honor. Transformations of narcissism—empathy, humor, appreciation of art—enhance one’s capacity for relationships. The better integrated, firmer, and more coherent is the integrity of one’s self, the better one is able to be open, available, and listen to the other. Yet in the matter of empathy, pride and honor lead precisely to the ultimate inauthenticity experienced by the author of knowing the answer. One becomes the “Shell Answer Man” of psychotherapy services. Instead of listening to what the other individual is saying, the therapist is listening to his opinion—his expert opinion—of what the other is saying. The therapist narcissistically considers his opinion a prospective interpretation. It is really a suggestion (Glover 1931). Inevitably, the suggestion is about the therapist, not the patient. Resistance to empathy looms large here. Even in empathic relatedness, empathy has its resistances. In addition to the therapist’s partially analyzed narcissism as a source of resistance to empathy, another source is that, like the patient, the therapist is a human being. The therapist is vulnerable. Empathic receptivity is openness to the other. This openness tests one’s vulnerability to the other’s painful experiences and exposes one to the other’s evaluations and enactments. If one works with a partial or incomplete definition of empathic receptivity, the risk of reactive resistance expands. Resistance to empathy is resistance to the vulnerabilities existing in oneself. One has to activate empathic understanding, empathic interpretation and empathic responsiveness to get the benefit of empathy as a filter against the full force of negative feelings. No one wants to be a mere narcissistic extension of another. Kohut (1959) calls out sources of resistance to introspection and empathy by the therapist in his opening engagement with it. He notes the close connection between free association and introspection while maintaining the distinction. Kohut does not speak authoritatively on which has priority, but, given that he is arguing in favor of the rehabilitation of an introspective psychology (in the face of the prevailing, pervasive behaviorism of 1959), it may well be introspection. Introspection is the founding experience of psychoanalysis. Free association is an instance of raw material for introspective (and empathic) processing. Free association is an entry point to introspection. Introspection, in turn, is a form in which free association is captured and elaborated.

44

Empathy and its resistances

Kohut is explicit that the source of the resistance to introspection is that the individual is “helpless in the face of tension increase” (1959: 465). Here Kohut is well served by his economic vocabulary of narcissistic investments, equilibrium and disequilibrium, resources and assets. The patient’s productive emotional resources and energies, which are indispensable to describing the experience of the individual in relationship with himself and the other, are tied up in the archaic structures of the grandiose and idealizing self until freed up by engaging the latter. What is the source of such increased tension? The process of working through engages experiences of conflict, ambivalence and such negative emotions as fear, anger, or sadness. The therapist is open to sample vicariously these negative experiences with the patient and in the interest of understanding the patient’s psyche in the context of the patient’s life. Even if the individual is experiencing happiness, joy, or enthusiasm, the forms of “aliveness” can be experienced as over-stimulating and a disruption to the listener’s evenly hovering equilibrium. Thus, the economic account of resistance to empathy. Advancing from energetics to interpretation, the tension increase in the empathic listener shows up as the requirement to learn to live with ambiguity. Instead of cross-examining the patient about the meaning of every detail, the empathic listener allows the narrative to unfold based on its own inner narrative logic. Clarifications are useful, but ultimately the information required by the empathic listener succeeds in finding him. No analyst or therapist can hope to experience the complete depth and breath of human experiences. Nor would anyone want to experience all possible forms of pain and suffering, hence, the uses of “vicarious experience.” The word “vicarious” relates etymologically to “vicar,” whose fundamental meaning is that of “representative.” The “vicarious” in “vicarious introspection” makes empathy well suited to diverse forms of representation. Vicarious experiences are the feelings aroused in story telling, reading literature, theatrical performances, or listening to narratives of real world human relations and their emotions, desires, beliefs. Vicarious experience gives individuals the opportunity to sample experiences representationally that would otherwise not be available to them. Vicarious experience delivers a “trace affect” or “signal” without an overwhelming loss of individuality in submersion or merger with the other. Kohut famously said that empathy is like oxygen for the soul (self). Is it any wonder that many students of “behavioral health” and candidates experience a shortness of breath? Most training programs do not need more readings, more meetings or more rules excluding “at large students” from confidential case conferences. They require expanded empathy. Exposure to the diversity of human experience as depicted in literature, art, and folk narratives is what is missing in professional training programs—arguably in psychoanalytic ones too—that neglect the humanities and empathy-rich, “thick description” of social sciences rather than categories of diagnostic data.

Empathy and its resistances

45

Resistance to vicarious introspection takes the form of substituting altruistic surrender, a distorted form of empathic receptivity. Vicarious experience is intimately related to “living vicariously,” which is identified by Anna Freud via altruistic surrender as a defense against experiencing life in its affective depth (1936: 132). The vicarious experience is distinct from living vicariously as a defense mechanism in which the individual gives up his own hopes or fears in favor of those of another, with whom he partially identifies, and whose interests gives priority over his own (Anna Freud 1936: 132). A. Freud cites Edmond Rostand’s drama of the largenosed Cyrano de Bergerac as someone who lives vicariously in his love for Roxanne through his friend Christian. Living vicariously through vicarious experience counts towards legitimizing the value of letting our clinical sensibilities be informed by works of literature and related narratives. Empathy with intense negative affect—hostility, loss, narcissistic injury, sexual danger, deep melancholy, extreme sleep deprivation, overly intense experiences—is painful. We are vulnerable to it—hence, the resistance to it—nevertheless the role responsibility of the therapist is to be available to the patient in his despair, distress, and isolation to be joined in his hell by the therapist, prior to moving out of it. Now that does not mean that the therapist has to have a deep attachment to his fundamental masochism, rather it means that he has to be able to be vulnerable enough to sample the experience of the other, get a trace affect, without being overwhelmed. Resistance to empathy on the part of the therapist is resistance to the vulnerability of being affectively flooded, overwhelmed or open to excessive stimulation. Vulnerability to psychosis in its tortured suffering and anguish arouses a deeply troubling aversion in most people. Images of fragmentation, double binds, and disturbing phantasies are frightening. An uncanny sense of vulnerability to losing one’s mind when in the presence of out-and-out psychosis is a function of empathic distress, over-identification with suffering humanity. However, being vulnerable to a taste of the suffering is essential to establish humane relatedness to anyone in extreme distress, vicariously feeling a sample of the fear, experiencing vicariously what the other endures. Vicarious experience is like a film or theater piece based on their suffering. This is different than being in the movie itself. This limits the vulnerability to merging with the distress. Indeed empathy acts as a stimulus barrier and, like a filter, tunes down the vulnerability experienced by the listener/viewer to an individually manageable level. Every therapist has to say for himself what are the limits to his vulnerability—just how much provocation, boundary pushing, and upset occurs before his resistance to empathy reaches a threshold requiring pushback and firm negotiations about enforcing limits. A case can be made that too many therapists err on the side of a quasi-masochist over-toleration (e.g. Racker 1968: 174–180). For example, J. Frederickson (1990) seems to have had near super-human resilience in the face of vulnerability without

46

Empathy and its resistances

the need to retaliate towards his deeply upset patient. Frederickson’s article documents hate in the countertransference as a function of empathy. He found himself not merely being put upon and provoked, but acquiring a real hatred for this patient. The patient is filled with hatred, too. But the therapist’s hatred is not just picking up on a subtle unexpressed communicability of affect (emotional contagion). The patient is being provocative, acting out in the session. The therapist’s hatred is caused by a patient who returns insults for the therapist’s attempts to be decent and humane in the face of real suffering. No delicacy of empathy is needed. Virtual insensitivity will suffice. According to Frederickson, the cause of the therapist’s own hatred is not vicarious experience of the other’s hatred, but projective identification as the patient inserts hatred into the therapist’s experiential ownness through his provocations. Two paths—empathy and projective identification—lead to the same result—hatred. The therapist’s empathic receptivity—openness —leaves him vulnerable to the hatred from which the patient also suffers. Frederickson’s countertransference interpretation is to acknowledge his own vulnerability to projective identification; and this interpretation redescribes the therapist’s hatred as a reaction to the patient’s own fragility in the face of being vulnerable—along with generous doses of patience and boundary setting. Therapists are not always so patient. In a bold act of therapeutic nihilism, sometimes the conclusion is drawn that a little empathy goes a long way, listening for the first 20 minutes. Okay, that’s enough empathy. Now time for a confrontation, some tough love, and what is really bothering you. Other therapists gravitate to the other extreme. Instead of therapeutic nihilism about empathy, a therapeutic ambition to cure the world through empathy is the order of the day. The patient gets empathy—and gets better. Wouldn’t it be nice? From an alternative perspective, self psychologists are at risk, who are “conditioned” to look for tactical failures of empathy, narcissistic slights, as the occasions for set backs in the therapeutic process. Since progress occurs in repairing the breakdowns—the non-traumatic failures— in empathy, some self psychologists get a “flinch reflex,” expecting to be blamed for whatever goes wrong, even if, for once, the grain of truth in the patient’s distortion does not relate to the therapist. While it is easier said than done, the therapist needs to go beyond blaming himself for empathic failures in negative transference reactions and analytic stalemates (e.g. Newman 1984). Making oneself available as a usable therapeutic subject is different than being used in the sense of misused, but sometimes not different by much. This perhaps lies near to the therapist’s underlying masochism. From another perspective, empathy disappoints and in a strategic way. The breakdown in empathy and the restoration of empathic relatedness is one description of how structure gets built in self psychology (e.g. Wolf 1988). Defenses against empathy are mobilized to protect vulnerable aspects of the fragile self such as low self-esteem, poor affect regulation, or a tendency

Empathy and its resistances

47

to experience shame. The risk is that, in any given would-be empathic encounter, one is wondering—when is the empathic rupture going to occur? Rather than an interpretation of a defense against aggressive or erotic drives, the defensiveness against empathic relatedness is redescribed as expressing resistance to owning up to one’s phase-appropriately experienced vulnerabilities and deprivations as reactivated in the countertransference. When is the selfobject going to disappoint, so that the repair gets a chance to occur? Couldn’t we do without the disappointment, and just move to the progress part? Actually, one can’t. Yet the resistance to empathy on the part of the therapist is that in deploying empathy one is already vulnerable to being a mere narcissistic extension of the other’s immature, archaic self. On the one hand, it is devaluing to be treated as an extension of the patient’s archaic grandiosity without being a stand-alone, independent subject on one’s own. So that is a source of resistance. On the other hand, even if one is an independent subject, if one experiences just a little of the patient’s upset, then maybe one will be unable to stop. This is not irrational. This is a real issue. Given the level of empathy training in the profession, rare is the person who has masterful, expert control over her or his empathy regulation to tune it up or tune it down based on a continuum of disturbances varying from the mildly, everyday neurotic to the deeply psychotic. In the matter of empathy we may usefully be more like Freud in one particular respect. Freud wrote to Wilhelm Fliess in 1897 about one of his patients whom he called Cäcilie M, naming her his Lehrmeisterin, his master teacher (cited in Appignanesi and Forrester 1992: 86–87). Cäcilie M’s claim to fame was that she insisted that Freud stop asking her so many questions and let her tell her story without interruption. In Freud’s case, the breakthrough was for him to get out of the way of the patient, provide a gracious and generous listening, provide empathy, and let her tell her narrative. The narrative, in turn, exposed the relatedness required to grasp the transference. Clinical vignette: dynamics of idealization

Having a conventionally successful father, who literally has a 101-page résumé, can be challenging for children of any age. That was so for Mr. D, the 20-something graduate student, who came in denouncing the Freud of psychiatric diagnosis. I told Mr. D so, as a result of which he shared with me the first personal experience that he could remember about his father. In the recollection, Mr. D was seven years old. It is the weekend. Dad is working, working, working on building his successful software firm. The young D interrupts his father’s single-minded work in his home office; tentatively testing the boundary of the office study, and D feels that he [Mr. D] is a “horrid pest” to his father. Now the phrase “horrid pest” is from a series of children’s books by the brilliant story teller Richard Scarry and

48

Empathy and its resistances

funny enough in its original context. Nevertheless, as a test on the part of the young boy, things do not go well. The urgency and neediness driving what is perceived by the father as interruptions are not funny. One hypothesizes that as a busy, “on the go” child with a lot of energy, making many inquiries, often interrupting his parents, Mr. D frequently hears “Not now, I’m busy!” “Not now, D, later!” and maybe even “Give it a break, boy— go away!” D experiences himself as not appreciated. D experiences himself as not acknowledged. D is dismissed, devalued, rejected, not okay the way he is. D feels uncertain of himself, harboring an unsatisfied longing for recognition, affirmation, and response. Even today, Mr. D feels like he is a bother; yet he is unrepentant about it, in effect saying, “Love me the way I am.” Then Mr. D is surprised and reactively outraged when people reject him for behaving like a 23-year-old going on 7, testing boundaries by being provocative, sarcastic, cynical and assertive. Thus, with the anecdote of the “horrid pest,” I obtained a fore-taste of what to expect in the relationship. Missed sessions. Phone calls. Lastminute cancellations. Seemingly constant requests for scheduling variations. Billing disputes. Angry denunciations about unfairness. Was I pestered? Yes indeed. Was my empathy inhibited? No doubt. Throughout this testing period, two things sustained me. First, he was actually providing me on a silver platter what it felt like to be in relationship as the offspring of this successful, unavailable entrepreneur. I was inside his experience, inside his movie, one of his pet projects, “the Education of Mr. D.” Second, he had many engaging qualities and a background similar to my own in additional to challenges with the father. When the relationship got “too hot” and he seemed really spoiling for a fight to justify flight—which flight, in its own way, would have been gratifying to him, I avoided confrontation. Instead, I restricted myself to expressing necessary truths: “Given your experiences, it is perfectly understandable that you would act and feel this way—the way you feel and act. What do you think it means?” Within the constraints of our agreement and what was fair to me, I decided to err on the side of generosity and flexibility. I often wondered, especially when pestered, which was often, if I should expand my repertoire of confrontational methods. I stuck to my empathic approach and was eventually rewarded as the enactments around schedule and fee diminished, and we were able to engage the deep issues in the area of disappointments of idealized but elusive father, and the recognition that was so hard to obtain. As soon as Mr. D sat down to do his written work, he was stopped by anxiety that erupted from the inner conflicts with authority and his requirement to excel in such a way that others—especially his father—realize he really is an original, disruptive, and innovative thinker. The goal of treatment was to transform the split off grandiosity and the “energy sink” it represented into productive results through the formation of psychic structure that regulates affect and creativity. The goal was to release the emotional

Empathy and its resistances

49

resources tied up fighting battles in the present over grandiosity and idealization with the relational introjects from the past. This father complex occasioned conflict, distraction, and the eruption of unbound “angst” that (in turn) was bound to physical restlessness (to which there was an already existing physiological disposition), aggravating a delicate tangle of inhibitions in “decathecting the ego” in order to let the creative energies flow into his writing. Thus, Mr. D struggled with chronic lateness, distraction, and selfinterruption. His inner experience is rushing to get where he should have been a while ago. His inner experience is of a “wirbel,” interrupting himself with multiprocessing, incomplete tasks, going in a circle, repetition, and a series of minor slights and narcissistic injuries that epitomize his own experience at the hands of his father. As a boy, he was constantly experiencing that his father was late for their outings or had to cancel at the last minute due to the business emergency of a major customer. I was “honored” to get a taste of this unreliable selfobject environment in our on-going meetings. This points to the early selfobject milieu, and shows up in the therapist’s countertransference. Being Mr. D on the inside feels like being driven from one urgent project to another. He is driven in a cognitive-emotional wirbel to interrupt himself with multitasking. In the long run, Mr. D may prove to be merely an aboveaverage individual or a truly gifted person. But meanwhile, Mr. D reminds one of the comment in Kohut (1971: 108–109): “A gifted person’s ego . . . may well be pushed to the use of its utmost capacities, and thus to a realistically outstanding performance, by the demands of the grandiose fantasies of a persistent, poorly modified grandiose self.” Mr. D was not recognized as a whole person but only fragmentarily by his father as an “A+ grade producing machine” bound for software glory at MIT. This leaves Mr. D feeling alternatively depressed and empty as well as reactively enraged. Mr. D has also lacked accessible role models that he might both idealize and interact with meaningfully. The absence of suitable role models extends from his father all the way to the celebrity academics at the university as he (Mr. D) tries to firm up his identity as a graduate student and manage fragmentation in the face of loneliness. In relational terms, Mr. D has a hyper-critical (“hostile”) introject. Mr. D has internalized his father’s requirements to produce A results (and go to MIT). Mr. D is struggling to understand how he can have turned out to be both sloppy and a perfectionist, a perfect epitome of his dilemma. Initially, I provided the kind of recognition and acknowledgment that was missing from Mr. D’s experiences as a young child. I saw value in his scholarly work and authentically validated the work by commenting with understanding of the subject and with responsive feedback. Mr. D felt good. I spoke in an accepting way about the opportunity offered by his relationship with a new, would be girlfriend, Ms. S. Mr. D’s good feeling expanded.

50

Empathy and its resistances

Mr. D experienced an all-too-brief calming effect and equilibrium of affect. He got a date. They hit it off. Mr. D was happy about this. Indeed, he was over-stimulated, but in a generally positive way. All of this, especially the momentary equilibrium, enabled him to stop acting out by testing boundaries and getting into conflicts with the school administration and other authority figures. Alas, it was not to last. The new relationship with the girlfriend, Ms. S, was rocky from the start. Mr. D experienced frustration and suffering due to the interaction of his own issues with Ms. S’s. He was used by Ms. S to reenact her own conflicts, which largely seem to consist in “I love you—go away—I can never see you again.” Ms. S’s psychotherapist told her that she “needs stability.” Mr. D was eager for the relative instability of a mutual romantic idealization. Then Ms. S sent back to Denver for her pet dog. A disaster loomed. Mr. D was beside himself. Mr. D has pet allergies. Physiologically, Mr. D’s experience is that these allergies make him itch and sneeze and experience watery eyes. He expressed himself in a fourpage letter to me. His righteous indignation had advanced from the fraud of psychiatric diagnosis to that of psychotherapy. The fraud of psychotherapy —telling someone they need stability! More angry denunciations. I am momentarily idealized as the one exception to this latest fraud (now of psychotherapy). I wonder: “Given the idealization, can deidealization be far behind?” I can only hope it is gradual. Initially, my own countertransference was to react with a devaluing labeling of Mr. D such as “spoiled brat.” Yet thinking back on my own experience and the experiences of those who succeed in doing something significant in the face of an indifferent, uninterested world, I pause for reflection. Another example of my resistance to empathy? Why should Mr. D not succeed? Mr. D has a project and a plan, the identifying particulars of which are thought out in considerable detail, not able to be discussed here. The matter sounds a tad grandiose and caused the mental health professionals at student services to apply devaluing labels such as “hypomanic.” His plan is perhaps a tad disorganized by the standards of advanced project management, but he has a plan. His energy is dispersed, distracted, and even occasionally selfhandicapping, but he has energy. His self-presentation is awkward and socially clumsy, yet there is charm and innocence that is attractive in its own way. Mr. D interviews a number of celebrity professors and graduate students, and publishes the results. In contrast to student services, one hears an aspect of Marian Tolpin’s (2002) tentative tendrils of healthy engagement at the “forward edge” of transference. I am diplomatically responsive: “Whatever happens, you are sure to learn a lot.” I decline to be interviewed or filmed. In any case, “be realistic” is not necessarily a good response, much less an optimal one (e.g. Kohut 1971: 176). Thus, the countertransference becomes a receptivity to the experience of the other individual. The receptivity becomes a possibility of understanding

Empathy and its resistances

51

the other as a human being struggling with the possibility of making a contribution worthy of recognition, which, in turn, becomes an opening for an empathic interpretation and response to the other. The resistance to empathy develops into what it must be like to experience the world from “inside” the other person’s experience. In this instance, the identification is concordant rather than complementary (to use Racker’s distinction (1957 [2007]: 734, 735)). Regardless of what Mr. D is doing, a background conversation is occurring in his consciousness that includes self-doubt combined with disruptive, compensatory grandiosity. “Can I do it?” “What if the educational video does not get an Academy Award?” “Is it innovative enough?” “What if it is a mere B+ paper?” Mr. D’s energies for productive work are engaged by the grandiose requirement of perfection taken over from identification with the perfectionist father. Psychodynamically, the activated grandiose self requires a level of accomplishment by Mr. D correlated to an unfulfilled need for recognition of him as a whole person. Absent such recognition, unsatisfied grandiosity and unfulfilled idealization dominate his emotions and behavior. My countertransference of devaluing labels (such as “spoiled brat”) gives way to a felt sense that Mr. D had not been well listened to. He had not been listened to as a whole person. Mr. D had not been well listened to by his basically loving parents who did not (do not) know what to do about this busy, bothersome, always-on-the-go child and (now) young man. Mr. D benefited from having his genuine strengths and accomplishments acknowledged. He calmed down significantly and has expressed interest in engaging his written work. He still struggled, but incremental progress was occurring.

The patient’s resistance to empathy Speaking of the patient’s resistance to empathy sounds strange. Everyone wants to be the recipient of empathy, don’t they? Empathy is the new love. Empathy is what everyone really wants. Well, not exactly. The patient’s ambivalence and vulnerability about being intimate with the other person may inhibit his empathic relatedness and create resistances. People want to be understood—gotten for who they authentically are–yet they do not want to be understood too well. People want others to know how they may have struggled and suffered and overcome adversity, yet they do not want to look at how they have regularly contributed in self-defeating ways to their own struggle and effort. The patient’s resistance to the therapist’s empathy is distinct from the patient’s resistance to empathy toward the therapist. Arguably, those patients with harsh super egos—suffering from moral masochism—are resistant to empathy with themselves (the latter a distinction to which we return below

52

Empathy and its resistances

in “Re-engage with the Development Process,” pp. 184–188). Strictly speaking, empathy towards the therapist is not part of the patient’s “job description.” Yet the patient’s empathy for the therapist is less rare and less distorted than one might think, though also rarely the topic of explicit consideration. The patient’s empathy for the therapist is wrappered in the thought, “Is the therapist okay? Is he okay so that he can take care of me and help me deal with my issues, etc.?” Patients are exquisitely sensitive to the therapist’s affects and attitude, no matter how guarded and anonymous the therapist tries to be. It is often true of both patients and therapists that “betrayal oozes at every pour” (Freud 1905), even if not in the same way. However, absent explicit self-disclosure on the part of the therapist (not recommended), patients lack verbal content and orientation to the therapist’s vulnerabilities, though, once again, they may be sensitive to unspoken nuances. If the patient comes into the session in distress, his perceptions may be inaccurate, and he may fill in the perceived affects on the part of the therapist with reasons or causes specific to the patient’s own issues. Any patient really needing help will be self-involved and engaged by his own issues, as is properly so. What was said about the therapist’s resistance to empathy can also be said, though at another level, about the patient. Empathic receptivity is openness towards the other and openness leaves one vulnerable. Resistance is resistance to vulnerability. Even if the therapist is delicate in his probing of issues of self-esteem and affect regulation around the patient’s fragile vulnerable self, therapy can still seem to the patient like an all-too-clumsy dentist taking sharp instruments to an exposed nerve in a tooth. If the psychotherapy is working as designed, it is precisely those deformations of the self that are most sensitive that will be activated in the relationship. Ouch. A risk exists, especially from the perspective of self psychology, of taking a reductionist approach to different types of individual psychopathology by tracing them unilaterally to empathic deprivations and vulnerabilities of the self laid down in childhood. Such failures then are activated and repeated in the transference, whether the misfirings of empathy are related to personality deformities, the therapist’s style, or a disruptive institutional framework. Patients do not arrive at psychotherapy with coherent, unified selves. It is precisely the fragmentation and lack of cohesion that give rise to the lack of satisfaction and disruptive upsets that characterize the struggles of the self. Here, self psychology may usefully be cross-referenced with Racker’s (1957 [2007]; 1968) observation that the therapist is confronted with diverse parts or aspects of the self that are unconsciously split off. This raises the issue as to which dimension of the patient’s self does the therapist relate to empathically. If the psychotherapist is empathically receptive to one dimension only, then the risk is that the other dimensions are neglected, though they are also in need of empathic understanding. The preverbal world of unformulated experience looms large here as a source of understandings and misunderstanding.

Empathy and its resistances

53

For example, August Aichhorn (1925) was famous for overcoming the resistance to empathy with so-called juvenile delinquents by an ability to identify with the “little bit of larceny” in us all. In classical terms, that means that he was able to identify with the aggressive and libidinous id impulses of the wayward youth, thereby, in turn, enabling the youth to accept and use him as an auxiliary object to control these impulses. Far from pushing back on the superego, progress occurred when the young person started experiencing a guilty conscience. From an object relational perspective, Aichhorn was able to normalize the paranoid position by working with the community to advance from the paranoid assertion “There must be something wrong here—and it is due to your behavior, young man” to a nuanced appreciation of the ambivalences of life’s disappointments, stresses, and upsets. In self psychological terms (it is no accident that Aichhorn was Kohut’s analyst prior to the latter’s having to flee Europe (Strozier 2001)), Aichhorn was able to redescribe the disruptive, symptomatic acting out of the youth as a reaction to real or imagined (narcissistic) injuries on the part of schools, institutions, parental roles, and employers, that diminished when recognized and repaired. Resistance to empathy goes deep. In the process of the development, a conflict can occur between the child’s need for empathy and the experience of non-empathy coming from the caretaking person. In this scenario, the patient uses hyper-cathected self-holding (Modell 1996), rationalization, sexualization of the drive fragments, and disavowal to distance himself from the missing empathy of the caretaker. The patient distorts the bad, unempathic, even sadistic, caretaker and, in conflict, looks to provoke and enactively call forth the antipathy (non-empathy) in the treatment as if it were the empathy for which he longs. Berliner (1958) calls this out as “pain wearing the mask of a smile.” As the superego develops, the suffering is incorporated into moral masochism. Here resistance to empathy shows up as an attitude that “cuts off one’s nose to spite one’s face,” “gets off the train and walks to spite the conductor.” Masochism mobilizes its own resistance to empathy. Masochism can be redescribed as a disturbance of intersubjectivity—a distorted and distorting way of resisting empathy. The patient identifies with a person— the caretaker of infancy—who delivers devaluing treatment and, in effect, the opposite of empathy—antipathy. The masochist protects himself against the suffering of unfulfilled empathy. But suffering is sticky. One keeps going back to, reliving, and reenacting what was developmentally an unempathic, or even traumatically antipathetic relatedness in childhood. In a classic study, Bernard Berliner (1958) asserts that masochism is a neurotic solution to an infantile conflict. Berliner is much taken with the central role of the search for love, and love indeed is on the critical path to a satisfying life. However, much of what Berliner says can be interpreted through the lens of empathy. According to this formulation, inspired by but

54

Empathy and its resistances

not limited to Berliner, the language of identification with childhood objects and with drive theory can readily be redescribed as an overlay resulting from fragmentation and breakdown of selfobjects and a narcissistic relatedness. The child and the child in the adult submit to and accept the suffering that the caretaker delivers as if it were empathy. This is the dis-order. The submitting was necessary for survival, but now is in effect a maladaptive, bad habit. Under the hypothesis that the neglected self craves empathy, and the search for empathy occasions the suffering, masochistic behavior is a failed attempt to arouse empathy while defending against it. The pain of masochism is continuous with the antipathic individual that once gave pain whereas the enactment represents the hope that, after all, empathy may yet be available. Berliner asserts: “Punishment out of guilt is not a valid explanation for moral masochism,” although identification with the aggressor lies ready to hand. But aggressiveness also expresses a demand for empathy from the object. Punishment of the unempathic object turns passive to active, providing protection against masochistic behavior by a reaction formation. An identification with the unempathic and punishing object is the motivation for the mechanism of turning of aggression against the self. However, what is turned is not the subject’s inherent aggression but rather the sadism of an unempathic selfobject which has been internalized. Masochistic suffering recruits the rage directed against the self at the loss of empathy. Masochistic defenses (denial and sexualization) are drive fragments that call out for empathy while being unable to accept it. However, if masochism is both the wish for and the fear of empathy and its unempathic fragments, that suggests that masochism itself is the manifestation of a deeper layer of resistance to empathy. In the context of a relational formulation, resistance to empathy is resistance to relatedness, since empathy is the foundation of relatedness. When faced with the prospect that life is empty of relatedness, lacking in responsiveness, and devoid of vitality, the search for sustaining relatedness leaves the fragile individual vulnerable to setbacks and breakdowns. Symptomatic behavior then escalates in an attempt to regain equilibrium, and the risk of retraumatization looms large. In the context of Winnicottian dynamics, this may usefully be translated: resistance to empathy is the need to protect the true self from injury of retraumatization in relatedness to others and the re-experiencing of the profound feelings of melancholia accompanying disappointments in the original relationships. In his Winnicottian phase, Modell calls out a group of patients who cannot utilize therapy because they cannot trust the therapist and are burdened by a requirement for self-sufficiency and a defense against relatedness in a kind of “cocoon” of “self-holding”(1996: 107). “Only grandiose omnipotence can make the young child self-sufficient” (1996: 107). The downward tuning of the communicability of affect allows for the emotional distance that keeps

Empathy and its resistances

55

such individuals in their comfort zone, albeit a zone of isolation and lack of vitality. Children who are emotionally or physically neglected or abused retreat for survival into Modell’s “precocious and fragile maturation.” The result is an exaggerated self-sufficiency and a distorted illusion of independence. Nor should we forget that unempathic or hostile caretakers can use their own empathy, even if distorted and mal-attuned, the “better” to dominate, manipulate, and impinge upon the child in line with the caretaker’s own need to control. The child may come to perceive accurately, though from a limited perspective, that more misattuned empathy means more suffering. Even given distortion, abuse, and neglect, the child’s perception can be more accurate, valid, and reliable than that of the parents’. However, by the time the person is an adult, that is no longer necessarily the case. For example, a survivor of abuse, who survived precisely by fighting back, finds that he is now no longer surrounded by abusers but that he is still fighting his way through life, hyper-vigilantly feeling as if surrounded by abusers. If no abusers are to be found in the environment, the survivor enacts provocations and perpetrations to call forth something she (or he) can redescribe as abuse. Think of the metaphor of the moth attracted to the flame. Given the existence of abusers of some sort in the environment, the survivor may uncannily hit the mark, dimly sensed and quasi-hypnotically attracted, and surface a latent abusive pattern in another. In the face of a hostile, threatening environment, whether real or imagined (and usually some of each), the creation of an alternative world, even an isolated one, can be life saving. Modell writes that “one’s caretaker self becomes hypertrophied” (1996: 107). Loneliness and a longing for relatedness are masked by exaggerated independence and self-holding. The psychotherapy navigates a delicate balance between an over-indulgent, corrective emotional experience and retraumatization, between “you were not treated well, but you still have to honor the therapeutic agreement” and “what might your contribution be to the struggle, granted that life has its share of difficult, unkind people.” Empathy is a welcome intervention in such scenarios, and empathy can indeed provide a shift in the direction of restoring emotional equilibrium, thus causing the acting out to remit. But sometimes that is not the case. Risking letting go of the suffering through the soothing balm of empathy shows up like an encounter with the unknown—and the unknown is and can be as anxiety inspiring as the suffering itself. Many people who fall short of a clinical label of “moral masochism” have an area in their lives where they are attached to their suffering. Once again, suffering is sticky. One keeps coming back to it in the hope that it might be magically shifted by the mere passage of time. Alas, it is not. Kohut’s work with hypochondriasis and conversion of shaky self-esteem (and shaky self-structure) into physical complaints provides rich examples. The specific symptom is preferred to the unspecific, widening expanse of undifferentiated loss of self-cohesion. The

56

Empathy and its resistances

specific symptom binds the anxiety. The unspecific one does not. One says, “I know my own dear little suffering up close and personal, and it is a comfort to me in its own way—it gives me all these secondary gains—even though the impact and cost is staggering in the long term—yet I cannot let it go.” This is where bottom-up empathic receptivity with the experience of the other’s suffering intersects with the top-down empathic understanding of the impact and cost of the suffering. How to be empathically responsive to the struggling individual and his “dear little suffering” requires an intervention of remarkable finesse and timeliness. No easy answer here. However, such an empathic interpretation can be use to move the therapeutic conversation out of its impasse. The examples provided by Freud (1893, 1909a), Waelder (Guttman 1987), Viderman (1979), and the author’s own practice further engage this below (see “Micro-Narratives and a Rumor of Empathy,” pp. 76–82). Unless handled with exceptional sensitivity—and, do I dare say it?— empathy—the patient’s resistance to empathy again risks devolving in a downward spiral into transference and countertransference enactments, reactions and counter-reactions, resistance and counter-resistance, resulting in retraumatization. Once such a reactive spiral of reaction and counterreaction is activated, there is little benefit in asking, who started it? Whether it is a subtle, barely perceived slight on the part of the analyst or vice versa, a series of small misunderstandings and narcissistic injuries add up to a large breakdown in empathy. Paradoxically, non-relatedness becomes a way of relating, albeit a non-optimal, frustrating one. Mark Gehrie (2000, 2011) usefully points to affect-laden, negative templates and early pathological identifications as well as minimally adaptive, kludgy structure (Gehrie’s “mal-structure”), derivative on the child’s struggle to survive. Engaging and working through such templates shifts the vulnerability that the resistance to empathy was protecting, enabling the empathic relatedness to be restored in an appropriately—and delicately—penetrating way to do its work. Clinical vignette: a bother instead of a belonging

Mr. D’s experience was that those in authority, the influential and powerful, were not in touch with D’s “greatness.” In reaction to this, Mr. D had a thing or two to tell them. He spoke truth to power, and power recommended that he get psychotherapy. In therapy, Mr. D’s experience is one of conflict between devotion and repudiation. He feels “jerked around” and at the effect of events. He masks his vulnerability at first with reactive rage but then with withdrawal and numbness. At the last minute, on the day of departure for a long planned trip to a university program in abroad, to register him (Mr. D) as a card-carrying member of an elite neo-Thomist group that he later describes as conservative “counter-revolutionaries,” Mr. D flatly refuses to go, returning from the airport like Napoleon from Moscow. Defeated.

Empathy and its resistances

57

Mr. D is emotionally spent. He retreats to his room at home and spends the summer there experiencing aphasia, unable to express himself. Literally unable to speak, he experiences a kind of world collapse of the everyday— there is nothing he believes in. He does not know what he values or who he is. He cannot articulate his values, lack of values, or how he got into such an impasse. He is numb. Looking for guidance from teachers, would-be mentors, and authority figures, Mr. D experiences being manipulated and not valued for who he is authentically as a possibility. Months later, Mr. D redescribes his experience. He asserts that he was unable to talk because he was trying to articulate the late medieval mysticism of Meister Eckhart. The reader may be pardoned for being skeptical, but he had actually read Meister Eckhart. Mr. D’s self-isolating behavior, the withdrawal into a kind of cocoon, the hyper-cathexis of self-holding, invites a narrative about “schizoaffective” everything (e.g. Summers 1994: 54–56). If ever an alternative redescription was required, this is one of those times. I think to myself, “if this is not a late adolescent identity crisis, I would not know one.” Mr. D is estranged from his father. He is estranged from his teachers. He is estranged from his peers. Mr. D is just plain estranged. Where empathy is missing, can narcissistic rage be far behind? The numbness gives way to rage. He is struggling with his reactive rage at the father’s actual or perceived narcissistic injuries. Mr. D alternatingly is enraged by and resents his father’s clumsy attempts in high school both to bribe and constrain Mr. D to conform by buying a Bronze Mustang and letting him (Mr. D) drive it only if he conformed (“behaved”). Mr. D rants about “The Bronze Mustang.” The relationship with the father has been “commoditized” by the Bronze Mustang. Mr. D’s inner experience is rage over which a layer of provocative humor is layered. Mr. D denounces a long list of people who claim to know what is best for him—the would-be rational emotive therapist, the priest, the dean, celebrity professors, father figures one-and-all— who allegedly have Mr. D’s best interest at heart, but who hypocritically really just want Mr. D to conform and “be less of a horrid pest.” He has a point. Mr. D wants to “belong”; he ends up being a “bother.” As a collegeage young adult from a privileged background, he left home and lived as a homeless person—ended up a bother with festering sores on his feet. From the narrative, it sounds like his father finally hired a couple of large, muscular men to strong arm him into a limo and then, by prior arrangement, deliver him to the inpatient psychiatric affective unit of a local facility—again forced into the passive, suffering role of a bother. Mr. D makes himself sound worthy of Amnesty International status as a prisoner-of-conscience during his three-day inpatient psychiatry stay (which had occurred prior to our sessions). Mr. D survives. Mr. D feels inhibited in his writing. Mr. D describes himself as being constipated and needing a “mental laxative” to express himself in writing. I think to myself: “Therapist as enema?” The writer has to let down his

58

Empathy and its resistances

defenses in order to let the creative flow of words and ideas bubble up without inhibition. The would-be grandiosity of the process of writing—that what the writer has to communicate is great enough to be welcomed by the reader—is overwhelmed by the anticipation of the unresponsive, unempathic selfobject. It is also overwhelmed by shame at the prospective of being a bother to the reader. Mr. D was reportedly never good enough for his perfectionist, entrepreneur father. That still, quiet voice in the background of his listening kept time to the steady drum beat, “It’s not good enough!” The therapist is responsive enough on a good day, yet the relationship is not the unconditionally positive empathy that Mr. D craves. Mr. D reflects on his father hunger and his search for role models who respond to him and his aspirations, not what someone else requires him to be. Empathy is available, but maybe not the unconditional kind imagined and rarely ever experienced even in childhood. A turning point is in the offing. Mr. D is looking for powerful individuals (mentors) from whom he can draw strength through idealization. He does not see value in studying science and he is not good at it (probably because it does not interest him). Absent such a strong figure to idealize, Mr. D interrupts himself, flitting from one project to another. Hypothetically, Mr. D feels like a fake in comparison to the conventional success of his father, the Entrepreneur of the Year. Hypothetically, Mr. D feels empty in comparing his modest accomplishments with the conventional trappings of success of his father, who owns intellectual property and has a 101-page résumé. Mr. D feels “not good enough”, shaky, and has low selfesteem. He shares that he feels he has to drop everything and study five languages. Mr. D has mastered Arabic, but it is not good enough. In order to compensate for feelings of inadequacy, Mr. D distracts himself by trying to learn three more languages simultaneously and auditing three classes and several academic workshops in addition to a full course load. It doesn’t work. The feeling is of being overwhelmed. Notwithstanding my ability to comment sensibly on his work, the overwhelm keeps getting reenacted as the return of Mr. D’s experience of having a lot of energy, yet struggling to be productive in the face of an unresponsive and hypercritical selfobject environment. Meanwhile, Mr. D is living in angst and uncertainty. He is “bound for glory,” destined to do great things. Yet his father—and the authority figures around him—are not in touch with Mr. D’s greatness. They are not in touch with his authentic contribution. Mr. D expresses anxiety that, given his leadership skills (this is accurate) and aspirations to run for public office, his medical records may disclose an issue around his having had a short course of attention-deficit medication at one point (similar to about one-third of the students in the average high school class). Of course, this is not about the medicine—it is about the underlying dynamics of hope and fear. Thus, Mr. D recalls that in later grammar school grade he had memorized the entire

Empathy and its resistances

59

list of presidents and vice-presidents of the United States. His friend Michael told him, “You are going to be the youngest president of the USA!” The confession of grandiosity here is palpable, mixed with shame at its inappropriateness. Fast forward ten years, and Mr. D is a disappointment and now deeply ashamed of himself that he has not accomplished more. In his own heart, Mr. D is a disappointment to his father. He did not get into MIT—he had to settle for a degree from a prestigious but less well-known liberal arts college. The bar keeps going up—Mr. D feels like a hamster in a wheel, running faster and faster, as life passes him by. Mr. D’s eventual success with his voluminous bachelor’s thesis fits the description of what Henri Ellenberger calls a “creative illness” (1970: 447–448): It is a polymorphous condition that can take the shape of depression, neurosis, psychosomatic ailments, or even psychosis . . . He suffers from feelings of utter isolation, even when he has a mentor who guides him through the ordeal (like the Shaman apprentice with his master). The termination is often rapid and marked by a phase of exhilaration. The subject emerges from his ordeal with a permanent transformation in his personality and the conviction that he has discovered a great truth or a new spiritual world. While I am occasionally over-stimulated by Mr. D’s rapid ideation and innovative ideas, I find Erikson a useful guide to getting inside Mr. D’s experiences: Erikson (1958: 42): In their late teens and early twenties . . . young people offer devotion to individual leaders and to teams, to strenuous activities, and to difficult techniques; at the same time they show a sharp and intolerant readiness to discard and disavow people (including, at times, themselves). This repudiation is often snobbish, fitful, perverted, or simply thoughtless. Thus, Mr. D speaks about one of his celebrity professors as “totally amazing and inspiring”; expressing admiration, on another occasion, expressing definite devaluation, the same individual is “useless.” The deidealization is as sudden and dramatic as the initial idealization. I wonder when I will become the target. Attesting to the resilience of youth, a summer-long, psychosocial moratorium and Mr. D’s working through provide a much needed success, at least in the short term. Mr. D reflects on how my refusal to be provoked by his disagreements, combined with my steadfast acceptance of his aspirations has enabled him to recover a measure of equilibrium. He has never experienced such generosity. He breaks down and cries. Mr. D reports that he rallies emotionally and overcomes his intellectual “constipation.” He writes a 150-plus page honors thesis.

60

Empathy and its resistances

Empathy and its discontents One of the sources of resistance to empathy is the fear of being perfectly understood and interpreted. Kohut (1977: 146) provides the example of the children of psychoanalysts, whose participation in their children’s lives was such that “they knew more about what their children were thinking, wishing, feeling, than the children themselves.” Parenting is not easy, requiring much trial and error, and if it were a profession, it might make the short-list of impossible ones. Nevertheless, the approach of informing the child authoritatively what he was experiencing was perhaps not the analytic parent’s most empathic moment. The response was experienced as not optimal. When badly timed, too intrusive, “too smart,” such interpretations are experienced by the child as penetrating, violating, a source of shame that someone should know one’s private thoughts so well. Kohut goes on to make the point about the consolidation of the child’s self. The lesson is that this breakdown in empathy on the part of the parent and resistance to would-be empathy on the part of the child happens when empathic understanding occurs without sufficient empathic receptivity to the other’s emotional life. Another of the discontents of empathy is the idea of empathy as a corrective emotional experience (Alexander 1950 [2007]). A corrective emotional experience is controversial—a method of compensating for deprivations or developmental experiences of the patient that are hypothetically identified as pathogenic. A corrective emotional experience is regarded as an enactment that departs from classic neutrality. It may also be a form of gratification, though not narrowly libidinal or aggressive. (Anna Freud’s short definition of neutrality is that the analyst is equidistant from ego, id, and superego.) Alternatively, it is regarded as an innovation able to accelerate the process of recovery. Kohut explicitly rejects such an approach and argues against critics who accused him of engaging in a process of corrective emotional experience (e.g. 1984: 153). The implication is that a “corrective emotional experience” would be a kind of “enactment,” presumably based on a narrow countertransference issue. The short definition of “enactment” is that the patient attempts to realize the transference and the psychotherapist responds in such a way as to validate the patient’s perception or fantasy. Thus, the debate is joined. Owen Renik (e.g. 1996: 506) proudly states that his (Renik’s) commitment is indeed precisely to a corrective emotional experience, and cautions against “the perils of neutrality” in an article of the same name. Judith Chused (1996: 1051) counters Renik, arguing that if everything is enactment, then both enactment and neutrality are illusions. Once corrective emotional experiences are privileged over and above the transformational power of the “emotional dissonance of informative experiences” (the latter being Chused’s alternative), then all is flux. Chused acknowledges that enactments—and corrective emotional experiences—do occur. But a neutral

Empathy and its resistances

61

position is needed as a kind of baseline to which to return occasionally or the risks of neutrality vanish along with engagement of therapy itself. Corrective emotional experiences are generated by life itself. Therapy creates an opening for development to resume by removing resistances, etc., and development brings both breakdowns and breakthroughs in its wake. Therapy removes resistance to empathy, and empathy develops. Corrective emotional experiences occur as a by-product of standard therapeutic action. The attempt on the part of the therapist to “role play” a corrective experience is a set-up for a clumsy escapade that will leave the parties wondering what they could possibly have been thinking. The result is a caricature of therapy, not therapy itself. In the context of corrective emotional experience, deidealization is problematic and the therapy is at risk of being “interminable.” Another way of attempting to finesse the corrective emotional experience—and preserve the distinction without the negative connotation of a gratifying violation of abstinence it has acquired—is to distinguish between needs and wishes. Arguably, it is not okay to gratify infantile wishes through a corrective emotional experience. But the satisfaction of authentic needs for human recognition, warmth, and decency via spontaneously emerging corrective emotional experiences are arguably proper. However, such an approach confronts the objection that in the heat of the therapeutic moment wishes show up as needs and vice versa. An example is helpful. Franz Alexander (1950 [2007]) provides a paradigmatic example of a corrective emotional experience. Alexander reports that his college-aged patient was stuck in a depressionlike funk and had a story that his father had never done anything for him. The patient devoted himself assiduously to behaving unpleasantly in terms of attitude, speech, and even neglecting personal hygiene to enact the same rejection that he supposedly experienced from the father. After impatience experienced by Alexander, the patient jumped up and challenged him to admit that he disliked the patient. Alexander properly judged that even for the psychoanalyst, betrayal oozes at every pore, and to deny his negative feelings would be an obvious deception that the patient would discern. So Alexander acknowledged the dislike, however, with the proviso that the patient was behaving in this way to allow him to continue to wage the old battle with his father. The reader’s sense is that Alexander was as spontaneous and confrontational in the moment as the patient. This was confronting and perturbing to the patient. Yet it was the beginning of an authentic therapeutic shift in the patient’s experience. In this example, at no time was Alexander doing anything like role playing or trying to be the “good father” that the patient allegedly had never had. Indeed, if Alexander had tried to play the role of the “good father,” he would have missed the point, since the father was a mixture of positive and negative with the patient focusing only on the negative. Rather, Alexander was

62

Empathy and its resistances

spontaneously reacting in a way that Kohut might describe as falling within the range of standard human responsiveness: being kind when kindness was called for; being confrontational when it seemed to be unavoidable, and being outspoken when it furthered the treatment. Some of Alexander’s followers and critics then proposed to script such spontaneity and make it the basis of an entire program of role playing. Whether anyone has ever truly advocated such a program is debatable, but if they did, then it loses the value and impact of the authentic, spontaneous response. Still, there are other passages where a kind of intersubjective role-playing seems to be invited by Alexander, and that goes too far. Later in the treatment, Alexander learns (1950 [2007]) that the father was over-indulgent and had done positive things for the patient. The idea that the patient had a father who was consistently harsh and domineering was the patient’s narrative, not Alexander’s. Alexander had to lean into the wind, so to speak, to provide an example of emotional equilibrium in the face of the patient’s jumping up in disequilibrium. In this case, the narrative was one-sided and masked the nuances of the relationship with the father, which nuances came out in the transference to Alexander. This is a nice instance of where the narrative was rewritten in interpreting the transference, and the father’s behavior redescribed. The father had never done anything for his son? Methinks thou dost protest too much! In defending himself against the assertion that he is violating rules of neutrality and abstinence with his empathic listening, Kohut argues back directly (1984:153). For someone who has been chronically misunderstood, being in treatment with someone who finally listens and tries to understand has immediate benefits. The reactive rage on the part of the patient at being misunderstood is eliminated or reduced. Still, since the therapist is human, she or he will eventually fail to live up to an ideal of perfect understanding. Such misunderstanding then becomes the target for therapeutic clarification and interpretation. The therapist’s response in repairing the breakdown in the transference relatedness through empathic interpretation is restorative of emotional integrity and wholeness. It is not a corrective emotional experience in the narrow sense of role-playing the loving, supportive, ideal parent that the patient believes she or he never had. It is an experience of being listened to with understanding and empathy. That such a “good listening” is obviously a relatively rare experience in everyday life is a contingent fact that varies from one context to another. The therapist maintains a therapeutic stance and the patient has a different emotional experience that markedly contrasts with the experience of the past in spite of the automatic efforts of the patient’s unconscious to repeat the past in the transference. However, the positive emotional experience is the by-product of the empathy, not the goal of the therapeutic interaction, the latter remaining working through and the building of enhanced psychic structure.

Empathy and its resistances

63

In an ironic statement that should not be taken out of context, Kohut asserts that if a good interpretation is like a corrective emotion experience, then make the most of it: “[T]he only way by which we could avoid gratifying the patient’s need to be understood would be by consistently confronting him with erroneous, inaccurate, or untimely interpretations” (Kohut 1984: 153). This is reduction to absurdity of the position that what self psychology (Kohut) is doing is providing a corrective emotional experience. More positively expressed, the key distinction is: therapy is not a form of gratification that induces interminable dependency but rather an application of empathy that leads in the direction of building self-structure and autonomy. In the end, we return to where we began. In an ideal world, empathy is the natural condition of human beings in relationship. We are naturally disposed to be empathic unless something gets in the way. Empathy emerges spontaneously unless something interrupts the process, incites reaction, and generates resistance. Empathy happens of its own accord—unfolding naturally sui generis—unless one or both of the individuals inhibit it by abstracting, treating others in a devaluing way, or otherwise invoking alienating tactics. Such emergent empathy is usually in the background and remains undeveloped. The inhibition of empathy for the purpose of survival is born in the face of anxiety. Often it deteriorates into emotional contagion or a reactive form of pity, compassion, sympathy, or superficial “niceness.” Once again, there is nothing wrong with compassion, and the world needs more of it. Anecdotal evidence suggests that the average person on the street regards “empathy” as synonymous with “compassion,” but “compassion” is not “empathy” (Agosta 2013, 2014a). Other times, the bare communicability of affect becomes the basis of altruistic intervention, which, in a therapeutic context, becomes an enactment—too active intervention—on the part of the therapist. However difficult, anomalous, or even traumatic the therapy may be, empathy is a source of integrity, cohesion, and wholeness in the face of suffering. This is the filtering function of empathy as a stimulus barrier—to tune up or tune down one’s receptivity to the other’s experience —without being a defense or resistance in the narrow sense of the words. Once again, the genius of Kohut’s 1959 paper was to introduce a certain distanced-relatedness into empathy as data gathering as the core of empathic receptivity. This innovation created a distinction between empathy and merger-like phenomena that are a source of compassion fatigue, emotional burnout, or mystical merger based in over-identification with suffering. In other words, empathy is a protection—one might say “defense”—against burnout and compassion fatigue because empathy takes a sample of the suffering of the other without merging or over-identifying with the suffering. Empathy uses an introspective vicarious experience of the other’s experience akin to the vicarious experience that one gets in the theater or movies or reading a novel. Echoing Kohut’s use of “vicarious introspection”

64

Empathy and its resistances

(1959: 459), there is a significant difference between a vicarious experience, which is a representation, and the experience itself in life. That is not to underestimate the capacity of empathy, vicarious experience, to seize one emotionally in the depths of one’s being. Rather it is to estimate properly the capacity of empathy to put us in touch with and restore our humanity.

Chapter 2

A rumor of empathy . . .

Language and speech acts A rumor of empathy advances from resistance to empathy to testing the presence of empathy. Empathy defines being human, and without empathy a person is missing a significant aspect of her or his humanity. Paradoxically, empathy comes into language as listening. Listening is a form of empathic receptivity to the other person. One must be quiet—be silent—in order to activate one’s empathic listening. Even then one has to be fully present, reducing the filters with which one selects and organizes the information data coming at one. That means distinguishing what the other person has said from one’s opinion of what the other person has said. In the multidimensional definition of empathy language as listening knits together empathic receptivity with empathic responsiveness, in which language is used to articulate an explicit empathic understanding and interpretation of the other’s experience in a form of words (see Figure 1.1 on p. 23). In that sense, language knits together the entire hermeneutic circle of empathy in each of its phases. Language gives people the ability to talk about what is not the case. Language gives people the ability to talk about the future and the past, to talk about “as if” and “what might have happened,” to tell stories, both factual and fictional, and even to tell lies. Language gives one the ability to say, “It is raining cats and dogs outside”, while the sun is shining. It also enables one to tell a “tall tale” to oneself, forming the basis of self-deception. The speech act that corresponds to empathy is narrative. Narrative empathy is the speech act in which relatedness is instituted, founded, and established. Another word for “relatedness” that appears in the literature is “intersubjectivity”—a relationship between two or more persons that relate to themselves as first person subjects who say “I am . . .,” “I have . . .,” and who relate to the second person as a “thou,” a “you,” with whom one gets personal, even intimate (see also Agosta 1984). A “speech act” is defined as a form of language that accomplishes something through the words as such: the words perform an action, establish

66

A rumor of empathy

a commitment, or create a present or future expectation. Arguably the most famous speech act is: “I now pronounce you husband and wife,” said by a preacher in front of a couple who are not already married and want to be married. More mundane instances of speech acts abound. For example, I say that I promise to meet you for coffee tomorrow at 2 pm, then my statement has created a commitment. You have the right to expect me to perform on my statement, or at least to honor my word by calling you if my auto has a flat tire and is stuck on the side of the road. If I do not show up and do not call, then you would be justified in accusing me of breaking my promise. You would challenge me as to why you should trust me in the future, given that I did not honor my word. A complex, special case is selfdeception, which is lying to oneself, being all the more persuasive because, at some level, one believes one’s own deception. The size of the fish in the “tall tale” seems to grow each time the fisherman retells the story. He is so persuasive precisely because he believes his own fiction. Promising is the most famous example of a speech act, and provides the basis for agreements of all kinds from marriage to therapeutic contracts to real estate and international agreements between nations. A speech act literally creates a new world in a non-trivial relatedness, adding a new agreement, possibility, or expectation to the community. Other examples of speech acts include descriptions: “The earth goes round the sun,” which is true or false; desires: “I wish I had a drink of water”; commands or orders: “Close the door!”; knowledge: “I know [that] the earth goes round the sun,” which includes a requirement to provide evidence and say how one knows; apologies: “I apologize for stepping on your foot,” which aims at restoring the integrity of the boundary of relatedness between individuals; beliefs: “I believe [that] the earth goes round the sun,” which does not require the truth of the statement but requires that the person’s conscious, psychic intention be in agreement with the assertion. A rumor is also a speech act, expressing information of questionable quality yet of interest in that it might be the first disclosure of an emerging trend or significant event. Thus, the Evangelist Matthew reports (24: 4–6), “There shall be wars and a rumor of wars . . . but the end of days are not yet nigh”. The report of “wars and a rumor of wars” is taken to portend the time of transition between a pagan and a Christian one civilization, but not the end of the world. In the same spirit, a “rumor of empathy” points to the possibility of empathy where we might not have expected to find it. Is the rumor validated or does it just remain a rumor? Stand by for update. Narrative empathy is its own speech act. Narrative empathy requires a separate set of conventions different from the “I promise . . .” or “I believe . . . or “Now hear this . . .” of ordinary language speech acts. The “Once upon a time . . .” with which a folktale or Märchen begins is such a speech act—also sometimes called a “performative.” It performs the suspension of belief in the distinction between factual and psychic reality—the bracketing,

A rumor of empathy

67

as it were—of the standard conventions of ordinary conversation, fact-based journalism, and positive science. Empathy comes into language as story telling—narrative empathy. Narrative empathy is a speech act at a level of relatedness that creates a community between the storyteller and the listener, humanizing them in an intersubjective community of two. The story does not pretend to create a community—it really does so. This occurs even if the story is fictional—as it definitely is in the case of a folk story. The empathy to which the story telling gives access is an artifact of language. It takes one to the empathic source of community as vicarious feeling, which is articulated, implemented and communicated in the story itself. This points to the creative dimension of language in generating an interpretation. The creative function of language operates narratively, capturing expressive experiences in words, articulating unformulated experiences. Although poems also are sometimes narratives, poetry is even more concise—a micro-narrative—containing a reflection on a theme, capturing unformulated experience into words, or playing with words for their own sake. Experiences are articulated and thereby made accessible in a form that was not previously available. Thus, Hans Loewald: Language, in its most specific function in analysis, as interpretation, is thus a creative act similar to that in poetry, where language is found for phenomena, contexts, connections, experiences not previously known and speakable. New phenomena and new experience are made available as a result of reorganization of material according to hitherto unknown principles, contexts, and connections. (1957: 242) When the therapist uses a form of words in which the patient recognizes his own experience, then that is empathic responsiveness. The patient is able to integrate the experience empathically. With Loewald’s comment in mind, one appreciates that empathy provides the matrix and source of the interpretation. We now turn to narrative as speech that delivers empathic interpretation and empathic responsiveness.

Narrative and interpretation The seductions of narrative are many. A narrative provides a context of meanings within which reference can occur to an engaged world of human desires, beliefs, emotions, intentions, actions, and results. The prospective patient comes in with a narrative that has dramatic features, but also gaps, inconsistencies, omissions, and deletions. The story is dramatic, or, alternatively, there is a noticeable absence of drama. Life is boring. Life is passing him by. The prudent and practical psychotherapist does not

68

A rumor of empathy

contradict the narrative or invalidate the client’s experience. The therapist appreciates that the would-be patient is struggling with something = x that is only partially and incompletely articulated. The patient comes in with one narrative, but may leave with another. The seductions of narrative are diverse, opening up interpretations and shutting them down. Thus, a word of caution is appropriate. Every psychotherapist is familiar with the narrative that seems to go on and on without end while calling forth a deadening affect in the listener. The comically neurotic humor of Philip Roth’s Portnoy’s Compliant is based on the protagonist’s life story—hundreds of pages of sexual adventures and misadventures—being a way of avoiding intimacy, a way of avoiding authentic relatedness. Therefore, the final line in the novel hits the reset button as the psychoanalyst who has been listening says, “Now we may begin.” Don’t get distracted by the content, fascinating though it may be. If the narrative provides access to the relatedness, whether in the transference or in life, then possibilities are opened and the treatment gets forward traction. What, then, is the criteria to differentiate the defensive, smoke screen, fog of transference narrative from the enlivening, clarifying, forward-edge narrative that opens up possibilities? The answer is direct, though, as usual, the devil is in the details. If the narrative goes from specific to vague anxieties, a series of pointless escapades (as in Portnoy’s repetitive misadventures), or is lacking in vitality, then it is protective of vulnerabilities (defensive) and may usefully be interpreted as such. However, one inevitably traverses the narrative to get at the relatedness. The narrative is of variable value, depending on the delivery, but it is reliably useful in providing the listener with access to the relatedness, reliably useful in providing access to the transference. There are psychotherapists (and related thought leaders) whose strength consists in the consummate telling of stories, and using them without dry analytic terminology to surface and demonstrate the relatedness in the transference—and in life. For example, the narratives of Stephen Grosz (2013), Arthur Kleinman (2006), Irv Yalom (1989), James Garbarino (1999), or Alfred Margulies (1989) pointedly make manifest and disclose the underlying humanity, using the story as a vehicle of consummate relatedness. Rumors of empathy live in institutions, too. One of the colorful characters from the history of the Chicago Institute for Psychoanalysis, Lou Shapiro, is supposed to have said to an analysand, who after much struggle and effort “confessed” to a faux pas from his life: “Is this supposed to relate to anyone in the room?” An appalling lack of empathy or a sublime interpretation of resistance? Dismissing the lack of relatedness at the end of a story, the faux pas felt was a devastating source of shame, and is perhaps useful as a didactic lesson. Explicitly calling out the relatedness at the end of a powerful story seems trite, though once again useful as a didactic lesson. The story itself

A rumor of empathy

69

makes manifest the relatedness, and, shows the qualities of the relatedness. The relatedness is what makes the story matter to us. That is what makes it a “page turner.” That is what rivets our attention. For example, the drama of Oedipus by Sophocles has moved and shaken audiences for centuries, though the abstract account of the relationships that unfold leaves most people puzzled and skeptical. A baby is orphaned, growing to be a young man who is unwittingly overly aggressive towards his real father and overly affectionate towards his birth mother. The results are disastrous. The narrative is required to make the relatedness come alive and matter to us, which is otherwise rather like an over-intellectualization without affective engagement when recounted on its own. In short, a story encapsulated in a micro-narrative such as “speak truth to power,” “the shoemaker’s children have no shoes,” “the truth hurts,” or “a skeleton in the closet,” describes a relationship in a concise and powerful way that enlivens any abstractions we might bring to it. Both are required: Narrative without relatedness is empty. Relatedness without narrative is blind. If relatedness is the father of interpretation, narrative is the mother. Narrative constitutes a matrix of formulations out of which multiple interpretations can be constituted and generated. A narrative is different than an interpretation, but sometimes not that different. In a clinical context and as used in this book, a narrative is synonymous with a high level formulation (e.g. McWilliams 1999), a personal myth (Kris 1956), a latent subtext or secondary narrative beneath a manifest one (Schafer 1981), or an extended psychobiography (Erikson 1975). Narratives are the matrix and source of potentially multiple interpretations. Freud (1937) gives the example of a construction in which he is telling the patient that up until a certain age he enjoyed the undivided attention of his mother, but then his sibling was born and he was cast out of paradise and sibling rivalry, envy, and negative emotions emerged, as he turned attention to your father, who in turn was responsive in certain ways, etc. Here “narrative” is synonymous with “formulation,” in effect a construction that is the source of multiple interrelated interpretations. The short definition of an interpretation is that it is a mapping from a domain of distinctions to a range of experience according to a model, pattern, or template. The domain functions as the input to the process—whether as a presenting symptom, manifest dream, the day residue, a hypothesized unconscious wish, or cultural artifact. The range functions as the output of the process of interpretation—which is the interpretation itself. The interpretation articulates the implicit distinctions and structures of experience that dwell there prior to being expressed in language. For example, see that cloud as a camel; regard the psychoanalyst as if he were a harsh (or kind) father. The “as” and “as if” of interpretation articulate the structure of experience. Powerful interpretations have an unmasking or disclosive aspect that show something that was not obvious prior to the interpretation, often

70

A rumor of empathy

resulting in seeing old things in new ways and appreciating what was all along “hidden in plain view.” By the time a dream is remembered, recorded, and told to oneself or another person, it too forms a narrative. In the case of dreams—and in an over-simplification—the dream work relates the manifest dream to the latent content such as day residues and unconscious wishes. Functions such as condensation, displacement, symbolization, and considerations of representability are the mapping(s) that generate(s) the meaning of the interpretation. The interpretation is the process of mapping the elements of the domain and range, and generating the meaning of that which was to be interpreted. The interpretive activity relates the manifest and latent content to the patient’s life, which, in turn, generates the meaning, expressed by the interpretation itself. The surface structure of the dream is redescribed as being about a latent conflict that provides the motivation to express a set of thoughts about an issue in a disguised manner. The interpretation in effect redescribes the manifest dream using the distinctions of the underlying latent content. This “redescription” is a key distinction, which we have been using already, and to which we now turn.

Description and redescription Human perceptions, memories, intentions, and actions fall under descriptions and are captured by descriptions. Action is action under a description. Intention is intention under a description. Memory is memory under a description. Descriptions give us access to all these phenomena. Descriptions in turn are iterated and reiterated as redescriptions. In a famous example, the philosopher G. Elizabeth M. Anscombe (1959) engages in an inquiry into “intentions under a description.” She describes a widening context of descriptions and redescriptions of the same event with a remarkable result. Thus: The man is moving a lever up and down. Redescribe the event. He is pumping water. Now redescribe the event. He is pumping water into a cistern that supplies the house on the hill. Redescribe the event again. He is pumping water with poison in it, poisoning the men in the house. Redescribe the event. The men in the house are plotting a genocide and the pumper is a partisan fighting them. Every redescription provides access to another aspect of the intention of the action. Another redescription seems to call forth another action (see also Hacking 1995: 234, 248–250). Redescribing the action seems to give us access to a different interpretation, which, in turn, expresses a different action. A different description—a redescription—yields a different intention. A different intention yields a different action. A different action is redescribed in its own diverse and different way. The relationship is circular and looping. Wherever there is description, redescription is also possible. We must understand the whole context to grasp the meaning of the particular

A rumor of empathy

71

element. We must grasp the part to understand the total context. The value consists in the going back and forth at richer and richer levels of detail, nuance, and significance. We are in the hermeneutic circle. The clinical application is stunning. Different descriptions yield different intentions. In turn, these yield different actions, calling forth different interpretations, which themselves loop back to different descriptions. “Dora defends her integrity against the advances of Herr K.” “Dora is a teenager preoccupied with learning about sex.” “Dora’s father offers Dora to Herr K as an exchange for ignoring his own adultery with Frau K.” These descriptions and redescriptions are not mutually exclusive—indeed, they complement one another. Each is the jumping-off point for a complex and nuanced interpretation that takes on a life of its own. The description and redescription of human actions and intentions contain the key to understanding one of the most obscure yet powerful ideas in Freud’s clinical contribution, that of Nachträglichkeit, usually translated as “deferred action,” “retrospective action,” or “retroactive consideration” (e.g. Freud 1918: 94). A better translation would be “redescription”—a redescription of what occurred based on what one knows now but did not know before. The challenge of Nachträglichkeit is that it involves “20–20 hindsight,” opening the way to a redescription and, hence, reinterpretation of what occurred. Many redescriptions are unproblematic. They describe things about the past or people’s intentions in the past that we knew at the time but did not think of because we had other priorities. “The glass was half empty.” “The glass was half full.” But other times redescriptions can create paradoxes with substantial psychodynamic and clinical relevance. An example: Back in the 1950s a father showers with his eight-year-old son. There is “horse play” with snapping a wet towel at the son’s backside. One can almost hear an echo of locker room patter. “Buck up, be a man!” Hopefully, if the son had felt uncomfortable, the father would have sensed this and stopped. If the father insists on showering with the son, knowing the son is uncomfortable, then he is arguably being abusive, whether sexual or emotional is a point debatable in a forensic process. Yet in the 1950s, the distinction “child abuse” had not yet emerged as the phenomenon that we now know about (e.g. Kempe et al. 1962). The son did not have this distinction (neither did the father) at the time the events occurred, nor did the distinction exist in the community as it does now when children of tender age are given explicit instruction about appropriate and inappropriate touching. The son is now a 50-year-old man in psychotherapy in the 2010s. He recalls this past event and now thinks, given the way he recalls feeling at the time (and let us assume the recollection is accurate), it falls under the description of child abuse. He angrily denounces the father and breaks off all contact with him. The dominoes start falling, and the entire family is devastated. The experiential “bedrock” is inextricably entangled in our description and “what

72

A rumor of empathy

happened” is inaccessible independently of the description and redescription. A happy ending is not in the offing. Consider another example rich in redescriptions—Oedipus. The ancient Greeks exposed infants to die—i.e. killed those who were too sick, deformed, or fragile to be viable based on the sole judgment of the parents, midwife, and community soothsayer. No such thing existed in ancient Athens as antibiotics or even a germ theory of disease. No such thing existed as a nursing home or an extended care facility where those damaged beyond repair might spend their years with a measure of dignity or at least reduced suffering. From our perspective today, exposing infants to die is unacceptable and awful. No attempt will be made to excuse such behavior. None. What I want to ask is can we now in our present era redescribe the behavior of such Greek parents—and Oedipus’s biological parents would arguably be examples of such—as having the implicit intention of child abuse and endangerment? They were definitely guilty of attempted infanticide, but can we ascribe to them the intention of child abuse? If we do so, then do we not only change our description of the past and, thereby, paradoxically alter the past itself? The lesson is not that everything is relative. No possibility existed of imagining “child abuse” in a society where small children of tender age were the property—the chattel—of their parents. In such a society, one can imagine objecting to inflicting unnecessary suffering or pain. One can imagine objecting to squandering resources, since many hands were needed to collect the harvest and stave off mass suffering due to mass starvation. One can imagine many things—but can one imagine child abuse? Once again, was what the parents did “child abuse,” a distinction, which we now know was not even proposed until 1962 (see Kempe et al. 1962)? Indeed the distinctions “child” and “childhood” themselves did not emerge until centuries later (Ariès 1962). Children were regarded as small grown-ups. Oedipus’ parents are definitely implicated in attempted infanticide or cruelty to a child, but what about child abuse? Can we attribute to someone an intention when the description of the intention was not available to the individual or to the community as a whole? Saying that intention is “an intention under a description” or action is “action under an interpretation” does not mean “everything is relative.” It does not mean “take a vote.” We are disturbed by this example precisely because it occurs against a background where both truth and facts stand fast and are unproblematic. It means that there is a certain indeterminacy to events that is disturbing precisely because for the most part actions, intentions, and truth stand fast and do not slip out of our grasp. The child of tender age who witnesses his parents having sexual intercourse has his own initial description of what happened. He imagines that it is an act of violence, not affection, in which the one individual forcefully overpowers the other. If it is a fantasy, then it is traumatic? Not

A rumor of empathy

73

at first, but years later it is when the individual is again aroused sexually in a traumatic context and the initial event is redescribed retrospectively with an abundant admixture of emotional charge and sexual stimulation. The boundary between recollection and fantasy is permeable, but not arbitrary. Yet Freud’s argument is noticeably lacking in curiosity about the distinction between trauma in fact and trauma in fantasy. As Freud redescribes seductions as being mere fantasies, something gets lost—the trauma. If the precipitating neurosogenic event is a fantasy, then is it as traumatic as if it occurred in reality? If the reader finds that his head is spinning, then he is not alone. This gives new meaning to the “hermeneutic circle.” An example is useful. Let us suppose that the Wolf Man really did see his parents having sexual intercourse—as Freud suggests—three times on that sunny afternoon as he lay in his crib, recovering from a fever. Under this description, that is the factual, “historic” truth. But the scene gets redescribed in the Wolf Man’s imagination years later—psychic reality uses the grain of factual truth to spin out narrative meaning—and becomes the source of a phobia as his sister scares him with the picture of a wolf standing on its hind legs in a picture in a story book of fairy tales. The primal scene is elaborated and then becomes the content of a further narrative—the nightmare with the wolves. Presumably, psychic reality is capable of shaking one to the core of one’s being too. This raises a deep and disturbing issue. Cruelty to children at the hands of parents and caretakers is not a fantasy. Children have been beaten, used as means, not ends in themselves, and many died of their inexcusable, horrendous injuries. However, it was not until the 1960s that the distinction “child abuse” was elaborated as we have come to know it today. A group of pediatricians in Denver led by C. H. Kempe started looking at the X-rays of children after they were brought to the emergency room, revealing disturbing evidence of repeated hair-line fractions that had healed. Evidence of prior trauma. This was the “smoking gun.” It was a defining moment— and a defining redescription. People were soon writing retrospectively about “child abuse before Kempe,” meaning that a new way of redescribing data that had not previously been accessible was now available (Kempe et al. 1962; also cited in Hacking 1999: 136–37). Once again, it must be emphasized that no one is saying that violent, boundary-violating behavior towards children did not exist before 1962. Sadly, children have been treated cruelly at least since Pharaoh ordered the slaughter of the first-born innocents and Moses was cast adrift in the basket made of reeds. However, the distinction “child abuse” as such did not exist. This distinction made it possible to identify the results of actions that had previously not been able to be described. A deep inquiry into how people’s intentions relate to the psychological and categorical distinctions operative in a community (and clinical) context reveals a measure of indeterminacy. This does not mean that everything is

74

A rumor of empathy

relative. It does not even mean most things are relative. It means that, against a background of facts and truths that stand fast, caution is required. An indeterminacy of the past gets exposed. The way the intentions of the participants are described results in a slippage of meaning. If we cannot accurately say that they had the distinction “child abuse,” then what sense does it make to attribute such behavior to them? The difficulties of indeterminate redescription only make sense against a background of truth and falsity, facts and fiction, objectivity and subjectivity, that stand fast and give us a world that is predicable and stable. I am a cautious clinician and am inclined to say that in some cases we are simply unable to say whether the retrospective redescription gives us access to a truth that had not previously been available or makes available retrospectively facts that were previously present at the time but overlooked. Absent an appreciation of the possibilities of the context and the conversation at the time of the events in question, much room exists for reasonable doubt. This does not mean responding skeptically to the patient or that the patient has to prove anything to anybody. The patient has to say what is present to his consciousness in the form of free association. This is completely consistent with the fact that people seeking psychodynamic therapy are suffering in the present and are seeking ways to express their suffering that can be heard and responded to empathically. Redescriptions have further practical psychodynamic and clinical uses. Many psychological mechanisms are redescriptions of behavior and intentions. An overly affectionate and solicitous behavior of a young child towards its newborn sister and rival for the affection of the parents is redescribed as masking an underlying hostility and sibling rivalry based on a reaction formation. “Reaction formation” redescribes “affectionate solicitude.” The delusion of persecution “He hates me” is redescribed using the mechanism of projection and reversal “I love him,” whereby an homoerotic relatedness that is at variance with the individual’s personal standards is able to be maintained through hostility rather than affection. Projection is a redescription: “You are angry at me” is redescribed as “No, I am angry at you.” Identification with the aggressor is a redescription of introjection and a reversal of passive to active (Anna Freud 1936: 115). Altruism as a psychological process is a redescription of experiencing life vicariously through the life of another (Anna Freud 1936: 122). Denial itself is a redescription of relatedness as negation of relatedness. Even if one disagrees with the particular details of the redescription, the overall method is compelling.

Interpretation and micro-narratives A micro-narrative is a concise “story in a statement” that creates a world of meaning in an instant. For example, “speaking truth to power,” “the emperor’s new clothes,” “the shoemaker’s children have no shoes,” “people

A rumor of empathy

75

in glass houses throwing stones.” Each invokes a world of meaning to be further specified in the complete narrative. In the folk story, the shoemaker is so busy making shoes for the village, his own children are neglected and go barefoot. In the “emperor’s new clothes,” only the five-year-old child speaks the truth to the emperor—that he is naked—the emperor who is otherwise surrounded by “yes men.” In speaking truth to power, we think of Malcolm-X’s celebrated commentary to his constituents: “You did not land on Plymouth Rock; Plymouth Rock landed on you!” Malcolm-X’s micro-narrative provocatively shifts centuries of suffering into a righteously indignant wake-up call to the community to stop being passive bystanders in the face of social injustice. Typically, a micro-narrative uses a slogan-like “story in a statement”— or even a single, resonant word—to highlight an aspect of the relationship not previously noted, taking the relatedness to another level of intimacy. A micro-narrative uses language to show what was previously hidden in plain view. A micro-narrative uses language to bring into focus an aspect of the situation between the speaker and listener that was implicit but neglected. A micro-narrative is a coded or reiterated utterance that implicitly invokes a context of associated meanings like a citation or abstract while nevertheless being concrete. The micro-narrative expresses the empathic receptivity that was present all along and points to empathic understanding of what is possible in interpreting the communicative context in which the individuals are relating. This promotes relatedness and builds community. In a psychodynamic context, a well-crafted micro-narrative aims at an optimal response and is an empathic interpretation in a form of words, succinctly surfacing and redescribing a relationship that was present yet not discussed. A micro-narrative is an interpretation in a single statement or even a single word. For example, the patient dreams that he hands a bouquet of six roses to his father. The father is dying of cirrhosis of the liver after a lifetime of alcohol abuse. The psychoanalyst, Viderman (1979), asks “six roses or cirrhosis?” In French “cirrhosis” is pronounced as “six roses.” This micronarrative acts as a concise, precise interpretation in the strict sense and discloses a world of psychic and material reality. If further validation is required, though the distinction micro-narrative did not exist explicitly 1979, Arlow might have added it to his genesis of an interpretation alongside thoughts and jokes: The thought that first appears in the analyst’s mind rarely comes in the form of a well-formulated, logically consistent, theoretically articulated interpretation. Often what the analyst experiences takes the shape of some random thought, the memory of a patient with a similar problem, a line of poetry, the words of a song, some joke he heard some witty comment of his own. . . . It is at that point that the analyst’s experience is transformed into an interpretation. (Arlow 1979: 200)

76

A rumor of empathy

Likewise, every psychodynamic symptom tells a story. Every psychodynamic symptom is a narrative—a micro-narrative, albeit a well-disguised one. The interpretation is the full narrative which the symptom expressed. For example, Freud’s (1893a) patient, Elisabeth von R, has pains in her legs that say in effect: “I can’t go on—I can’t move forward in the face of the disappointments in love that I have confronted.” Lucy R (Freud 1893a), the governess, hallucinates the smell of burnt pudding that expresses her ambivalence between the smoldering desire for the widower father of the young children for whom she is a nanny, and her longing to go home to England and be done with the troublesome family. Frau Emmy von N has a rich set of symptoms. One is a burning pain in her face, her cheek. The family of her rich, older, deceased husband is accusing her of having poisoned him, an insult landing literally like a slap to her (innocent) face (Appignanesi and Forrester 1992: 99–100).

Micro-narratives and a rumor of empathy There is nothing like a good story. A good story incorporates the benefits and features that result from positive developments of the self and the working through of its struggles. Developments include humor, wisdom, creativity, artistic finesse, and empathy. These features include the foundation and elaboration of community known as “intersubjectivity.” Thus, telling a good story requires that we distinguish entertainment from information. Some stories get “better” with each telling, even if not more accurate. Now what was the size of that fish you caught? The story can go either way, depending on the commitment is to entertainment, information, or both. The listener may well be entertained, stimulated, inspired, touched, moved, motivated—and misinformed. The challenge is in maintaining the balance between interest and accuracy. A fundamental lesson emerges. The fundamental feature of human story telling—and the language and speech of which story telling is a part—is that we humans may say what is not the case. We may say that “The sun is shining,” but outside it is pouring rain. The patient argues with his brother and offers the micro-narrative, “Mom liked you best.” Fact or fiction? Consider another micro-narrative: the story of the stork. The celebrated example of Freud’s famous four-year-old patient, Little Hans (1909b), was treated by Freud second-hand through the father, Max Graf, the latter one of Freud’s early protégés and a noted literary critic in his own day (e.g. Ross 2007; Halpert 2007). At least one moment exists when Freud engages Little Hans with incomparable empathy. Freud’s empathic receptivity and understanding are second to none in this instance. In effect speaking for Little Hans, Freud verbalizes Hans’s thoughts in so many words:

A rumor of empathy

77

Regarding where babies come from, in particular my little sister, I (Little Hans) know that I may not have all the facts. But I ain’t believing this story about the stork that my parents are telling me—that the stork delivers babies. No way. I have been down to the lake and I see stork babies but no human ones. My parents are not being straight with me. Liars! Children such as Little Hans frequently know when their parents are lying to them. The parents are fooling no one—with the possible exception of themselves. Tell the child the truth about human reproduction in language appropriate to his age. The micro-narrative has no intrinsic truth value, however clever, and must be assessed by following up the context, references, and network of associations as indeed Hans does as a “child scientist,” testing the matter against his experience down by the lake. The prudent clinician allows for the possibility of multiple agendas, conflicts of interest, and misunderstandings. Above all, self-deception. For example, in Robert Waelder’s “Five Lectures on Psychoanalytic Technique” (Guttman 1987: 34), Waelder tells of a patient who momentarily seems to vaguely recall a pregnancy by his mother, but the memory is immediately swallowed up by forgetting. The patient believes he is an only child. The patient knows that he grew up as an only child. The patient, wishing to be Waelder’s “only child,” experiences “sibling rivalry” with another of Waelder’s woman patients, causing the patient provocatively to ask: “So you have a daughter, too?” Waelder says only one word: “Stillborn?” This is a compelling one word “micro-narrative,” invoking all the background and details of the patient’s development, in an inchoate, emerging interpretation. Waelder comments: “All his unhappiness about his mother’s pregnancy came back to him, and with an enormous amount of emotion he could now recall all the details of this totally forgotten event” (Guttman 1987: 34). A single fact comes into existence for the patient where there had been a wall of unawareness. Yes, the baby had died. Yes, the mother had experienced depression and been emotionally unavailable to the boy. The single fact triggers a virtual tidal wave of emotional experiences, associations, relationships, etc., of the young boy’s emotions, desires, and fantasies regarding his mother’s pregnancy, which, in turn, would properly be described as “psychic reality.” We are not accustomed to describe the emotional experiences in question as having a historic reality, even though we could give them a specific date and timestamp. But we might redescribe the emotions in that way. Let us not forget the possibility expressed at the beginning of the movie, “The events depicted are based on a true story.” What happens between the true story and the case history is like the dream work creating a manifest dream from latent, underlying thoughts. The ability to say what is not the case—to deny, substitute, and transform—is the power of creativity, invention, and innovation, but also of deception and distortion. How does one distinguish a good story from an accurate one? A story that propagates a

78

A rumor of empathy

rumor from a story that confirms a rumor—a truth serving story? A selfserving story or—to coin a phrase—a self-dis-serving story from a truth serving one? Additional clinical vignettes of micro-narratives follow. The psychotherapist is sitting there listening to the patient, a 20-something female, tell how her Mom was working day and night taking care of the neighborhood children in preschool, and how her Dad was working day and night running an extended care facility for geriatric patients. The parents seemed to be taking care of everyone else in the community, but no one was taking care of their children. The patient was home alone, and, while not actually neglected, she was at loose ends, lacking guidance. She was lonely. The therapist realizes to himself, “The shoemaker’s children have no shoes.” What to do with the association? I suggest that this association, the emergent thought, lives like a rumor of empathy from the unconscious. It shows up like a communicability of affect, tentatively encapsulating unformulated experience (Stern 2003) into a form of language that includes the possibility of empathy with the patient. Rarely does a would-be empathic listener apply the multistep process of empathy explicitly—until now. As an exercise, explicitly stepping through the phases in sequence is useful—empathic receptivity, empathic understanding, empathic interpretation, and empathic speech. The beginner partitions what the advanced practitioner grasps as a single totality, in an instant: 1

2

Given the association “The shoemaker’s children have no shoes,” one’s empathic receptivity is open to a feeling of deprivation. The empathic receptivity invoked in the therapist opens toward scarcity. The shoemaker is busy making shoes for all the people in the village, but what about his own children? They go barefoot. Their feet are exposed to the cold. Shoes are a symbol of our contact with the earth beneath us, providing protection, traction, and enabling forward progress. The daughter literally did not get the shoes she longed to get. She wanted ballet slippers. She wanted dance lessons. She wanted gym shoes— gymnastics lessons. She wanted patent leather pumps to go to the party— the ball. She didn’t get them (and apparently not for financial reasons). The parents were neither rich nor poor; yet seemed to be poor in spirit. Amid the parents’ struggle for survival, their daughter’s emotional, spiritual development seemed not to be a priority. Empathic receptivity unfolds into the empathic understanding of possibility. A positive possibility is present amid the scarcity. The possibility of productivity is engaged. In the folktale the helping elves come. Magical thinking? When it works, therapy can seem like magic. The therapy makes a difference by clearing away the obstacles to accessing reserves of emotional energy available to the patient as a possibility, once she engages and works through her lethargy in relating to the past— and to the therapist. The elves cobble all the shoes in the night. The

A rumor of empathy

3

4

79

cobbler becomes prosperous and is able to provide shoes for all his children. The process of psychotherapy is able to release emotional energies that have been tied up in entanglements with parents, hostile introjects, or sticky suffering that gets unstuck through therapy. Based on his associations, the therapist offers a micro-narrative—an interpretation—“You were like the shoemaker’s daughter. The shoemaker was so busy making shoes for the village that he did not have time to make shoes for his own children.” Left open is whether there will be a miracle provided by the elves—or the unconscious fantasy of a miracle provided by the therapist—or whether step-by-step, like a shoemaker, the patient “cobbles together” and accesses her emotional resources for productive projects on her own behalf. Will help arrive in the form of magical elves that make all the shoes at night while the family dreams—that is, the daughter benefits from therapy, works hard, and earns a scholarship for crew rowing to a prestigious university? Or a combination of the above themes and variations. Unlike in the fairy tale, life does not guarantee a “happy ever after,” but one is open to the possibility. The empathic interpretation takes a perspective inside the experience of the patient, expressing what it is like to experience parents who are too preoccupied to provide the bare necessities of emotional responsiveness. More practically, the psychotherapy makes possible uncovering sources of emotional energy that were not otherwise available to the patient—like the imaginary helpers in the folktale. The therapist listens to the client’s struggles in her present romantic relationships with boyfriends and discretely inquires as to her relationship with her parents when she was growing up. While empathic speech is paradoxically a form of keeping silent and listening, thus linking it back to empathic receptivity, it is also a form in which empathic responsiveness is articulated. Empathic responsiveness makes explicit the possibility of productivity in overcoming stagnation through recognition of relatedness. The responsiveness gets articulated in empathic speech in the association “the shoemaker’s children have no shoes.” When put into context, the responsiveness about “the shoemaker’s daughter” had an irony that dissipated blame, and new possibilities opened up for the patient in an area where she had been struggling. The treatment is sufficient to allow self-discovery and exploration. The patient realized that she is committed to a possibility that has no future—as she concisely puts it—“the men I am dating are just not good boyfriend material.” Left to her own devices she filled the emptiness of teenage loneliness selfmedicating by smoking weed and having casual sex with available “slacker” boys. The shoemaker’s daughter indeed. After a series of superficial sexual encounters, on-going, that attempt to substitute sex for intimacy, and which seem to consume her life in a vicious cycle of dissatisfaction, the patient is able to use the therapy, even while

80

A rumor of empathy

fighting tooth and nail, to let go of old patterns. Unlike Shel Silverstein’s celebrated Cynthia Stout, there is still time to take the garbage out. The shoemaker’s daughter takes out the trash. She sends the slacker boyfriends packing, one after another. More emotional resources become available. She creates a clearing for a new possibility—and a new narrative, a new boy friend. One shows up. An authentically caring and considerate individual. A rare find. Long story short, the relationship flourishes. Emotional resources multiply, and an entry-level teaching job is in the offing. This one gets to a happy development, though the ending is always a work in progress. Consider another clinical vignette. The therapist is sitting there listening to the patient, a 20-something graduate student, tell how time after time she calls attention to the weak points, fallacies, and shortcomings of her teachers, bosses, and authority figures of every kind. She does so with accuracy and finesse. She continues to press her point, barely allowing the other to “save face,” recover a modicum of dignity, until the authority figure finds a pretext to exercise his authority in an authoritarian way. The therapist thinks, “This is like the emperor’s new clothes.” The thought continues and the therapist realizes to himself, “In the story of the emperor’s new clothes, the little child speaks truth to power and survives because he is a 5-year-old child. My patient is 20-something years old.” What to do with that realization? As an association, the thought “the emperor’s new clothes” shows up like a rumor of empathy. It emerges like a rumor from the unconscious—a countertransference (Racker 1968). It lives like a communicability of affect, delicately capturing barely formulated experience into a form of words that points towards the possibility of relating empathically to the patient: 1

2

The association shifts the focus from the emperor to the child, who is now the hero of the story, because he “speaks truth to power,” saying what was hidden in plain view. Given the next association to “speaking truth to power,” the communicability of affect that gets activated in the listener’s empathic receptivity is one of high spirits, a fearlessness bordering on being fool-hardy, or even an enthusiasm with a tinge of hypomania. The empathic understanding of possibility resonates between confrontation and a desire for recognition and leadership. When men such as Henry David Thoreau, Gandhi, or Martin Luther King marshaled the courage and leadership to call for social justice in the face of bad laws, legal segregation, prejudice, and bias, they appealed to our shared humanity and to the conscience of the oppressor by enduring the consequences of civil disobedience. In contrast, the patient’s adolescentlike rebellion has aspects of a classic identity crisis. This points to the empathic understanding of the possibility of the forward edge: expanded cohesion, integrity, and confidence, and diminished pressure to confront,

A rumor of empathy

3

4

81

contradict, and criticize. For this individual, the forward edge looks like the possibility of the development and exercise of her leadership abilities. The empathic interpretation unpacks the understanding of the developmental issue—that a five-year-old may be able to get away with things in relationships in which a 20-something year-old may require more diplomatic finesse. How to provide leadership in the face of a leader (e.g. the emperor in the story) who is surrounded by “yes” men? Conformity is not the answer. But ultimately a hypercritical non-conformity—which is what the young rebel is practicing—is just another form of conformity. When the responsiveness is expressed in empathic speech as a question “What about this recalls the emperor’s new clothes?” then the therapist works to get inside the patient’s experience and give that experience back to her in a way that allows the patient to see her own world in a new way. The patient is eager to make a contribution for which she can be acknowledged and recognized and she undertakes a political engagement in social justice that harnesses her energies in a productive way.

A third clinical vignette. The therapist is sitting there listening to the patient, now a medical student, telling how, in an authentically dark and difficult time, she was set upon at a tender age by sexual predators who were members of her own family and managed to escape by courageously fighting back, but not without significant emotional damage. This is not an isolated incident, and the therapist is saddened and inspired by the examples of such courage at such a young age. It occurs to him, “Every family has a skeleton in the closet. But with this family, it’s getting crowded in there.” What to make of this association? Again, the emergent thought lives like a rumor of empathy from the other person and from the other’s unconscious to the listener’s. The association presents tentative tendrils of an empathic receptivity, empathic understanding of possibility, empathic interpretation, and empathic responsiveness, including listening and story telling. In a multistep process, occurring in a flash, the association captures emergent experience into a form of language that includes the possibility of empathy with the situation of the patient: 1

2

Given the association “It’s getting crowded [with skeletons] in the closet,” what affect does our empathic receptivity activate? The skeleton in the closet is that of which one is ashamed and has to keep hidden away. The therapist’s empathic receptivity picks up on the shame against which the patient is well compensated by a reaction formation that she is special and destined to do great things (of an unspecified kind). The communicability of affect in turn points to the possibility of an empathic understanding of possibility. The possibility is to be known for who one is as a survivor—a survivor of molestation and child abuse.

82

A rumor of empathy

3

The empathic interpretation is that when one’s life is threatened, then extreme measures are necessary. If a person decides that she wants to live, then she does what she has to do to survive. She fights back. She fights back until she decides she cannot safely fight anymore and gives in—placates, conforms, cooperates under duress. The latter is, of course, another form of defense. The expression of this at the time may look like fighting back in words and deeds or going along with the perpetrations—placating and conforming temporarily—until she is able to escape. “When someone threatens one’s life—as credibly seems to have been the case here— most people decide they want to live and do what they have to do— however unpleasant—in order to survive.” This interrupts the survivor’s self-blame. The empathic responsiveness was powerfully instrumental in reducing the patient’s shame and guilt, though additional working through was needed. “Most families have a skeleton in the closet—but with this one, it is getting crowded in there.” In the moment it lent a much needed lightness to a difficult and dark subject.

4

Now what is the therapist to do with these micro-narratives? Strictly speaking, an emergent interpretation has the status of an association—a mere idea, a hypothesis. All the usual challenges to construction in analysis apply (Freud 1937; see also Arlow 1979). The therapist says to the patient, “Let me tell you what I get from what you have been telling me. It is just like the story of the emperor’s new clothes. . . .” Or “It is another example of the shoemaker’s children who get no. . . .” Or “No family is like the one in the TV show the Brady Bunch. Most families have a skeleton in the closet—but it is getting crowded in there.” The responsiveness may be more engaging, colorful, or rhetorically impactful, but it is no less exact (Glover 1931) for drawing on a micro-narrative that resonates in one’s listening and speaking. The micro-narrative captures the personal struggle confronting the individual in its emotional depth and drama. It captures a conflict not available to a list of diagnostic categories, history of the current illness, precipitating events, or medical history. Naturally, there is nothing wrong with the latter. But they do not touch the patient where she lives or start the process of opening, integrating, and transforming experience into a coherent whole. Perhaps the interpretation gets traction with the patient and releases a flood of additional associations or it falls flat or (most likely) something in between. That counts as verification. The treatment advances.

A rumor of empathy in Freud Freud was an accomplished story teller. The dramatic struggles of obsessional and hysterical patients call forth treatment in narrative form. The subject matter calls forth empathy. Freud’s empathy for his patients is front

A rumor of empathy

83

and center. Freud (1913) explicitly cautions physicians practicing psychoanalysis that they will fail if they use any other approach than an empathic one. However, Freud received no credit for this caution, or his empathy. A rumor of empathy becomes a scandal of empathy as James Strachey mistranslates “empathy” as “sympathetic understanding” (Freud 1913: 14). Close but no cigars. Freud’s application of empathy was pervasive. Yet in the 24 volumes of Freud’s Standard Edition, some 9 of the 22 mentions of “empathy” occur in an aesthetic context in Freud’s (1905a) Jokes and their Relation to the Unconscious. Freud endorses the clinical use of empathy in the other 13 instances, but once again none of them are translated as “empathy” (see Pigman 1995). None. Freud encountered an external obstacle to the widespread mention of the word itself. The word “empathy” was monopolized by the academic psychology of Theodor Lipps (1903, 1909) and his followers. Freud was his own man, and he did not want to risk being considered a follower of Lipps. However, even without calling out the word, Freud’s clinical methods were highly empathic. A comment is required on who is Theodor Lipps, who in his own day was a celebrated academic psychologist. Freud had some seven volumes of Lipps’s works in his library and read and marked many of them (Trosman and Simmons 1973). In one of his letters to Wilhelm Fliess, Freud says of Lipps: “I found the substance of my insights stated quite clearly in Lipps, perhaps rather more so than I would like” (Freud 1898). One of the accidents of historical contingency is that Lipps’s popularity arguably reached beyond the originality of his analyses, although he is enjoying something of an ex post facto revival thanks to his anticipation of mirror neurons. Lipps well may have been the Antonio Salieri to a would-be Mozart (such as Freud), who, in any case, is well remembered today while Lipps is nearly forgotten and unread (Agosta 2010: 6; 2014b: 53–64). This means that thinkers such as Freud, Husserl, Scheler, or (Edith) Stein, could not use the word “empathy” [Einfühlung] without invoking and critiquing Lipps’s approach, which was highly idiosyncratic with its use of projection as the main mechanism of empathy. Today, “projection” pure and simple is regarded as a distortion in the standard account of the operation of empathy. If my recurring reference to the fact of Lipps’s domination of the mention of “empathy” sometimes sounds repetitious, I must nevertheless insist on repeating the refrain since it is a variable to which we, as clinicians in the year 2014, no longer have visibility. The reader overlooks and forgets it at the risk of fragmenting the phenomenon of empathy even more so than usual by ignoring that against which everyone was arguing in the years prior to the Second World War. After Lipps, the thinker most responsible for giving “empathy” currency in English is Edward Bradford Titchener, who founded the psychology laboratory at Cornell University after studying with Wilhelm Wundt in Leipzig. Titchener’s suggestion of translating Einfühlung as “empathy” can be found in his Lectures on the Experimental Psychology of the Thought-Processes

84

A rumor of empathy

(1909: 21). Titchener was engaged by the controversy whether thinking was possible without images, and passionately espoused the position that all thought was accompanied by kinesthetic images. In an account that ultimately gives introspection a bad name and makes it vulnerable to refutation by the behaviorists of his time, Titchener writes some remarkably silly things about introspection, based on his own idiosyncratic introspective images. For instance, in defining the meaning of meaning, Titchener gives the example that “meaning” is accompanied by: “[T]he blue-grey top of a kind of scoop, which has a bit of yellow above it . . . and which is just digging into a dark mass of what appears to be plastic material (1909: 19; cited in Lanzoni 2012: 311). Even if Titchener’s experience of meaning was so accompanied, it is hard to believe that such an experience had anything other than personal idiosyncratic significance. Those wishing to discredit introspection regularly quote Titchener and his followers. While images may indeed accompany our thinking, their semantic function remains debatable and such statements became an easy target for behaviorists who reduced such motor mimicry to the status of an epiphenomena, an idle wheel that does not move any part of the psychic mechanism. For our purpose here, the point is about a rumor of empathy—and resistance to it—in the Standard Edition of Freud’s works. As noted, a rumor of empathy becomes a scandal of empathy in mistranslation. In translating Freud’s “Einfühlung [empathy]” from the original German, Alix Strachey writes to James Strachey: “In any case, it’s a vile word, elephantine, for a subtle process.” The words “sympathetic understanding” were chosen in this case as the translation in its place (see Strachey and Strachey (1986) cited in Pigman (1995) and Shaughnessy (1995)). This devaluing description of the word “empathy” as “vile” comes from the same translators, including A. A. Brill and Joan Riviere, that propagated the words “cathexis” and “parapraxis.” Vile indeed. Readers may draw their own inferences about the depth of the resistance to empathy in an otherwise monumental effort on the part of the translators. For those interested in every mention—and mistranslation—of “empathy” in Freud we are indebted to George Pigman (1995). Meanwhile, at the beginning of his career, Freud wrote: I have not always been a psychotherapist. Like other neuropathologists, I was trained to employ local diagnoses and electro-prognosis, and it still strikes me myself as strange that the case histories I write should read like short stories and that, as one might say, they lack the serious stamp of science [. . . .] The fact is that local diagnosis and electrical reactions lead nowhere whereas a detailed description of mental processes such as we are accustomed to find in the works of imaginative writers enables me, with the use of a few psychological formulas, to

A rumor of empathy

85

obtain at least some kind of insight into the course of that affection. Case histories of this kind [. . .] have, however, one advantage over the latter [psychiatric cases], namely an intimate connection between the story of the patient’s sufferings and the symptoms of his illness—a connection for which we still search in vain in the biographies of other psychoses. (Freud 1893: 160) From the perspective of classic psychoanalysis, the patient comes in with a narrative that has discontinuities, omissions, and, strictly speaking, is lacking in connection. The incoherence is a reflection of these struggles, not the cause of them. If all mental acts and intentions are conscious, then the narrative does not add up. It makes no sense. However, if it is possible that there are also unconscious intentions, then the process of therapy is able to restore meaning to the narrative of the otherwise absurd symptoms and behavior. Meaning is restored through the recovery of an unacknowledged intention—one to which a counter-veiling intention is opposed. The unacknowledged intention is the nucleus of a conflict of intentions. In turn, this conflict of intentions makes a good story, and forms the basis of a narrative conflict. The conflict exists in a latent narrative—a subtext—behind the manifest narrative. When the latent conflict is acknowledged and inserted into the manifest narrative, then the continuity and integrity of the life is promoted. For example, in one of Freud’s clinical vignettes, Miss Lucy R, a 30-yearold governess from a poor background, is working for a rich, widowed businessman. She is struggling with a severe but chronic sinus infection, loss of the sense of smell intermixed with the oppressive smell of burnt pudding, along with loss of energy and fatigue (“depression”). She readily recollects the occasion on which she burnt the pudding upon receiving an upsetting letter from her mother in England. The plot thickens. She has the thought— at this point it is an unacknowledged intention, an intention in fantasy—and an alternate life story—that she might replace the now deceased wife of her employer; but realistically the likelihood seems remote due to differences of class, station, education, background, and her own wanting “to look good.” The intention is unacceptable. The would-be love story is too improbable and confronting. It violates class distinctions. It violates Miss Lucy’s own upbringing. It just tests too many boundaries. In answer to Freud’s question why she did not mention her secret love to Freud, she replies: “I didn’t know—or rather I didn’t want to know. I wanted to drive it out of my head and not think of it again; and I believe lately I have succeeded.” [Freud asks:] “Why was it that you were unwilling to admit this inclination? Were you ashamed of loving a man?”—“Oh no, I’m not unreasonably prudish. We’re not responsible for our feelings, anyhow. It was distressing to me only because he is my employer and

86

A rumor of empathy

I am in his service and live in his house. I don’t feel the same complete independence towards him that I could towards anyone else. And then I am only a poor girl and he is such a rich man of good family. People would laugh at me if they had any idea of it.” (Freud 1893a: 117) In addition to wanting to “look good” and not be laughed at, the patient says, “I didn’t know—or rather I didn’t want to know.” Access to this micronarrative of “knowing and not knowing,” which Freud acknowledges in a footnote, is a part of his empathic responsiveness to the patient. Freud responds in this footnote (1893a: 117ftnt) that this is the best example he has yet discovered of a “the strange state of mind in which one knows and does not know a thing at the same time.” Freud acknowledges having been in such a state himself, but then does not say what is the state in question. Freud writes: What happened was that I saw something which did not fit in at all with my expectation; yet I did not allow what I saw to disturb my fixed plan in the least, though the perception should have put a stop to it. I was unconscious of any contradiction in this; nor was I aware of my feelings of repulsion, which must nevertheless undoubtedly have been responsible for the perception producing no psychical effect. I was afflicted by that blindness of the seeing eye which is so astonishing in the attitude of mothers to their daughters, husbands to their wives and rulers to their favorites. Freud might have added, “sons to their mothers.” This sounds for all the world like the occasion on which, traveling with his mother as a boy, Freud saw her naked, and he had to deal with the perception that she did not have a penis. He deleted the recollection of the perception of the absent penis from his experience, thus, becoming like the patient—knowing and not knowing at the same time. Hence, the conflict of intentions in the wish and the fear: The boy’s wish (a form of intentionality) is that everyone has a penis, and the fear (another form of intentionality) is that some penises may have been “deleted.” This splitting—knowing and not knowing—is a significant psychological mechanism implemented by a conflict of intentions— and underlies self-deception. In our own time, it has been developed with conditions and qualifications as “being of two minds”—the vertical split (Goldberg 1999). The rumor of empathy in Freud is confirmed. Freud is able to make a difference in Miss Lucy R’s relationship with her employer. Miss Lucy R’s micro-narrative was the barely latent intention in fantasy of marrying her widower employer, the father of the children to whom she was nanny. Freud’s empathic receptivity elicits her latent narrative and through his

A rumor of empathy

87

empathic understanding and interpretation. Freud uses it to restore meaning to that which was otherwise absurd (the hallucinated smell of burnt pudding, the loss of energy, the low mood). Her job is saved, though, unhappily, not the prospect of marriage. This is a compelling example of the power of a short-term psychoanalytically oriented therapy to make a difference. Freud’s empathic responsiveness creates a clearing for Miss Lucy to move forward. After these few sessions, Miss Lucy R returned to Freud symptom-free, acknowledging her infatuation with her employer but recognizing she was not going to attain her wish, and she expressed determination not to make herself unhappy over it. Yet, as noted previously, one person’s empathy is another’s countertransference. Though Freud’s Dora has been thoroughly covered in the literature (including by this author (Agosta 1976)), what is arguably new in my argument is determining the role of description and redescription in Freud’s empathy—and our own with him and Dora. For Freud, retrospective action—Nachträglichkeit—is a redescription fundamental to the formation of symptoms. In Freud’s Dora (1905), an initial “boundary violation” occurs. Herr K makes an inappropriate sexual advance towards Dora while she is of tender age. Empathically describing the incident from Dora’s perspective as (1) having no significant emotional effect, but remaining in her preconscious as a memory. Then some years later, after the onset of puberty, Herr K makes another sexual advance at her. From the perspective of the later advance, the initial event is redescribed in Dora’s experience as actually having (2) “an over-stimulating, erotic aspect combined with out-and-out disgust.” Dora has access to the initial gesture (1) under a new description, (2) a sexually informed redescription, and the impact of the initial gesture takes on new meaning. This new meaning, in turn, evokes a reaction from a counter-veiling force (her moral standards and personal integrity), resulting in a conflict of intentions that, when aligned with the aroused but promptly repressed sexual drive, results in symptom formation. In either case, the selfserving description of the would-be sexual provocateur, the family friend Herr K, is the proposal of a kind of quid pro quo, exchanging a “nod and a wink” with Dora’s father’s affair with Frau K for his (Herr K’s) sexual access to Dora. We should not underestimate Dora’s ability to defend herself in a difficult situation. But why should she have to defend herself? Another redescription which relies on our empathy for her predicament? She is vulnerable and exposed due to the misbehavior of the grown ups in her life. We redescribe what was already described, knowing what we do about redescription. Dora is surrounded by a wall of invalidation presented by the perpetrator, the family, and those who know but do not want to know. The danger looms large of misconstruing “construction” as privileging “building a consensus” rather than “constructing an inquiry into what is so.” Herr K and Dora’s father are attempting to build a consensus into which they can enroll Freud. It is not clear that Freud knows all the details of the father’s

88

A rumor of empathy

conflict of interest (though Freud does know of the latter’s syphilis). The father’s intention is to continue his extra-marital affair uninterrupted with Frau K in exchange for turning a blind eye to Herr K’s intentions toward Dora. Dora’s father tries to recruit Freud to persuade his daughter to “be reasonable.” Freud appreciates how Dora was “honored” by the attentions of Herr K—flowers, letters, walks around the lake. She thought she liked the attention. Yet Dora has her own redescription of what such ministrations mean. Dora does not allow that such attentions were necessarily and logically connected to an intention to respond sexually (a description with which most modern readers would tend to agree). Freud is sensitive to Dora’s ambivalence and finds that Dora’s maturing sexual response is relevant to her dilemma. But Freud has his blind spots, too. An issue of Freud’s self-knowledge (or lack thereof) occurs—and today we might say “countertransference.” Freud is writing the case of Dora after abandoning the so-called “seduction theory,” and his revised theory is in need of a cause of hysteria that does not include a factual seduction (boundary violation). Hence, what some have interpreted as Freud’s tendency to try to persuade Dora that she is elaborating, perhaps even imagining, the exchange down by the lake. The bottom line? Freud makes the case to Dora that she deceives herself about the depth and extent of her emotional ambivalence. But hers is more in the nature of a self-misunderstanding, which gets support from the environment, rather than straightforward lying to herself. Freud is definitely onto something. Dora is ambivalent. Who wouldn’t be? She likes the attention from her married family friend and suitor, Herr K, but only up to a point. She retains a strong sense of autonomy and integrity that she gets to say who she gives permission to kiss her and under what circumstance. Freud’s timing—and empathy—are off. He presents the ambivalence to Dora in such a way that she cannot possibly hear the grain of truth amidst the complexities of her properly outraged reactions to the actual and prospective boundary violations. But she also suffers from disquieting and disruptive physical symptoms. The body symbols forth the conflicts of the psyche. Dora somaticizes—symbolically. Her life doesn’t make sense. The adults in her life make life difficult for her, and she makes life difficult for them. Freud’s “blind spot” is exposed by his struggle with abandoning his initial Seduction Theory that (to use neutral language not available to Freud), boundary violations were the sole cause of hysteria. Freud’s intellectual integrity should be acknowledged. We identified cases where hysteria included a fantasy and elaboration (e.g. kissing is not fellatio), and there was a noticeable absence of physical trauma. Yet at least one phenomenon was missing in such a turn. One open question remained: Was a fantasy seduction as powerful a neurosogenic factor as an actual seduction? Does psychic reality cause a trauma, and if so, is it a trauma in fantasy? Or do we have a non-traumatic cause of symptom formation that constellates sufficient

A rumor of empathy

89

energy from endopsychic sources to act like an “as if” psychic trauma? What would that even be? The fantasied sexual romance was the cause of hysteria proper with its compromise formation. Freud’s blind spot was that he was looking to identify a fantasy as a cause of Dora’s hysterical symptoms—perhaps a kiss confused with fellatio—not a factual, real-world boundary violation as enacted by Herr K, which would have supported Freud’s abandoned physical seduction theory. Thus, Freud was noticeably inattentive to the wall of silence, in which he was perhaps unwittingly complicit, that surrounded Dora about what really happened as Herr K made his sexual advances. In this celebrated failure, Freud provides an example of what not to do in terms of technique. Freud uses confrontational methods. He confronts Dora with what may indeed be the facts, but which Dora is in no condition to hear. He confronts Dora with her bed-wetting, masturbation, homoerotism, and emerging sexual interests. Dora is ambivalent about her sexual feelings for Herr K. He sends Dora flowers everyday for a year, and she is flattered by the attention. Yet Herr K is a married man. Everyone in this soap opera knows that too. It is the two-ton elephant in the family living room. If there is any self-deception on the part of Dora, it is in allowing herself to be receptive to Herr K’s romantically valued attentions. However, we must be careful not to blame the victim. Today we would redescribe Dora as not having reached the age of consent and needing the guidance of her parents, who were otherwise preoccupied. The Victorian world was one in which the treatment of girls and women was patriarchal in an extreme. In most legal jurisdictions in the Austro-Hungarian Empire, the age of consent was 12 years old. The distinction “statutory rape”—the child cannot give consent, all the responsibility lies with the adult—had not been invented. Women and children were still treated at the property of the husband. The two key adult males in her environment were either involved in an adulterous, extra-marital affair (Dora’s father with Frau K), in which Dora became a pawn, or were actively trying to bring about an affair (Herr K with Dora). These descriptions are valid in both Freud’s time and ours. Amid all the boundary issues it is no wonder that Dora’s own self-understanding is limited by the wish to escape from her predicament—perhaps via a marriage proposal from Herr K?—and the fear of being used and “dishonored.” Dora fights back. She also suffers. She expresses her suffering in one socially sanctioned way allowed to Victorian women. She expresses her suffering in her diverse bodily symptoms that symbolize emotional conflict and ambivalence. Here hysteria redescribes her suffering in a coded language unintelligible to the parents and provocateurs surrounding her, but to which Freud arguably has access. Under this description, Herr K commits a verbal boundary violation with his micro-narrative saying, “You know I get nothing from my wife” as if Dora is supposed to want to do something about the breakdown of his

90

A rumor of empathy

marriage. This is the same language Herr K used with the governess that he seduced and abandoned, dishonoring her. Dora may be inexperienced, but she is no fool. She slaps him, sends him packing, and tells her parents. Then all hell breaks loose, because her father is turning a blind eye to this boundary violation. He is willing to exchange Dora for the opportunity to have his own way with Frau K (Herr K’s wife with whom he is already having an affair). The next thing is that Dr. Freud is being recruited to try to get Dora to “be reasonable.” Dora is referred for psychoanalytic therapy by her father to Dr. Freud, to see if the professor can persuade her to be sensible. Thus, the battle for wellbeing is joined. The chance of rescuing Freud from the entanglements and conflicts of interests into which he stumbled is strictly limited—probably impossible. The case is complex, messy, filled with opportunities for retrospective redescriptions of the intentions, recollections, and actions of the participants, and this in 1905 much less 2014. Dora is struggling to grow up and come to terms with her own emotions, ambivalences, and emerging sexuality, surrounded by a group of grown-ups behaving badly. Still, it is precisely due to the ambiguities that the case continues to resonate. Where does psychic reality end and factual, “historic” reality begin? What is fact and what is fiction? What “really” happened down by the lake? As noted, the risk is that we may create a misunderstanding when we retrospectively redescribe an event, intention, or action using distinctions that did not exist at the time of the action or were otherwise not available to the actors due to world-defining boundaries, dividing cultures and communities. That acknowledged, Dora nevertheless protests to Freud in so many words that her one-time family friend and admirer, Herr K, has committed and continues to commit boundary violations. One description is that Freud responds with neutrality and tries to make the case that she was stimulated by the attention and is not as innocent as she seems to maintain. Dora finds herself outvoted three to one. Dora’s father, Herr K, and the professor (at least initially)—all maintain that no inappropriate behavior had occurred down by the lake to which she had responded with a slap, or, if it had occurred, she had somehow invited the behavior. Arguably, the initial consensus is to redescribe events to blame the victim. This contributed to unleashing Dora’s narcissistic rage and ultimate decision to discontinue the analysis. This is a proper point at which to take a step back. The hermeneutic construction of facts—relevant data—is not to be mistaken for taking a vote. Rarely has a conflict of interest among the father, friend and psychotherapist (at least initially) been so evident as in this instance. Dora is vindicated years later, in a visit of condolences to Frau K upon the death of one of the children. Herr K “comes clean” and acknowledges to Dora that she was right. Still, in spite of being entangled in what today would be an unacceptable conflict of interest, Freud acquits himself well in subsequently acknowledging his

A rumor of empathy

91

errors and attempting to report on them. To whom was Freud supposed to refer the case—Joseph Breuer? There was no one else practicing the method in the neighborhood in 1897, so against his own good advice (that to perform psychotherapy on one’s friends is to lose both the friend and patient) Freud proceeds to matriculate in the college of hard knocks. Dora expresses her firm grip on reality and her contempt for the process of inquiry by summarily leaving, in her narcissistic and reactive rage delivering a slap to Freud’s mishandling of his own method. Given Freud’s description of Dora’s parents, where the father brings syphilis to the marriage and infects her mother, Dora may well have the unconscious fantasy that sexual intercourse makes one sick, a complex likely to intensify her anxiety (and indeed likely to drive her in the direction of a safer physical intimacy with Frau K) as she contemplates becoming sexually active. In a parallel redescription, the unconscious fantasy “sexual intercourse makes you sick” was the historical reality of Dora’s mother as she was infected by her father’s venereal disease. This became the second narrative behind the narrative for Dora as she contemplated whether she should entertain Herr K’s advances, at least prior to realizing that she was a pawn in a game. The “game” was the devaluing use of Dora as an item of exchange with Herr K whereby the latter was encouraged to pursue Dora as everyone else—everyone except Dora—turned a blind eye to the extra-marital affair between Frau K and Dora’s father. A very penetrating empathy indeed would have been needed to disentangle the disruptive reality of this virtual viper’s nest of boundary violations. With the benefit of 20–20 hindsight (i.e. Nachträglichkeit), an argument can be made that Freud mistook Dora’s anger and rage at him (as a father figure) for an Oedipal betrayal with Frau K. Under an alternative redescription, Dora was reacting with narcissistic rage to a monumental breakdown in empathy whereby the would-be sexual predators (in this case, not Freud but Herr K and Dora’s father) succeeded in duping the bystander, Freud, into blaming the victim. Where, then, do the material facts end and the psychic reality begin? Where does the historic truth end and the narrative truth begin? That Dora’s father was infected with venereal disease is a medical fact. That she had various discharges—catarrhs and leucorrhea(s)— were also facts. At one level they were medical facts in that they mapped to the body. But at another level they were symbols representing possible symptoms of a conversion hysteria that had meaning in terms of sexual ambivalence, stimulation, and repression, which, in turn, are elaborated into psychic conflicts. A skillful differential diagnosis is required. That making such a diagnosis is difficult and subject to revision against the future course of events does not in any way detract from the process whereby a psychological fact is constructed. A kiss is not fellatio. If it comes to symbolize the possibility of fellatio, then a method of distinguishing manifest and latent

92

A rumor of empathy

intentions is required in constructing psychoanalytic facts to make sense out of the differences. In this case, we have to learn to live with ambiguity since the treatment that might have confirmed the original diagnosis by “curing” the symptoms—making them go away—was unable to be completed. Whenever empathy breaks down can narcissistic rage be far behind? Dora would not put up with the lack of empathy and stomps out. This tests the limits of description and redescription. Freud’s position was more nuanced and subtle than either side of the weary battles over seduction and memory imagined. In the following three sentences, Freud shifts his perspective three times and skillfully ends up in a position of studied ambiguity: Phantasies of being seduced are of particular interest, because so often they are not phantasies but real memories. Fortunately, however, they are nevertheless not real as often as seemed at first to be shown by the findings of analysis. Seduction by an older child or by one of the same age is even more frequent than by an adult [. . . .] You must not suppose, however, that sexual misuse of a child by its nearest male relative belongs entirely to the realm of phantasy. (Freud 1917: 370; translation altered to render misbrauch as “misuse,” not “abuse,” the distinction “child abuse” did not exist as a separable concept from cruelty to children in 1917) So-called “seductions”—what today would be redescribed as “boundary violations” or even the rape of a child by an adult—do indeed happen. Freud’s position devolves toward being a masterpiece of nuanced ambiguity. That some “seductions” are actually by children is consistent with and implies that some “seductions” are not by children but rather by adults. Even if Freud was not dealing with exactly the same descriptions and categories that we use today, he did not underestimate the significance of the matter, referring to “sexual misuse.” Strachey translates Freud’s German word Misbrauch as “abuse” whereas Joan Riviere stays with the more literal and accurate “misuse.” The action being described was child abuse and indeed sexual molestation or rape and today would be redescribed as such. Freud asserts that “seductions” happen, but they do not happen as often as is alleged. Freud’s initial position, which was supposed to secure his fame and fortune—the sole cause of hysteria is a traumatic boundary violation involving sex—and indeed by the father—does not pass the test. The scientific hypothesis is refuted—there are counter-examples. The reminiscences from which hysterics suffer are sometimes real—but sometimes the recollection has only psychic reality. Sometimes when there is a sexual boundary violation, the violator is an older child, controlling and dominating a younger one, either with or without the latter’s cooperation. Even if

A rumor of empathy

93

everyone of Freud’s first 18 cases had been entailed a “seduction,” subsequent cases did not do so. Alternative results and redescriptions emerged. Furthermore, the danger of a suggested recollection on the part of the psychoanalyst looms large. The risk is that the patient “recovers” that which the physician has suggested. Freud’s new improved method of free association along with the analyst’s neutrality, abstinence, and anonymity is supposed to be effective in controlling such a risk of suggestion. How unfair are we being to Freud in accusing him of presiding over an attempted boundary violation? Freud and the world in which Freud operated did not have the distinction “boundary violation” the way we do today. More redescription? More Nachträglichkeit? Our boundaries are different than those of Freud’s time. For example, in Freud’s time unaccompanied single women would be regarded as having committed a boundary violation in going out in public without an escort. In our own time, it is common. Today, Herr K’s behavior during his walk around the lake, etc., with the 14-yearold Dora would be a boundary violation. His implicit proposition to Dora two years later, as Herr K reflected, “You know, I get nothing from my wife”—where “nothing” points to “no sexual contact”—would be a boundary violation. Yet in the years 1900–1905 in Vienna, “statutory rape” had not yet been invented, though once again the actual physical contact between Herr K and Dora is reconstructed. When we retrospectively start to describe the dynamics between Dora and the participants in the drama around her as “boundary violations,” then do we not create intentions to which the participants could not have possibly had access? Once again, redescription is 20–20 and ours is working overtime if we expect Freud to know then what we know now. Dora’s father was—how shall we express it delicately?—a philandering chauvinist, a so-called parent, neglectful of his duty to protect his daughter. Herr K is a would-be seducer of a relatively inexperienced young lady, who wisely refuses to be his Lolita and sends him packing. Our empathy for Dora is activated. Freud succumbs to the contingencies of the historical moment in which he is inevitably a participant. Still, the lessons are rich and rewarding. What makes the case so engaging is precisely the way in which narrative reality, accusation and counter-accusation mix with rumors about what factually happened. However, at another level, there is this small voice in individuals who have been scientifically trained in the experimental method—admittedly at times overrated but still the best method we have so far—who just experience a genuine curiosity to know: What happened really? The facts are fragile. To Freud’s credit, he aspires to learn from his mistakes. This example of a failed case demonstrates that if a discipline such as psychoanalytic therapy cannot fail, then it also cannot succeed. However, one cannot simple reverse the hypothetical. All we have salvaged is the logical possibility of empathy. The rumor of empathy in the case of Dora remains a rumor.

94

A rumor of empathy

Narrative truth and historical truth revisited Donald Spence (1982) has famously elaborated the distinction between narrative truth and historical truth. It has been hovering in the background of our discussion of how empathic responsiveness emerges into language as listening and story telling. We now engage with it explicitly. The distinction maps closely to that between fact and fiction: (1) telling a story that is richly humanizing and emotionally satisfying in terms of psychic reality and (2) telling a story that accurately maps to the factual, material world of events in the context of space and time, nature and human history. Many narratives do both—are both personally satisfying and factually accurate. However, the boundary between narrative truth and historical truth is the locus of the difficult cases. Spence never denied historical truth. Positively expressed, historical truth exists. Spence argues that psychoanalysis in a practical, clinical context simply does not aim at historical truth. Spence gives three reasons for this: 1

2

3

The translation of images, dreams, and screen memories from pictorial to verbal form is fraught with uncertainty and involves a strong element of indeterminism, even given the discipline of psychoanalytic methods. A picture is likely to exhaust any description that one brings to it as an image is translated into words. This indeterminacy of translation means that the target experience, the pictorial representation, tends to recede into the indescribable (Spence 1982: 63). The process of capture and construction overwhelms the would-be facts and leaves us with mere psychic reality—that is, our own process of construction. Reports of eyewitnesses are supposedly a high standard for accuracy, including “eye witness” reports of one’s own introspective experiences. Yet mounting evidence exists of the fallibility of such reports. For example, in a clever psychological experiment, merely asking the observer if he remembered the barn in the background of a film of a speeding auto causes a significant percentage of observers to remember such a barn (1982: 90). There is no barn. The question introduces the content, which, in turn, influences the recollection. It spins. Thus, Freud hypothetically proposes to the Wolf Man a reconstructive memory in which the young Wolf Man urinates as an expression of his three year old sexuality upon seeing the backside of his nanny, Grusha, as she is down on her knees, scrubbing the floor. A few pages later this memory has been incorporated into the narrative as a fact (Spence 1982: 118–119). The past is a hostage to the transference (1982: 95–96). Spence plausibly suggests that such is the case with the Wolf Man. The need to be a good patient and bring in useful material can create a powerful gradient in the direction of the need to accommodate. Yes, the Wolf Man works hard and remembers, but he also conforms.

A rumor of empathy

95

The result is an undermining of the epistemological status of psychoanalysis as yielding knowledge that stands fast in the face of attempts to refute it. Notwithstanding Spence’s protests to the contrary, the psychoanalysis is not on this slippery slope; it is at the bottom of it. This is so even from the hermeneutic perspective. Psychoanalysis was supposed to be more like archaeology or certain forms of history (e.g. Ricoeur 1965) rather than the caricature of positive science that so enthralled Freud in his time and Ernest Nagel and Heinz Hartmann in ours (e.g. Agosta 1976). This deep debunking of what the Achilles heel of clinical practice—see Spence’s three reasons above—is undertaken by Spence even as he protests his commitment to psychoanalysis, a commitment that is supposed to distinguish Spence’s approach from that enacted by Frederick Crews (1980), who held psychoanalysis in deep contempt, even while distorting its methods and contribution. Yet unwittingly or not, Spence’s approach also undermines hermeneutic inquiry in psychoanalysis. In Spence’s hands, narrative truth starts out being the noble and inspiring truth of literary accomplishment, dealing with the great human themes of birth, death, the struggle for human dignity and recognition. These struggles occur in all manner of extreme situations that disrupt conventional narrative forms. For example, in Kafka’s haunting tale, Metamorphosis, Gregory Samsa undergoes a surprising, arbitrary and nightmare-like transformation. He is turned into a giant insect. It is not historical truth, but it captures a deep underlying fear of the loss of one’s humanity. Strictly speaking, the experience of the loss of humanity is untranslatable into any human language, but, under one redescription, it expresses man’s loss of humanness and alienation from his fellow humans and from himself. In the hands of Heinz Kohut, Kafka’s Metamorphosis becomes a narrative of a world without empathy or responsive selfobjects (the latter being defined as the way one’s psychic representation of another person functions in and contributes to one’s own psychic equilibrium). Kafka’s narrative yields narrative truth; and it is a compelling example of the loss of humanity experienced in the historic reality of twentieth-century totalitarianism. The truth—narrative and historical—is that people live lives of emotional desolation without becoming insects. This happens for many reasons, including the misfortune of being born to a deeply disturbed psychotic parent (Maechler 2001) or born in a North Korean labor prison camp (Kirby et al. 2014). However, by the time Spence is done with his inquiry, he makes it sound like the psychoanalyst and analysand are just telling tales, inventing fictional scenarios, albeit comforting ones. For all anyone knows, narrative truth becomes fiction in the sense of fabrication, lying, and deception. But wait a minute. Even if Spence indulges in hyperbole for rhetorical effect, the definition of great literary art is that it expresses the conflicts of human beings in extreme situations. Deception, especially self-deception, is of the essence in the process of psychotherapy as that which is to be overcome

96

A rumor of empathy

where one suspects that things are not as they seem to be. Self-deception is only meaningful if there is something, about which to be deceived, against a background of facts that are stable, steadfast, and secure. The clinical relevance of historical truth is supported by all the tough examples. In historical events and the reports that emerge in clinical practice, people do what they have to do to survive and that includes deceiving themselves. Historical practice resonates with clinical practice. For example, when at the end of the Second World War the Swedish Red Cross liberated the Theresienstadt concentration camp and took statements from the women survivors of the camp, the reports were astonishing. Some of the survivors stated under oath that conditions in the camp were so nice that the SS Officers brought breakfast in bed to them each morning (cited in Laub 2005). What we would today elaborate clinically using diagnostic labels such as the Stockholm Syndrome is operative as is the expectation of the survivors that to say otherwise, even to the Red Cross, would risk being taken out and summarily hanged. Truth is truth under a description. Description is description under an interpretation. The interpretation maps the narrative to a context of psychological and environmental—historical—distinctions. The interpretation maps history to a context of narrative distinctions. History informs narrative; narrative emerges as history. Yet there is the concern that to allow multiple perspectives, including those of the suffering self-deceivers, puts one on the slippery slope to “everything is relative.” As noted, narrative truth is not on the slippery slope; it is at the bottom of it. This is a great issue of our time— not mere denial of the Holocaust, which has earned a certain special status (e.g. Young 2007), but denial of the murder of the six million. Are these two redescriptions of the same event? And if they are redescriptions does that make the events relative to a description? The perpetrator acts as if the facts of the murders were matters of opinion about which different perspectives can be co-constructed. And if relative and perspectival, can Holocaust denial be far away? The answer is direct. Our attempts to engage the truth are enriched by the tension between narrative and historical approaches. But in any case, there is such a thing as truth. There is such a thing as truth, and sometimes the truth is obvious. Sometimes it is not. Sometime the truth is so obvious that we must take special measures not to experience it as did Miss Elizabeth von R and Freud himself in the examples cited above of knowing and not knowing at the same time. But that does not mean it is always as easy to determine what is the case as it is here. Granted that it is a historical fact— historical truth—that a plurality of Germans voted to put Hitler into power. Yet there are many matters of fact—truths of fact and reason—on which one cannot simply take a vote. The murder of the six million is not subject to a vote. That Anne Frank was murdered stands fast. The Nazis produced the best documented crime in human history. That’s a surprisingly easy

A rumor of empathy

97

example. The evidence is overwhelming. So while it may be hard to access the truth in selected complex, individual situations, the case of the survivors of the concentration camps is an easy one from the point of view of epistemology, the point of view of knowledge, though no less troubling for all that. Holocaust deniers want to make the murder of the six million out to be like the murder of the original Egyptian Moses, lost in a past where myth and reality converge as a special case. It is simply not so. More problematic is that other survivors of trauma in our own time—of domestic violence, dysfunctional families, emotional devastation, paranoid processes of envy and revenge—struggle to be heard and known. Many subtle and powerful points exist in Spence’s analysis, especially the emergence of truth from a narrative context. He would have done well to follow out the tension-laden implications of such an analysis into a hermeneutical circle between narrative and historical truth. Spence overlooks at least one point that is relevant to psychoanalytic inquiry: the tension between narrative and historical truth is what drives the psychoanalytic inquiry. Even when they flat out contradict one another, the contradiction speaks volumes. Contra Spence, stories are often told by patients in the interest of figuring out what really happened. That does not mean that the analyst and analysand always succeed in getting at the historic truth. This does not mean that an analyst or analysand never stretched the historical truth or cut loose with narrative truth. Narrative truth points to the way to historical truth. For example, Dora, her parents, Herr K, Frau K, Freud, and hundreds of commentators since 1905, argue in a wirbel of descriptions and redescriptions about what happened down by the lake. Years later, Herr K confesses to Dora that he was dissembling about what happened by the lake. Freud’s “confession” is the case history itself (1905). Are we now better informed? The hermeneutic circle starts spinning. To make sense out of what happened requires that events be wrappered in narrative form. The bait of falsehood catches a carp of truth. The reverse is often also the case. Historical truth points toward narrative truth. Freud speculates that the Wolf Man urinated on the floor (narrative truth), only to assert a few pages later that this really happened (historical truth). In another example that can arguably be described as Victorian pornography, Freud reconstructs the sexual positions used by the Wolf Man’s parents in having sexual intercourse that sunny afternoon while he was in his crib—and what was visible in detail. This is controversial only if it is asserted as historical truth. If it is just a stimulating fantasy (narrative truth), expressing (Freud’s) psychic reality, then it does not matter. Even if a narrative is a fantastic elaboration of a grain of historic truth, the two stand in a relationship with one another that reciprocally lend meaning. Without a factual reference in which to anchor the fantasy, it (witnessing the primal scene) is an idle wheel that moves no part of the psychic mechanism. But if it really happened, then it accounts

98

A rumor of empathy

for the hypothesis that the Wolf Man was afraid of the picture of the wolf standing upright on its haunches (narrative truth), because it reflected the position of the father during intercourse a tergo (historical truth). In another celebrated example, Herr K (Freud 1905) is supposed to have pressed his erect penis up against Dora as he tried to kiss the 14-year-old girl down by the lake, thus arousing a feeling of disgust in her. That she was disgusted and not “normally” sexually stimulated is supposed to be evidence that she was already redisposed to hysteria, as if the advances of a would-be sexual predator were supposed to be welcome. Freud begins by offering this as speculation, but within another few pages, the disgust is taken as a given fact. The alleged fact is itself the outcome of a process that interweaves an amalgam of psychic and factual reality. How can this be so? This is so because narrative truth and historical truth emerge together, and stand or fall simultaneously. In the following examples, historical truth is the account of everyday happenings in the past (indicated by (a)). Narrative truth provides the context and significance (indicated by (b)). First example: (1a) A patient associates to the image of his mother wearing a gas mask during the Second World War as protection during one of the German bombing raids of London. (1b) The patient reports making bizarre faces at himself in the mirror (Niederland 1965). Second example: (2a) A patient recalls being four years old and her father dismissing her fear as she ran to him with a bloody discharge from her genitals. (2b) The patient communicates her anxiety that she is concerned that the analyst’s niceness is not genuine (Spence 1982). Third example: (3a) A patient comes in and expresses concern that her housekeeper did not show up as expected. (3b) During the preceding session, the analyst had announced a pending vacation (Spence 1982). Fourth example: (4a) The patient’s father is an alcoholic and is dying of cirrhosis of the liver. (4b) The patient comes in and says that he dreamt he gave his father six roses. The analyst asks, “Six roses or cirrhosis?” (Viderman 1979). A pattern emerges. In every case, the fact cited in (a) is devoid of context, empty and meaningless, and takes on new meaning when juxtaposed and completed by the narrative reported in (b). The relation is reciprocal. The narrative in (b) takes on new meaning, acquires reference and significance, providing the “So what?” when juxtaposed and completed by the fact in (a). When the fact cited in (a) is made the basis for an understanding of the symptom, dream, slip, behavior, or emotion in (b), then we are at the boundary of narrative development where narrative truth emerges from historical truth. When we take the phenomena cited in (b) and look for an explanation, then we are at the boundary of historical facts where (a) historical truth is

A rumor of empathy

99

discovered by using (b) narrative truth, which, in turn, reciprocally illuminates (b). The circle is complete. Spence’s assertion that the “historical truth may be less important than its narrative truth” (1982: 150) is decisively undercut, because the historical event provides the background against which the narrative truth takes on meaning. In turn, the narrative—making faces in the mirror, the analyst’s vacation, and the issue of trust—points to and constrains the underlying history, calling forth its meaning in context. The matching patterns point to a hermeneutic circle between narrative and historical truth that restores the balance between them. Kris’s personal myth as narrative truth and historical truth

The contribution of Spence can be usefully juxtaposed with that of Ernst Kris on “The Personal Myth” (1956). Kris gives the clinical vignette of a patient who is a successful scientist. The scientist/patient presents his life as a rags to riches tale, a “Horatio Alger story” of succeeding against the odds. Kris’s other examples are perhaps less well-known myths but equally dramatic. Instead of being a Cinderella—an orphan sleeping in the ashes who is eventually recognized for the princess she really is—the protagonist (the analysand) is living like a princess but really believes herself to be a Cinderella-like individual—the daughter of the hired servant. The personal myth is not explicitly offered by the patient. It emerges piecemeal as the patient’s autobiography. According to Kris, the personal myth functions analogous to a screen memory. Often it overlays a pathogenic idea. In one example, the stepfather makes sexual advances towards the daughter. She fends him off, but never tells the mother, harboring both the would-be boundary violation as a guilty secret and the death wish against the mother for seeming to offer the stepfather to the daughter in fantasy and then taking him away again. Kris’s point is that the personal myth communicates powerfully and organizes the patient’s experience, but it contains distortions and even systematic self-deceptions. In one case, there is a two-year gap in the myth. The patient goes off to college at the age of 16, not the age of 14 as reported in the initial presentation of the personal myth. The hero was merely above average, and not as much a prodigy as the personal myth made him out to be. There is also a two-year shift in the chronology, Kris asserts, whereby the affection and closeness with the otherwise under-achieving father is disguised because of the homoerotic, negative Oedipal aspects. In short, the gaps and inconsistencies in the narrative are of the essence. Spence never comments on the work by Kris. Perhaps he could not because Kris was “old school” and still adhered to a concept of truth with a capital “T” as in positive science. However, a reconstruction can be made that Spence would assimilate the personal myth to the narrative truth and the

100

A rumor of empathy

underlying, latent material that is covered by the screen memory to historical truth. We can readily imagine distorting and embedding the historic truth— the stepfather really did make sexual advances—in the narrative truth—for example, that this boundary violation meant that the mother was an “Indian giver,” first offering the liaison, then disrupting it. But this overlooks that meaning as such is fundamentally different between psychic and real world. The treatment options are likewise going to be different if the boundary violation (the sexual advance) really occurred in historical reality rather than being fantasized. What happened versus what did the patient make it mean is a useful distinction. But when “what happened” was an imaginary wish or a fear rather than a factual seduction, beating, or rape, then the “what one made it mean” is differently assessed and worked through. Psychic reality is significant and important but its significance varies in relationship to other realities and other times. Although Kris did not have Spence’s inquiry in mind, Kris would arguably map the personal myth to narrative truth with the condition that it is a useful method of getting at the historical truth. For example, the analysand’s myth presents him as the heroic loner, succeeding against all odds. But on further inquiry the protagonist received crucial assistance from friends and family at key points in his development. The difference points to the hero’s partially analyzed narcissism and resistance to relatedness that eventually unfolds in analytic engagement. In another instance, the analysand has what is in effect a reverse Cinderella narrative. She is privileged and enjoys a princess-like existence, yet deep inside is her conviction that she is really the laundry woman’s daughter. The personal myth is revelatory of an emotional and psychical desolation that discloses the analysand’s life of emotional struggle in contrast to the personal myth. Addressing this inner narrative truth is a more relevant analytic task than the historic circumstances of her privileged, factual existence. Yet the personal myth of feeling like the laundry woman’s daughter takes on significance in relation to the factual life of privilege— and vice versa. Thus, the narrative “feels emotionally like Cinderella” is complemented by the narrative “lives privileged like the bad step sisters.” Whichever narrative is made, the explicit focus of the analytic work is correlatively accompanied by the other narrative as a complementary subtext. In the course of the analysis, the personal myth shifts, is transformed. Gaps are closed. Details are revised to accommodate the few facts that are definitely known to be the case, which, in turn, act as organizing nodes in the network of narrative associations. Narrative truth and historical truth in Pierre Janet

Although Spence had no interest in the work of Pierre Janet, narrative truth and historical truth interact in a surprising way in the clinical work of Janet.

A rumor of empathy

101

An unexpected relationship between narrative truth and historical truth is highlighted by at least two of Janet’s case histories. The symptoms presented by his celebrated case of Marie included terrors of a quasi-hallucinatory intensity, delirium coinciding with her monthly menstruation, and yearslong hysterical blindness. Janet builds rapport with her—“rapport” being a technical term for an early form of “transference”—and works with Marie to determine the historical truth. Janet seems like a courageous seeker of the historic truth, reminiscent of Freud, with whom he was a contemporary and professional rival. Janet provides a gracious and generous listening to Marie. Her historical narrative unfolds. Years before meeting Janet, during the initial commencement of Marie’s first menstruation, she was afraid that her menstrual bleeding was pathological and stopped the process cold, literally, by plunging herself suddenly into a cold bath. Furthermore, Marie witnessed the gruesome and bloody suicide attempt of an individual falling down the stairs. The traumas continue. She was forced to sleep with another child, who had a non-contagious but repellent skin disorder after which occurred the sudden onset of Marie’s blindness. Janet works on co-constructing a narrative with Marie. But it is not the usual historical narrative. Janet tries to convince her that the initial trauma never occurred. Her well-being improves. Here “co-constructs” means “suggests,” and includes the use of hypnotism. Janet persuades Marie of what was not the case: I was able to succeed only thanks to a singular means. It was necessary to put her back into the initial circumstances of the delirium, convince her that the menstruation had lasted for three days and was not interrupted through any regrettable incident. (Quoted in Ellenberger 1970: 363) Janet continues: I put her back with the child who had so horrified her; I make her believe that the child is very nice and does not have impetigo (she is half-convinced). After two re-enactments of this scene I get the best of it . . . (Ellenberger 1970: 364) Janet’s professional priority was to relieve the patient of her pain and suffering, not to expand the patient’s grasp of the historic truth. Though it was not the case, Janet persuades Marie that she had really had a normal menstruation. The bloody recollections were devalued. Janet continues replacing the historic truth with a narrative of well-being. The child had really had a pleasing complexion worthy of being caressed. Yet the value of historical truth stands fast because Janet had to determine the historic truth

102

A rumor of empathy

precisely in order to undo it. Furthermore, Marie’s hysterical blindness, which had persisted for years, is cured and her sight returned. Janet asserts that the cure was sustained going forward. One wonders whether suggestive methods—including hypnosis and co-construction—are undervalued and ought to be rehabilitated in the interest of reducing human suffering. Janet’s example both supports and is the reduction to absurdity of Spence’s position. Yes, symptom relief occurs. Marie’s quality of life is enhanced. That may be good enough even though Marie had to continue to live in an institution, albeit with improved emotional well-being. No prospect emerges of getting a job or establishing a family, etc. Duly noted. Yet something is definitely lost in the matter of integrity by replacing the historic truth with a fictional narrative. In so far as one is committed to promoting coherent, autonomous persons with a strong sense of decision making and autonomy, one has to be skeptical that the treatment was complete. Still, Janet’s accomplishments point toward a different paradigm, currently enjoying a revival. In short, bring forth and interrupt the pathogenic thought or experience— whether based in psychic or historic reality—and replace it with “positive self-talk.” Janet is a contemporary of Freud, but the men are worlds apart. After the First World War, Janet lives in obscurity, documenting case after case of hysteria, paranoia, delusions, and all manner of obscure emotional disorders. Thousands of cases. Janet is keenly interested in the lives and sufferings of his patients. He is a warm and responsive but authoritative and magisterial presence. Janet appreciates “the Rapport” of the ancient magnetizers (Ellenberger 1970). Janet uses suggestion. We do not know the details. He convinces long-suffering patients of what is not the case. Janet suggests to them that the meaning was different than what they imagined. The patients get better. Janet claims that his cures endure. He uses evocative, directive, suggestive, and inspirational methods. He anticipates forms of cognitive behavioral therapy—he interrupts the pathogenic idea. He promotes what we would today call positive self-talk. He works in isolation without a clinic, without colleagues, without a movement such as Freud established. The world cares little for Janet. He cares even less for the world. Upon his death in 1947, Janet’s Last Will orders that his detailed notes on 5,000 case histories be burned. The executors of his estate comply. A life’s work—a vast clinical archive—literally goes up in smoke to make a point about his integrity and the confidentiality of people who were otherwise anonymous and mostly dead (Ellenberger 1970). Our potential knowledge of psychotherapy is immeasurably diminished. We literally do not know what we do not know. There is no specific way that historical truth has to be. Historical truth strikes back. Princess Marie Bonaparte, a protégé of Freud, buys the Freud–Fliess correspondence on the open market. She receives Freud’s personal request to hand over the letters so he can burn them. She stalls.

A rumor of empathy

103

She prevaricates. Freud does not get the letters. They survive. Our knowledge of what Freud was working on and thinking in the 1890s is greatly expanded. We latecomers are immeasurably enriched in our understanding of the origins of psychoanalysis and get a window into what is, in effect, Freud’s own selfanalysis. We lose the archives of Janet. We get those of Freud and Fliess. It is worth repeating: there is no way that history has to be. A stern lesson for all historians—and clinicians. Absent heroic efforts at archival processing and record keeping, oblivion is the default result. If the example of Janet’s convincing Marie what is not the case to promote her recovery is the target of Spence’s distinction of narrative truth, then Spence has unwittingly hit the mark. Yet even in the case of Janet’s extra-psychodynamic methods of hypnosis and the charismatic power of his personality, Janet still had to have a strong sense of the historic truth in order to negate it. First he finds out what is supposed really to have occurred. Then he deploys tactics to undo it. The patient “gets better” in the sense of symptom relief. The lesson learned? Facts are fragile. We return to “The Facts are Fragile” from the last chapter, “Acknowledgment of What Happened.” The Oedipus complex and the original trauma = X

If facts are fragile, self-knowledge is like looking into the abyss. One’s head spins. Here I take as an inspiration the example of Freud and the early psychoanalytic innovators courageously facing their own “abysmal thoughts”—the thoughts that people might prefer to avoid. For Freud there is an original trauma buried deep in the past, which, in itself, is insufficient to cause the symptom formation characteristic of an adult neurosis. Under one description, Dora is entangled in a would-be seduction as a child of tender age (today it would be properly described as “abuse” or at least a significant “boundary violation”), from which, however, she escapes mostly but not completely unscathed. The Wolf Man indulges in sex play with his older sister as a boy of tender age, but neither he nor Dora fall ill with neurotic symptoms until the event is redescribed retrospectively (nachträglicherweise) and takes on sexual meaning in a rewritten psychic narrative. In the case of Dora, Herr K makes another pass at her—a more explicit proposal wrappered in thinly veiled euphemisms—and, in the case of the Wolf Man, he is presented with a provocative picture of a fairy tale wolf up on its haunches like his father in having intercourse with his mother a tergo. The original trauma gets redescribed—rewritten—within a subsequent narrative that gives us access to it. The original trauma is precisely the clinically relevant boundary violation from which the modern-day survivor suffers and about which we may (or may not) try to capture the facts in our narrative of what happened. The indeterminacy of the past looms large here. And the suffering of the past is sticky. The survivor keeps probing

104

A rumor of empathy

the wound under the constraints of the compulsion to repeat that which is incomplete and unmastered. The original trauma gets reenacted in a “return of the repressed.” An interpretation emerges as an narrative. At the top of the list of defining narratives for Freud is the Oedipus complex—the unbridled sexuality and aggression that is awakened at an early age in the young of the species and that must be brought under control of the standards of the community in order for the individual to make a useful contribution to that community. While the Oedipus drama is well rehearsed in the literature (see Rudnytsky 1987 for a nice overview), what is arguably new here is determining the role of description and redescription in our empathic understanding and response to the story. What we would today call the “prequel” to the movie—is that Oedipus is abandoned by his biological parents under the threat of the curse that he will kill his father and marry his mother. The biological parents attempt infanticide. Nevertheless, Oedipus is such an attractive baby that he is rescued by the shepherd and rises meteorically, solving the riddle of the sphinx, to the role in which we customarily encounter him. One thing is definite. Those who are entangled in the boundary violations—whether as (unwitting) perpetrator, victim, or both—end up badly. One definitely wants to keep such matters as homicidal anger and incestuous desire in the realm of fantasy where they can be dealt with in a vicarious manner, say, by means of a work of art such as Sophocles’ dramatic theater piece. The fulfillment of the deed destroys those involved. The existence of the drama by Sophocles is itself one of the main pieces of evidence in favor of the existence and efficacy of the Oedipus complex. I repeat: the very existence of the drama itself is the evidence. Freud argues that the way the drama touches and moves audiences in all ages through a vicarious experience of fear and pity demonstrates that the events depicted are a part of what makes us human. The narrative is spell binding. Every action, every step, every gesture that is taken by the protagonists to avoid the unhappy prediction unwittingly moves events in the direction of their fulfillment. Freud’s point is a powerful one. The story of Oedipus continues to engage us today because, being in the grip of the same conflicts and ambivalences, we are able to identify with the protagonists. Every member of the audience recognizes him- or herself. The astute reader recognizes that Kohut (1982) redescribed the events using a narrative of the initial perpetration of abandonment in the Oedipus legend—an enactment likely to resonate powerfully with the development of the self. The worst products of the Oedipus complex—murderous rage, incestuous desire—are already fragments of a basically healthy process gone bad, whether through deprivation, trauma, or developmental derailing. Instead of the pathologically experienced conflict of drives, colliding with the father’s superego, this universal phase of development is joyfully engaged by the healthy family as a step opening up new possibilities for growth even

A rumor of empathy

105

as the regressive possibilities of immaturity are transcended. Although an over-simplification, Kohut’s formulation is normative, devaluing punitive fathers and seductive mothers who literally become a clearing for the neurosis in the child instead of responding with pride to the child’s immature affection and clumsy competition. Kohut says (in effect)—it’s just a fiveyear-old boy—he is behaving affectionately towards Mom and competitively towards Dad. Be proud. He is growing. By all means set boundaries. My son, you have got to sleep in your own bed. Will he be disappointed that he cannot displace Dad? Naturally. Will he not only survive but prosper when the limit setting is handled with empathy and kindness? Yes, indeed.

From empathic narrative to optimal responsiveness We have distinguished empathic receptivity, empathic understanding, empathic interpretation, and empathic responsiveness in listening and narrative as the hermeneutic circle of empathy (Figure 1.1, p. 23). Optimal responsiveness is primarily a form of responsiveness in language. The response is often a narrative or micro-narrative. A smile or a commiserating look of concern in context are also examples of empathic responsiveness. The point is that without the expression of a response, the individual who is receiving the empathy does not recognize it. The empathy is an idle wheel, turning inside the person who is being empathic without touching the other who is supposed to receive the empathy. In order to experience the benefit of being the recipient of empathy, the recipient himself must be open to the empathizer’s animate expression of life as an empathic response. In order to close the loop and complete the hermeneutic circle, empathic responsiveness is an essential part of the multidimensional process of empathy. Communicating an empathic narrative, in which the patient’s experience is acknowledged and mirrored, is an example of an optimal response to the patient’s self-expression. Responsiveness lives on a continuum between negative or non-responsiveness (which can be traumatic), optimal frustration, and optimal responsiveness proper. Though “optimal frustration” and “optimal response” are sometimes represented as “either/or” choices, forcing a choice between them is unnecessary. Each has its place: they are on a continuum. These responses go to the heart of how dynamic psychotherapy makes a difference and shifts the struggle of the patient towards emotional well-being. Empathy comes into language as an optimal response. Recognition of the other person’s humanity and struggles, acknowledgment and mirroring of the other, provide the very paradigm of an optimal response. Recognition a kind of “limiting case” interpretation that captures expressions of feeling that are examples of optimal responses. Recognition becomes a special case of empathic interpretation. The therapist responds in such a way that the

106

A rumor of empathy

patient’s experience is given back to her or him as something he recognizes as his own. The above-cited examples from Viderman (1979) of a micronarrative of “six roses or cirrhosis?” or Waelder’s single-word response of “stillborn” (Guttman 1987: 34) are the very paradigm of optimal responses that function as interpretations, opening up possibilities for empathic understanding and structure building where previously there was stuckness and suffering. An empathic narrative is an optimal response, but that does not mean that all optimal responses have to occur in language. In what follows we have a rare example of how a preverbal experience gets captured in language. Dynamically, the purpose of analytic abstinence is to withhold gratification of infantile wishes from the unconscious and cause latent, emerging sexual/ aggressive desires to be articulated expressively, to “speak.” In a dramatic gesture, Kohut allows an analysand to hold two of his fingers. It is worth quoting at length: She lay down on the couch the first time she came, having interrupted a previous analysis abruptly and she said she felt like she was lying in a coffin and that now the top of the coffin would be closed with a sharp click. . . . She was deeply depressed and at times I thought I would lose her, and that she would finally find a way out of the suffering and kill herself. . . . At one time at the very worst moment of her analysis during . . . perhaps a year and a half, she was so badly off I suddenly had the feeling—you know, how would you feel if I let you hold my fingers for awhile now while you are talking, maybe that would help. A doubtful maneuver. I am not recommending it but I was desperate. I was deeply worried. So I . . . moved up a little bit in my chair and I gave her two fingers. And now I’ll tell you what is so nice about that story. Because an analyst always remains an analyst. I gave her my two fingers, she took hold of them and I immediately made a genetic interpretation—to myself. It was the toothless gums of a very young child clamping down on an empty nipple. That is the way it felt. I didn’t say anything . . . but I reacted to it even there as an analyst to myself. It was never necessary anymore. I wouldn’t say that it turned the tide, but it overcame a very, very difficult impasse at a given dangerous moment and, gaining time that way, we went on . . . with a reasonably substantial success. (Cited in Bacal 1985: 19–20) This is a nice example of how a preverbal experience gets wrapped in narrative empathy and emerges into language, albeit unexpressed to the patient except as the response of the two fingers. The experience gets woven into an enveloping form of words—the micro-narrative of the empty nipple—that might have been expressed and communicated to the other person, but was not. Given the patient’s fragile, fragmented state, it would

A rumor of empathy

107

not have made sense in the moment. Thus, as an example of empathic responsiveness, this goes under “relatedness” and “responsiveness to humanity,” not “interpretation.” Strachey (1934) would not necessarily endorse the gesture. Strictly speaking, neither does Kohut. Yet he makes the gesture. He makes an exception that proves the rule, giving those who disagreed with him “evidence” that perhaps he was in favor of a “corrective emotional experience” after all. I believe he would argue back that the way he wrappers the experience in the interpretation of the “empty nipple” raises it above the everyday corrective emotional experience. (On “corrective emotional experience” review the above section, “Empathy and its Discontents.”) Yet doubt remains. Is this not “gratification,” even if justified in reaching out at “a dangerous moment” to a suicidal client? Innovators such as Kohut may get away with such exceptions, but what about the rest of us mere mortals? Make a referral for psychotropic medication? That would have been another approach that would occur to many practitioners—and another form of defeat. No easy answers. When in doubt, standard, warm human responsiveness is the order of the day. Another vignette of ordinary human warmth and decency is provided by Freud himself, who writes that his patient, colloquially known as the Rat Man because of this preoccupation, reported that he was hungry. Freud provided him with a meal. Much of the conversation that Freud reports having with this analysand is didactic in tone, and suitable for an introductory presentation on psychoanalysis. Freud’s strong insistence that it is necessary to deny the patient’s wish for libidinal (especially sexual) gratification is often misunderstood as a requirement to deny all satisfaction within the therapeutic setting. Physical contact other than a handshake are counterproductive to the treatment process whereas it would be inhumane to withhold a glass of water from someone who has been coughing or a tissue from someone who has been weeping. This is a rich source of psychoanalytic humor. It is also perhaps the reduction to absurdity of certain forms of neutrality, abstinence, and anonymity. Be a Mensch. Regarding the case of the Rat Man, Samuel Lipton (1977) makes a compelling point. If the Rat Man was cured, as is the consensus in the psychoanalytic community, then either Freud’s technique worked, including providing lunch, or the cure worked in spite of bad technique. This should give pause to those whose paradigm of neutrality is threatened by accidental or occasional extra therapeutic contact or gestures. Ultimately, it is devaluing of the capacities of both the patient and the psychotherapist. Why should the Rat Man not have been emotionally coherent enough to distinguish his total relationship with Freud from his relationship in the transference—to distinguish where he was afraid of Freud’s fatherly wrath, from Freud, the humane doctor, who looked after the well-being of his patient as a complete human being? But what if the patient wasn’t coherent? Then no sandwich? The incoherent or the insane go hungry? The debate goes on.

108

A rumor of empathy

It has never been any psychotherapist’s job or intention to frustrate a patient, even in an optimal way. Nor, strictly speaking, is it the therapist’s intention to gratify him or her other than providing a professional service for the fee. However, for better or for worse, frustrations are an inevitable part of life. The therapist does not want to frustrate anyone. Yet one day he will be sick and have to cancel an appointment on short notice. On another occasion, he will schedule a two-week vacation in advance, and, though the patient is in crisis, the therapist will take the vacation. Even the best therapist is human, and, will inevitably offer an interpretation or response whose timing or content is off, incomplete, or clumsy. While these may be experienced in the short term as abandonment, they are “good enough” in the sense that the material can be worked through in such a way as to recover wholeness and integrity. People miss their therapists while they are on vacation. Misunderstandings occur. Being on time and available is gratifying to the patient, but not in the way that Freud wished to rule out in the wake of the romantic entanglements of Jung, Ferenczi, Frieda Fromm-Reichmann, and others (a compelling, short account of these boundary violations can be found in Ricci and Broucek 1998: 47; see also Ross 2007; Friedman and Schreiber 2013). The original paradigm of optimal responsiveness is the gleam in the eye of the parent, proudly admiring the child’s accomplishments and the child’s reception of the recognition as confirming his initiative. This gleam provides the ideal, initial model for Kohut that invites forth and confirms the emerging structure of the self: A child and the mother are in the park. The child was a young child who clung to the mother. The sun was shining; pigeons were walking around there. All of a sudden, the child felt a new buoyancy and daring and it moved away from the mother toward the pigeons. He goes three or four steps and then he looks back. The general interpretation of that is that he is anxious, he wants to be sure he can come back, to be encased in her arms, cradles. That is true, but something more important is true. He wants to see the mother’s proud smile; he wants to see her pride [looking] at him walking out now, on his own—isn’t that wonderful— and at this moment, something extremely important had happened: a low form of empathy, a body-close form of empathy expressed in holding and touching . . . is now expressed only in facial expression and perhaps later in words: I am proud of you, my boy. (Quoted in Bacal 1985: 17; see also Terman 1988) No “optimal frustration” here. “The sustaining echo of empathic resonance [. . .] available in this world” is an experience that promotes emotional wellbeing for the patient who otherwise feels isolated and detached from human warmth. This passage speaks for itself, and we will let Kohut have the last word on optimal response.

Chapter 3

Plato not prozac!

Plato not prozac Up until this point, the author’s sharing has focused on his own countertransference reactions, musings, and responses. In this chapter and going forward, the author’s voice grows louder and more opinionated—indeed polemical. These are fighting words: resistance to empathy takes the form of the prescription of psychotropic medication (or the referral for such a prescription). I once had a psychotherapy supervisor whose anxiety spiked due to his pending vacation, during which I would continue working with an intermittently delusional patient. He suggested a referral for medication. Not exactly a vote of confidence in me or my empathic capabilities; nor do I need to comment further on his empathy. I decided not to call him out on his enactment. I decided not to show him my copy of the book by Lou Marinoff from which the title of this chapter is taken, Plato Not Prozac! Instead, I stroked my chin and sagely mused that I thought the patient would find such a referral deeply devaluing, and, more importantly, that it would undermine the therapeutic alliance. The matter was tabled. The patient was benefiting from the psychotherapeutic process, but even if she had not been, this individual was a survivor. She would survive psychotherapy with me— and with this supervisor. Diverse circumstances exist in which prescribing medication makes sense even to someone who is promoting “Plato not Prozac!” However, such situations tend to be “medicate to save a life in a time of crisis,” short-term chemical vacations, band aids, or temporary fixes. Thus, a case can be made of medicating someone who agrees to be medicated, and who is in immanent danger of suicide, homicide, or significant harm. Save a life and live to struggle onward. On such an occasion, medication is more highly valued than empathy itself, especially if the person is too upset to perceive the available empathy. What used to be called a “straight jacket” may be more highly valued than empathy if a life is at stake. Yet no substitute for empathy exists, even if empathy is correlated with oxytocin-like chemical processes, and empathy, like psychotherapy itself, can produce results that no other

110

Plato not prozac!

approach can obtain. Once a person is so upset and the situation has broken down to the point of violence, all bets are off. Call emergency services. Write the script. Take the medicine. Yet our way of relating to such medications in cases of authentic emergencies is far from the way we relate to other emergency measures. They are being used far more routinely for a wide variety of reasons such as inducing conformity, putting a bottom under a low mood, mood brightening, and, above all, because patients continue to request them and physicians are accommodating. Taking the easy way out is a growth industry. Our relationship with powerful psychotropic medications is in flux. Aldous Huxley famously remarked: “The need for frequent chemical vacations from intolerable selfhood and repulsive surroundings will undoubtedly remain” (1954: 64; see also Lane 2007: 170 for a blistering critique). In our own time, Peter Kramer (1993) has inspired controversy about the unintended consequences of personality brightening and being “better than normal” as a result of medication. As noted, Plato Not Prozac! is the title of a book by Lou Marinoff, professor and former chair of philosophy at the City College of New York. The short review: two thumbs up. A person who is suffering emotionally and whose conditions are not occasioned by physical disease, drug abuse, accident, or genetics may be suffering from a misguided philosophy of life, according to Marinoff. I agree. What to do about it is to have a conversation. What to do is to have a conversation for what is possible in attaining satisfaction and meaning that draws on empathy, humor, an appreciation of finitude, and such wisdom is available in our individual and community experience. Plato’s teacher, Socrates, said that writing was the ruination of memory. Thus, he never wrote down his dialogues. Socrates’ guidance lines up nicely with Freud’s injunction that the psychoanalyst should not take written notes in session, but maintain an “evenly hovering attention.” We know what Socrates said through Plato’s documenting the dialogue after the conversation. Thus, Socrates famously said: “The unexamined life is not worth living” (Plato’s Apology n.d.: 38a). This chapter makes the case for examining one’s life.

Examining the unexamined life The unexamined life is a life of unawareness. The unexamined life is a life on “auto pilot,” a life of turning away from tough questions. The unexamined life misses the meaning provided by taking on the challenge. The unexamined life misses the satisfaction provided by getting answers to tough questions. The unexamined life takes the easy way out as the default. The unexamined life consists in absorption in complacency and conformity. It consists in the illusion of reduced stress as the “pay-off” for not examining

Plato not prozac!

111

one’s life. In place of stretching one’s “comfort zone” one indulges in the consumption of material and status goods—think: “shopping therapy.” Selfmedication with alcohol, and recreational drugs while watching sports—not participating in it on the field—are a further index of avoiding confronting issues. Still, an impact and a price are inevitably a part of the process. A robust account of self-knowledge is required to disentangle the pay-offs and the trade-offs of market price versus human value. Any sustained engagement with self-knowledge, in turn, requires an elaboration of the lack of selfknowledge through the distinction “unconsciousness.” The person struggling with issues of self-knowledge is strictly speaking unaware of her or his possibilities and undeclared commitments. The explicit commitment to selfknowledge causes that of which one was unaware gradually to come into awareness. Thus, an account is needed of how the unawareness was overcome, enabling one to attend to what was previously hidden in plain view. A rumor of empathy lives in Socrates’ inquiries too. Socrates provides inspiration to this project of confronting and overcoming resistance to empathy. Without a Socratic confrontation with our self-ignorance, we settle for an easy and facile kind of self-knowledge. Alas, things are not so easy, and self-knowledge is mediated by overcoming the unawareness—the lack of self-consciousness—in which we live. Socrates made his life an example of the commitment to examining one’s life and taking responsibility for the consequences of one’s choices. Socrates took a stand that when individuals knew what was the right thing to do, they did it. But this was a peculiar kind of knowledge. It was not what today we would call “information.” It was a deep commitment to knowing one’s own character—one’s strengths and weaknesses—and making a difference in what matters to humans as human. The palpable counterexamples of the rampant lack of integrity in the behavior of some of Socrates’ comrades—witness the carousing in the Symposium and Alcibiades’ cheating —meant that self-knowledge sufficiently deep to motivate the commitment to an examined life was indeed a rare quality in his time—and in ours. Socrates’ commitment to undertake an inquiry into his own self-ignorance was an example to others to inquire into themselves. This set Socrates apart from his contemporaries, the Sophists, for whom knowledge was a selfcentered, grandiose display of intellectual pyrotechnics. Instead, Socrates was intentionality other-centered. This intention to be intentional about questioning those things of which we are most unaware, i.e. unconscious, makes Socrates a candidate to be the first psychotherapist. This iterative questioning created an opening for the possibility of meaning to show up. This iterative questioning created an opening at the center of the spontaneous initiative of inquiring into meaning according to which, paradoxically, all that stood fast was that Socrates knew that he did not know. Granted that every individual Platonic dialogue shows Socrates questioning fundamental human issues such as justice, knowledge, goodness, beauty, piety,

112

Plato not prozac!

etc. However, “off-stage,” either prior to or after the dialogue is finished, Socrates is just this questioning—questioning ready to encounter a matterto-be-questioned. The intention of questioning takes on a life of its own like a reiterated doubt that engages with whatever alleged certainty comes its way, but otherwise lives fully and intentionality as a commitment to questioning. Socrates is the one exception, he is the questioning pure-and-simple, ready to engage that which is questioned but otherwise living as a full intentional commitment to questioning. Such an open-minded commitment to questioning is one reason why Socrates did not write anything down and commit it—the questioning—to a fixed form that makes it accessible. This commitment to questioning generates specific psychotherapeutic results—all learning is reminiscence. In Plato’s account of Socrates in the Meno, the interrogation of the slave boy about the Pythagorean theorem yields an account of cognition as overcoming amnesia, the overcoming of forgetting through step-by-step questioning. All learning is remembering. In this is an early rumor is heard of “where id was there shall be ego” (Freud 1933: 80). Remembering what one already knows at some deep level and is called forth by the challenge of the inquiry. In Plato’s account of Socrates in the Theatetus, we get an account of inquiry as a dialogue of the two and the one. Inquiry is a conversation that one has with an other, but the other is oneself. An assertion is the true or false statement attained as the individual succeeds in being at one with himself, attaining self-cohesion and harmony. The two partners in the dialogue reach an agreement yielding a result that stands fast. Socrates does not undertake a psychotherapeutic inquiry in the narrow sense of the word by which we understand it today. But it is a fundamental examination of key issues that make life meaningful and satisfying. The inquiry is a dialogue and a conversation for the possibilities of expanding one’s humanness—the direct descendant of which is the psychotherapeutic process. Socrates explains his role as a mediator in his commitment to the art of midwifery, but of a particularly soulful, psychic kind. The role of the questioning questioner constitutes the essence of Socrates’ art of midwifery. In addition to being the first dynamic psychotherapist, Socrates deserves the credit for being the first to exercise empathetic receptivity in human understanding. This practice is not self-centered— having to do with the eloquent exposition of his own wisdom (as was the case with the Sophists)—but rather is centered on the other. Too many selfprotective mechanisms exist—too much resistance occurs—for an other individual to come to self-understanding without another to mirror back what is said and in reflecting the said transform it. Individuals are too close to themselves—to their own ideas, feelings, opinions—to develop conclusions directly and without mirroring. A second person—an other—is required to meditate the relation of the person to himself. The second person is needed to listen, respond, question. The second person makes explicit the relation

Plato not prozac!

113

of the one to oneself, thus resulting in three. A third person is needed to bear witness to the dialogue of the two. It is at first strange, but arguably accurate, to write of there being three, not just two, for the empathic responsiveness—i.e. the Socratic midwife—mediates the birth of the third out of the second. Socrates casts a long shadow. The psychoanalytic “third” is a rich metaphor that suggest that the patient and therapist are not alone and the space is inhabited by others emerging in the conversation (on the analytic third in a psychoanalytic context, see Ogden 1994). “The child of the soul” is this emerging offspring of wisdom. Socrates says: I am so far like the midwife that I cannot myself give birth to wisdom, and the common reproach is true, that, though I question others, I can myself bring nothing to light because there is no wisdom in me. The reason is this. Heaven constrains me to serve as midwife, but has debarred me from giving birth. So of myself I have no sort of wisdom, nor has any discovery ever been born to me as the child of my soul. (Plato Theaetetus, n.d.: 150c–d) Those whose minds are not barren, but are suffering the pains of examining their own issues require someone like Socrates, who is able to deemphasize his own individuality in order to minister to theirs. But Socrates’ art differs from that of the ordinary midwife in one respect. More often than not a “child of the soul” is a phantom, not wisdom but nonsense. This is why Socrates’ midwifery is balanced with irony. Things often turn out to be the reverse of what we might have expected. The search for wisdom leads to the confrontation with our own self-ignorance. The one who seeks the honey of self-knowledge risks the stings of distortion and disguise. The balance of midwifery and irony characteristic of the Socrates dialogue approximates that of empathic receptivity and empathic interpretation. Empathic responsiveness is engaged in a committed but disinterested ministering to the other’s travails in bringing forth such wisdom of which the person is capable. Wisdom is a deep appreciation of the limitations of our self-knowledge—Socratic ignorance. In the final analysis, the wisdom of which Socrates speaks is an encounter with one’s own deep ignorance—a wisdom that consists in knowing that one does not know. Today’s breakthrough turns out to be tomorrow’s ego trip. Today’s paradigm shift turns out to be tomorrow’s special case. Today’s insight ends up being tomorrow’s blind spot. The task seems endless. By this point, the reader may well be saying—“This is too much. Just give me the medication!” Examining one’s life is difficult—engaging in introspection increases tension. Introspection causes an increase in stress, an increase in felt discomfort. It is just too hard. The tension increase of introspection points, in turn, to surmounting the high bar of empathy as vicarious introspection.

114

Plato not prozac!

Examining one’s life is an undertaking rarely engaged gladly or voluntarily. Yet there is no other way to do it than voluntarily. It often requires painful setbacks as one strives to attain one’s goals. It often requires a sense that something is missing, an absence of meaning where one might expect satisfaction, in order to motivate the examination. Even then such a project of self-examination is a challenge to undertake on one’s own. When the world seems to be caving in on one, it is tempting to hide one’s head in the sand. Ignorance is bliss. But sometimes ignorance is just ignorance. No one said it would be easy. The citizens of Athens had Socrates to goad them on, act as a gadfly, and provide them with the tools of their inquiry. Thus, the recommendation is to find an experienced guide who has been down the path already, who can provide guidance in avoiding pitfalls and dead ends. Different kinds of guides are available. Up until now and going forward, the psychoanalytically oriented therapist will be the one engaged in this work.

The micro-narrative of a chemical imbalance I continue by examining my training as a psychotherapist at the local inpatient unit. When I was in rotation through the inpatient unit, my approach was to visit with and talk to the patients there. Given that the individuals with whom I spoke were discharged in a week or two, limited time was available to establish relationships. However, the work that can be accomplished in a few conversations should not be underestimated. Without exception, 13 out of the 13 people with whom I met during the rotation and had the micro-narrative: “My chemistry is out of balance.” Now if, after talking with a psychoanalyst, 13 out of 13 patients had maintained that they had an “Oedipal imbalance”—regardless of what it meant—then many skeptics would have seen it as a function of suggestion. While the uses of suggestion are debatable (Frank and Frank 1961 argue that suggestion is undervalued), Freud and his followers fought mightily against the accusation that the therapeutic results they obtained were a function of suggestion. Anna Freud’s well-known recommendation counseled psychoanalysts to maintain equidistance from the id, ego, and superego in a neutral, anonymous, and abstinent position. Yet given the micro-narrative about chemical imbalance, can there be doubt that the patients acquired it as an explanation for their suffering that was suggested by their pharmacologically oriented psychiatrists? The micro-narrative of the chemical imbalance has the benefit of reducing the guilt or shame just in case the patient is one of those who tends to blame himself. While neutrality is more usable to a suffering patient than moralizing, patronizing righteousness, or advice out-of-context, it is sometimes hard to say anything at all without taking a position that, to a sensitive patient’s listening, implies a suggestion (e.g. Renik 1996). Ironically, in this

Plato not prozac!

115

case, the suggestion is accurate—that there is indeed a chemical imbalance operating in the neurons and neurotransmitters in the individual organism. But that is not the point. The question is what is the cause and what is the effect of the suffering that led to the person’s admission? The experiences that these patients had gone through hypothetically resulted in the emotional upsets and distress getting encoded in their neural networks. Such encoding lives on. Once such experiences get transcribed into the neural chemistry, the neurons cause a chemical imbalance. It becomes a matter of definition that the individuals indeed did suffer from a chemical imbalance. I nodded my head in a professional way, and sagely stroked my chin, thinking, “Okay—this narrative of the chemical imbalance has value in reducing self-blame. The individual is already struggling. Do not make things worse by blaming oneself for something like moral degeneration. As noted, human beings are neurons all the way down, so it is an accurate statement. That a chemical imbalance exists and is introspectively experienced as a mood disequilibrium is a necessary truth.” Nothing is wrong with the micro-narrative of the chemical imbalance, but it is incomplete. Something is missing: “These neurons start to generate consciousness, community, and meaning—above all, meaning—so there may be more to the story than chemistry.” “Chemistry” is another word for “somatic compliance” (Freud 1893, 1893a, 1905, 1905a), that symptoms correlate with bodily states. The only other thought I had at the moment—also unexpressed, “You got that narrative from your shrink.” However, the story was the story, and I would not take the person’s story away from him. It might be all he had. Thus, I prudently did not contradict the micro-narrative of the chemical imbalance. Neither did I bring up Plato or Socrates. I did not engage in discussing the person’s philosophy of life unless the person brought it up. What I did was offer to provide a gracious and generous listening—empathy. What I did was to offer to listen to an account of the experiences that resulted in her or his stay in the hospital. I invariably came away with the sense that the person was enlivened by the conversation and saw new possibilities where previously boredom and lethargy had predominated. An enormous gift on my part? Of course not. Being in the hospital is incredibly boring. The staff try to keep the patients occupied with artistic activities, group sessions, cognitive behavioral therapy, and diverse meetings requiring social interactions. However, the ever-present guidance from the professional staff to me (and the patients) was not to think too deeply about one’s problems. I am not making this up. I repeat: The guidance was not to think too deeply about what was bothering one. We will return to this point. Now I wish to introduce one individual who contributed significantly to my training, who we shall call “Mr. C.” I call Mr. C as a witness to the resistance to introspection and empathy on the affective disorders unit. Mr. C. is a 40-something entrepreneur and executive with substantial intellectual property in software and with an advanced degree in computer

116

Plato not prozac!

engineering. He is most proud of his grown-up children—boys and girls, both—and his loving relationship with his wife of many years. He is high functioning. Articulate. Accomplished. Depressed. Really depressed. Periodically Mr. C would “hit the wall”—emotionally. It was not just low mood. He really became inert, apathetic, lethargic. Unable to function. Vegetative inactivity. A kind of emotional zombie. What does “hitting the wall” look like for Mr. C? Functionally? Emotionally? Behaviorally? He is quasicatatonic. He is responsive when spoken to, but not by much. He is not unconscious. Extreme loss of vegetative functions—appetite gone, insomnia and overwhelming sleepiness (“hyper-somnia”), low mood alternating with emptiness, and no mood and no motivation. He received treatment for previous episodes, and we shall shortly discuss that in more detail. However, the depression came back. He is unable to identify the trigger or the cause— “Overwork,” says Mr. C. However, similar to the chemical imbalance, this confuses the cause and the effect. The need to overwork is usually the effect, not the cause. It is a commonplace and everyone except the patient seems to know that overwork is an emergency measure prior to the eruption of a looming psychic event such as depression (e.g. Kohut 1971: 119): Patients will often attempt to counteract the subjectively painful feeling of self fragmentation by a variety of force actions, physical stimulation and athletic activities to excessive work in profession . . . psychosis precipitated by [so-called] overwork (Schreber) . . . the patient, sensing the rapid and dangerously increasing fragmentation of the self which precedes the overt outbreak of the psychosis, attempts to counteract it by frantic activity. The good news is that Mr. C is responsive and chatty. Why do I get the feeling that most everyone on the inpatient affective unit here is bored out of their minds, even given that some might have literally been “out of their minds” when they arrived? “May I introduce myself?” Formalities are handled. “I am in training. My one claim to fame is that I am the author of a book on empathy. My commitment is to listening. Will you let me get some practice?” He perks up. Now he is interested. “Okay, can we talk? How did you end up here?” I ask. “Hit the wall—happens from time to time.” (Mr. C further describes his symptoms.) “What do you think is going on there? Any ideas?” I continue to inquire. Mr. C is not shy: “Aaah, thereby hangs a tale. Mom was a homemaker. Great cooking. Dad was an executive—helping other people with their retirement planning. He had a temper. He would go off unpredictably. I would try to escape and run away. [. . . .] He would chase me around the dining-room table. Eventually he would catch me and I would get walloped.”

Plato not prozac!

117

I raise one eyebrow. I cock my head sideways and scrunch up my face as if to say, “Not good. Tough stuff.” I think to myself, “Okay, so we are laying down the neurotransmitters and connections and lack of them that, after fast forwarding a couple of decades, show up as the ‘hit the wall’ depression.” I say nothing. Never was it truer that one man’s transference is another’s countertransference. In turn, one’s countertransference is another’s empathy. At this point, I distinctly think to myself, “Interesting. This guy thought that he could escape from his father’s heavy-handed behavior, and so, in the moment, he tried to run away, literally resulting in a chase around the dining-room table. How does this compare with your own experience, Lou? In fact, I never tried to escape from my Dad’s bad temper. I never tried to run away. Does this mean I was masochistic? One wonders. Doubtful—first of all, every time Dad blew up, it was without warning. The first sign that I had done something ‘wrong’—according to some secret list of criteria of right and wrong known only to Dad—was that I got slapped. All of a sudden. No time to even think of escaping. It was like Pearl Harbor. Surprise attack. Explosion. And then later when I was a teenager, I knew that it did no good to try to escape since he would threaten to withhold the tuition from Loyola Academy, which was an essential part of my plan to get into a good college and escape once and for all from his controlling and domination. Financial abuse? One wonders about such retrospective redescription, though at the time I did not have the distinction. So I was after all trying to escape, but had a bigger plan—to escape for real and for good. Then, having escaped physically, I could begin the process of escaping, i.e. recovering emotionally in years of psychoanalytic therapy.” All of this was condensed and constellated in an instant, and, naturally, not explicitly or well distinguished until I sat down later to write it out. But perhaps a masochistic moment on my part occurred after all. Suffering is sticky. We keep going back to it like a tooth with an exposed nerve, probing it to see if it hurts. Ouch, yes, it still hurts. In my case, for a while, Dad even had me buying into the micro-narrative that it was best to “take my medicine up front and get it over with,” the “medicine” being a couple of stinging smacks. He had me persuaded to “shape up and fly right.” An awful phrase in that it shows he had me enrolled in the idea that there was something wrong with me, that I was not flying right. Much work in therapy was needed to disentangle those micro-narratives. It took me a while to realize—as I finally did in my own psychoanalysis—that it is useful to take one’s medicine up front when there is an issue with which the “medicine” can make a difference; but that Dad’s approach was mainly about making life better for Dad, having me fill his narcissistic needs, and soothing over whatever imaginary narcissistic wound I had unwittingly inflicted through my clumsiness or symbolic trespass of some issue of his to which I had no visibility.

118

Plato not prozac!

Years later, Dr. Hal Operidol (not the real name), one of my supervisors, would call my attention to Winnicott’s notion of “impingement” (e.g. Winnicott 1965: 52, 54). This rich, multifaceted concept is not just having to accommodate the other; it is a complex of expecting to have one’s needs met but instead having to accommodate the other’s needs while falsely pretending to have one’s needs met. Here the “false self” is a complying, placating—“there must be something wrong with me since the guy over there is totally loveable (well, maybe not)”—designed to protect a true self that is hidden away until some day the process of development can be unfrozen and resume. In that sense, empathic receptivity and communicability of affect can provide the warmth that starts the processing of melting, through empathic understanding, responsiveness, and working through. Mr. C hears nothing about my experiences, though I am immeasurably enriched by his generous sharing. Now back to Mr. C. He continues the narrative of this father’s bad temper. On several occasions, his Dad became so enraged that he concluded that the boy was incorrigible. This boy just could not be improved. He would have to be taken back. Returned—but to where? The stork did not give refunds. Now there was in this town an infamous reform school, a site of detention for juvenile delinquents called the Home for Wayward Youth (not the real name). This is what would happen. Dad would load the young, junior Mr. C of tender age into the back seat of the car to take him there and drop him off once and for all. However, when they arrived at the institution, it would happen that the gates were closed. They could not get in. So junior was given another chance. Was this some kind of sadistic, cynical joke or a devastating threat? Unfortunately, Mr. C was of a tender age—six years old—and he believed every word of it. He was crushed. Psychological annihilation loomed large. It became an ever-pending background threat. Even when the young C was not specifically in trouble, the threat of imposing such a sanction was devastating, lurking in the background to enforce compliance and thwart selfassertion. The narrative gives us access to the quality of the relatedness. In this case, we might say “traumatic unrelatedness” or abandonment. Nor would it take too much imagination to connect the adult Mr. C’s “hitting the wall” with his sudden reversal of fortune as the gates of the reform school irreversibly slammed shut like the gates of hell. Indirect confirmation was provided by Mr. C’s family background in detailed accounts of how the father gradually withdrew into himself, isolating himself in his study, not communicating with those around him, in the long-term slide into passivity and low mood that characterized the father’s later years. Knowing that I was a beginner, Mr. C attempted to train me further. As part of his self-diagnosis, he recommended a book, I Don’t Want to Talk About It: Overcoming the Secret Legacy of Male Depression by Terrence Real (1997). I ordered the book and read it. But by then Mr. C was long

Plato not prozac!

119

discharged from the unit. The title said it all. This was the issue with which Mr. C was struggling. His deep lethargy, bordering on loss of presence, was a dynamic adjustment to the reactive rage and subsequent inhibition born in the searing relationship of his father’s physical and emotional abuse. What happened is unknown when Mr. C turned to the attending physician supervising his electroconvulsive therapy (ECT) sessions, affectionately and cynically known to the staff as Flash Gordon (not his real name), with his extra-curricular reading. A dedicated professional, Flash was doing what we all do—“you sell what you got”—offering, providing, facilitating, promoting, the service that he knew and had available. I came away from my interaction with Mr. C with the distinct feeling that he was an individual who was suited for and would benefit greatly from talk therapy. Yet so many obstacles existed on the affective disorders unit to even raising the matter. They dismissively said that I was out of touch with reality. I was. My status was basically that of a “guest” on the unit. How do I explain that one might do as much good in three weeks of psychotherapy, for example, on an every other day basis as one could do in three weeks of ECT, including some on an outpatient basis? You know, ECT may include a few microbursts over a period of a couple of minutes; but, after that, the individual has to spend the day in recovery. The day is shot. I’m not saying it will ruin your day; I’m saying it will consume your day, and consume it without remainder and the time must be charged to ECT. While guarantees do not exist, give a psychotherapist all that time in “short-term” psychotherapy with this high functioning individual, and the results could very well be just as effective if not more so. Sadly, we will never know. Once again, coming out of this conversation, I had the distinct feeling that Mr. C was training me in being introspective and empathic. In this case, notwithstanding my interest in Kohut, I had the thought that the objectrelational approach was front and center. Mr. C had internalized the punishing role, figure, imago, of the punitive father. The chase around the table with the father lived on with the powerful affects just below to the threshold of awareness. The chase created a struggle in Mr. C that consumed the energies he needed to live a productive, emotionally engaged life. The physical blows were bad enough, but the father’s studied enactment in disowning the boy and credibly pretending to send the child of tender age to the “reform school” must have landed traumatically. A hostile introject— the punitive, abandoning father—continued to live on; and it was just not obvious to Mr. C how that related to his “hitting the wall.” We often underestimate the challenges of self-knowledge and overestimate those of knowing others. It is often easier for an outsider to connect the dots; and it had taken me approximately 15 minutes. Once again, the point is not that I am so empathic, but that short-term dynamic psychotherapy was a good fit for the overall situation. With all due regard to the many psychologically sensitive and astute software developers practicing in the world, Mr. C was

120

Plato not prozac!

apparently not one of those on this particular occasion. Either that or he simply came from a background where a technological fix—in this case ECT—to a problem had priority over introspection and empathy. The absence of the possibility to talk out an empathic narrative meant that neither he nor his family would have an opportunity to find out about the value of empathy. The micro-narrative about “chemical imbalance” was a common occurrence during my tenure on the inpatient affective disorders unity. Actually, there were no exceptions. None. A micro-narrative would be presented to me about a chemical imbalance. Next, a ten-minute conversation would implicate complex and unresolved emotional issues. Not every individual was as out front about the experience that significantly contributed to their neurons being out of balance as Mr. C, but everyone had a sense of the failures in relationships that drove the emotional imbalance. Now the skeptical reader may expect me to say that the micro-narrative about the chemical imbalance was inaccurate. Far from it. This is not mere narrative truth, though it may be that also. It is historical truth, with a reference to a neurochemical reality in the brain of this individual with whom I was having a conversation. The micro-narrative referred precisely and accurately to a state of affairs that existed in the nervous system and brain of the individuals in question. The chemistry does seem to have been imbalanced. As Mr. C’s father chased him around the table at age five and caught up with him and hit him and drove him at age six (and thereafter) to the local reform school for juvenile “delinquents” and enacted a threat to drop him off, abandoning him there, neuronal connections were being laid down in the young Mr. C, the person. This happened many times. Patterns were being formed in the neural networks corresponding to his relationship with his much admired, loved, abusive Dad. While much opportunity is available for hypothesis, speculation, and debate, given that humans are composed of neurons and chemicals, how could it be otherwise? The chemical imbalance was evidence that some untoward events = x had transpired in Mr. C’s developmental reality. This was not some recovered memory. He recalled the details. The accessibility of the affect—fear, shame, rage—was arguably problematic. He was well protected against them, but the thoughts were definitely not repressed. The young Mr. C got chased around the table. He tried to escape. It didn’t work. He couldn’t run fast enough. The chemical imbalance was not some arbitrary accident due to the influence of the planets in the solar system on human neurology. In this case, significant evidence is available that the imbalance as experienced was due to traumatic events, but the psychic elaboration and what the individual made the events mean were unexplored. The friendly skeptic may well say, “Granted that the chemistry was out of balance for whatever reason, why not fix it using the best available

Plato not prozac!

121

chemistry?” Negative experiences caused a chemical balance. Maybe rebalancing the chemistry using chemistry would open up the possibility of positive experiences. Indeed, why not? The answer is complex, but compelling. The result of fighting fire with fire—a chemical imbalance of neurotransmitters with more chemicals (neurotransmitters)—is to promote rapid cycling of the disorder. Disorders that might spontaneously or eventually remit are shifted in the direction of a chronic cycle of recurrence, and this applies not just to mood disorders but seems to apply to thought disorders, too (Ronalds et al. 1997; van Weel-Baumgarten et al. 2000; Patten 2004; Whitaker 2010). Fighting fire with fire produces scorched earth. Unfortunately, in this case, medications had been tried earlier, and they did not work. The point was moot. So the recommendation, long before I met this individual, was ECT. I was in effect a guest on the unit and in no position to object. Yet another neutral bystander? I said nothing. I am not proud of it. This book is my response and a belated attempt at remediation. Yet I knew that three conversations with Mr. C had noticeably shifted his mood— “brightened” him up significantly—and I was at a loss why neither Mr. C nor his doctors saw value in doing more of the same. Expanded recognition and appreciation is required that conversation can change one’s neurons. The nervous system (and brain) changes in response to the experience that one has in relating to other people, including psychotherapists listening with empathy, responding optimally, or optimally frustrating the speaker. All these and more promote changes in the organism. New experiences of being listened to and appreciated provoke a permanent anatomical process causing neurons that fire together to wire together (Turnbull and Solms 2003). Arguably, the method of talk therapy, in its various forms, is less invasive. There are fewer—none—FDA-required warning black labels about toxic side-effects of conversation, and, I am so bold to say that the chance of drug-induced convulsions followed by coma and death is statistically zero. Make no mistake—words—conversations— are a powerful method of engagement and transformation. Words have the power to move mountains—through the actions that the words inspire in men with steam shovels. Words have the power to set armies marching—through the actions that words inspire in men who march on Washington, DC. Words have the power to apply a soothing balm to an emotional wound—through the actions that words perform in inspiring relatedness and empathy. We also operate at a level of commitment and community in having a conversation that examines one’s life where the patient gets to set the agenda and is guided in those areas where the psychotherapist’s experience is broader and deeper. Evidence of the effectiveness of talk therapy is substantial and needs to be better known (e.g. Frank and Frank 1961; Goldberg 2011; Orlinsky et al. 1978; Orlinsky and Howard 1986; Orlinsky and Rønnestad 2005; Schlessinger and Robbins 1983).

122

Plato not prozac!

From a rumor to a scandal of empathy in psychopharmacology Freud started out as a neurologist. Two words from Freud speak volumes: “somatic compliance” (1893, 1905). Nothing happens unless the body cooperates. Nothing. And yet upon autopsy of the hysterics and obsessional patients of his day no discovery of an anatomical lesion occurred. None. Nothing anatomically, neurologically, physiologically pathological could be identified as the cause of the disorder. The function was disordered, not the structure. While it is theoretically possible that additional resolution of imaging may disclose a hitherto hidden pathogenic element, there is every reason to believe that with disorders of behavior, ideation, or mood, additional imaging resolution will show correlations—somatic compliance—but not causation. Under one redescription, the challenge to those dedicated to relieving human suffering is how to adjust the neural patterns in an adult. Surely neural patterns change in an adult more slowly than in the young. Yet even the adult brain is plastic. Perhaps more plastic than was previously believed, though, once again, in different ways at different stages. The brain responds to experience. On-going research shows that the brain is responsive if given the right kind of stimulation and inputs—that is, new experiences of a useful and wholesome kind. As the philosopher Immanuel Kant (1781/1787 [1997]: 136; B1) argued, although all knowledge begins with experience and without experience we would have no learning, it does not follow that all knowledge arises from experience. Perhaps this source includes meditation— “meditation” not “medication”—practices or relaxation technologies such as sensory deprivation, meditation, or yoga that promote the transfer of information from the short-term memory to the long term. Paul Ekman (2008) quotes the Dali Lama as requesting expanded scientific research on the effects of meditation—meditation, not medication—in a non-Buddhist, secular context. An expanded capacity for introspection and empathy is likely to be one of the results.1 In 1993 Peter Kramer’s Listening to Prozac knocked the knees out from under all kinds of talk therapy. As the “jewel in the crown” of talk therapies, psychoanalysis was also on the list. Dr. Kramer reflected on the example of one patient where he thought that perhaps the individual’s personality had become “too bright” and perky. Had the personality become better than normal? Was this over-medication?—Kramer asked her (in so many words). No, she pushed back. She had always been that way, at least potentially, and the medication helped her to overcome her limitations and realize her authentic personality. This individual became the “poster child” for Prozac (floxatine). What Peter Kramer reported was that after the administration of floxatine, he found that the response was such that he was in the presence of another person. This is every psychopharmacologist’s dream—to produce

Plato not prozac!

123

an awakening—to bring forth humanity where there had previously only been inertness and dullness (the very paradigm of which is Oliver Sack’s Awakenings (1973)). Whereas the individual had been apathetic, unresponsive, lethargic, in short, depressed, afterwards the person was enlivened and emotionally engaged. One could have a conversation. However, Kramer then eventually came to regard the conversation itself as superfluous. All the work had apparently already been done by the medication. It is not so much that there was nothing to talk about as that the mood brightening was sufficient to enable the relatedness in the person’s life outside therapy for which the person had sought therapy. And yet ambiguities remain. A rumor is at risk of becoming a scandal of empathy as the line between the mentally disordered and merely unconventional free spirits is blurred. Mild afflictions such as shyness have been recategorized as diagnosable disorders, e.g. social awkwardness, opening up new markets for existing and emerging anti-anxiety medications (see Lane 2007: 170 for a compelling critique). The neurochemical reshaping of personhood (Rose 2003) and cosmetic psychopharmacology are the order of the day. One key question is whether the administration of the medicine makes the person more or less like who they see themselves to be. If subclinical dysthymia (mild unhappiness) is getting in the way of success at work or in relationships, then why shouldn’t one address the issue with every legal means at one’s disposal (such as prescription drugs from a cooperating psychiatrist)? Did the medicine bring out aspects of the personality that were blocked and inhibited by the depression in the person or did it create something like a temporary, emergency personality to cope with the expediencies of the moment (Lane 2007: 171)? It turned out to be a deal with the devil. At first, those who said that psychotropic medications were such a deal were summarily dismissed. Yet soon reports emerged of cases where floxatine was implicated in less favorable outcomes (e.g. Breggin 2008; Healy 2003)— one was never quite sure what was cause and what was effect. These unfavorable outcomes include the suicide of individuals who did indeed seek medical advice for what might be described as “personal issues,” including low or unstable mood (“depression”). Yet the issue was that the individual did not seem to be suicidal—prior to taking the medication. Suffice to say that major litigation resulted (Healy 2003). Nor was the controversy restricted to floxatine or SSRIs (selective serotonin reuptake inhibitors), and included examples where individuals became homicidal instead of suicidal, implicating the criminal justice system. Other individuals seemed to become unstable upon stopping taking the psychotropic medication. So suddenly stopping taking the medication can be as risky as starting taking it (see Breggin 1991: iii; Breggin 2008: 293). A double bind indeed. Even if Kramer was not responsible for how others redescribed his vision and even if the ultimate outcome was disappointing, the promises of

124

Plato not prozac!

“personality brightening” in a pill were abroad in the land. It turned out to be worse than disappointing—and, as with all deals with the devil, reading the fine print was of the essence. Some forms of unipolar depression were temporarily shifted and interrupted by fluoxetine, but the effects on bipolar depression were profoundly unpredictable or even negative. The complex differential diagnoses between unipolar and bipolar became a matter of controversy even among accomplished psychopharmacologists, the latter being all too rarely consulted by the family doctors and front-line general practitioner MDs prescribing the now in-demand SSRIs. Some “misdiagnosed” patients “went up” and incurred suicidal ideation and behavior with tragic results. It gets worse. Significant evidence has been published since 1992 that SSRIs increase the rapid cycling of a disorder that might otherwise have a significant chance of remitting spontaneously or remitting under the influence of traditional talk therapy. This research is complex, but compelling (Ronalds et al. 1997; van Weel-Baumgarten et al. 2000; Patten 2004; Whitaker 2010). The growing concern about “rapid cycling”—shifting the disorder in the direction of becoming chronic and recurrent—has spread, along with the pharmacological “revolution,” from bipolar medications to anti-anxiety, attention deficit, antidepressants, and even so-called second-generation anti-psychotic ones. Second-generation anti-psychotics are another chapter in the story. This is especially so as they are now sometimes added to antidepressants as “enhancers” or “modifiers.” Here the news is even more sobering. Stephen Stahl is one of America’s most published psycho-pharmacologists. Therefore, it is all the more compelling when Stahl writes: Atypical [so-called second generation] antipsychotics have been on the market for over a decade, and only now [2008] is it becoming clear that some of these agents are associated with significant cardiometabolic risk . . . and with pharmacological actions that may mediate this cardiometabolic risk. . . . At first, weight gain and obesity were clearly linked to atypical antipsychotics, but more recently, increased risk for dyslipidemia, diabetes, accelerated cardiovascular disease, and premature death have been linked to certain drugs in this class as well. (Stahl 2008: 383) “Premature death” indeed. Such statements are bound to give pause to any overzealous tendency to medicate. Most talk therapists, including psychoanalysts, will take a hard look at the cost/benefit calculation. They will hesitate in the face of the use of medications, all other things being equal. Why? As soon as the going gets tough and the patient faces uncomfortable truths about him- or herself, the temptation looms large to escape into a medication-induced mood-altering state, embracing the unexamined life. However, in the face of a constant drum-beat of prospective patients requesting a way to feel better right away—even though the psychotropic

Plato not prozac!

125

medications demonstrably do not work “right away”—and driven by now legal and—how to put it delicately?—self-serving advertisements from pharmaceutical manufacturers, even savvy practitioners, who ought to know better, can feel pressured into writing scripts or making referrals when they should be examining the patient’s life with the patient in context, duration, intensity, and depth. Growing numbers of studies are providing robust empirical data support that psychodynamic methods such as psychoanalysis are effective forms of therapy, not just in themselves but over and against psychotropic medications. This is definitely not a micro-narrative, and I ask the reader’s patience as we must necessarily spend some time on the complexities of evidence-based interventions. Evidence-based interventions are distinct from evidence-based outcomes. Further, evidence-based treatment as an outcome is distinct from evidence-based practice as an outcome. Given these distinctions, mere behavioral interventions are vulnerable—to trivialization. In the former, the research looks at whether the actual intervention strategy or treatment paradigm is responsible for any change, specific change, or change in a hypothesized direction as observed. Never was it truer that correlation is not causation. Evidence-based practice refers to a process of finding the optimal treatment protocol for a person, given the individual differences that exist for any single, actual person. For example, in a detailed meta study of the efficacy of psychotherapy assembled by Jonathan Shedler (2006, 2010) compelling documentation is provided that psychoanalysis is indeed evidence-based psychotherapy. In order to understand Shedler’s contribution, one needs to know the meaning of an “effect size.” Shedler writes: An effect size of 1.0 means that the average treated patient is one standard deviation healthier on the normal distribution or bell curve than the average untreated patient. An effect size of 0.8 is considered a large effect in psychological and medical research, an effect size of 0.5 is considered a moderate effect, and an effect size of 0.2 is considered a small effect. . . . (Shedler 2010: 100) Shedler’s reports must simply be seen to be believed: A more recent review of short-term (average of 30.7 sessions) psychodynamic therapy for personality disorders included data from seven randomized controlled trials. . . . The study assessed outcome at the longest follow-up period available (an average of 18.9 months post treatment) and reported effect sizes of 0.91 for general symptom improvement (N = 7 studies) and 0.97 for improvement in interpersonal functioning (N = 4 studies). (Shedler 2010: 101)

126

Plato not prozac!

These results need to be better known. When compared with the effect sizes of medications, the results reported by Shedler are embarrassing—to the medications: An analysis of U.S. Food and Drug Administration (FDA) databases (published and unpublished studies) reported in the New England Journal of Medicine found effect sizes of 0.26 for fluoxetine (Prozac), 0.26 for sertraline (Zoloft), 0.24 for citalopram (Celexa), 0.31 for escitalopram (Lexapro), and 0.30 for duloxetine (Cymbalta). The overall mean effect size for antidepressant medications approved by the FDA between 1987 and 2004 was 0.31. . . (Shedler 2010: 100) Nor were Shedler’s results restricted to short-term results: A meta-analysis reported in the Journal of the American Medical Association . . . compared long-term psychodynamic therapy (= 1 year or 50 sessions) with shorter term therapies for the treatment of complex mental disorders (defined as multiple or chronic mental disorders, or personality disorders) and yielded an effect size of 1.8 for overall outcome. The pretreatment to post treatment effect size was 1.03 for overall outcome, which increased to 1.25 at long-term follow-up (p = .01), an average of 23 months post treatment. (Shedler 2010: 100) In addition, further studies of psychodynamic therapy have shown that time and intensity can make a significant difference. That is likewise the case with psychoanalysis. Longer treatment sessions and more intensive sessions (i.e. more times a week) also demonstrably increase the effectiveness of therapy. Thus, the evidence of the effectiveness of psychoanalysis and its cost-based advantages are well documented. In addition, a final consideration for the cynics and skeptics: If a procedure or method cannot fail, then, by definition, it also cannot succeed. Psychoanalysis and dynamically oriented talk therapy do both (in addition to Shedler’s 2006, 2010, see Frank and Frank 1961; Goldberg 2011; Schlessinger and Robbins 1983; Orlinsky and Howard 1978; Orlinsky and Howard 1986; Orlinsky and Rønnestad 2005; Wallerstein 1986). The examination of a person’s life—especially if the individual is struggling with an issue that is a source of pain and suffering—works best when undertaken in a context of empathy. Absent empathy, examining one’s life, is comparable to undergoing dental work. No wonder that time-constrained, stressed-out practitioners rely on the use of powerful psychotropics. Nothing wrong with that as such. No one is recommending dental work without Novocain. However, Novocain does not work in psychotherapy. The result is numbness, not vitality or aliveness.

Plato not prozac!

127

Also worth noting is the alternative micro-narrative: “Take your medicine.” Kay Redfield Jamison is a self-described individual who suffers from mood swings categorized as bipolar disorder, cycling type. Recommended reading includes her body of work, which are “page turners.” Jamison has contributed a series of gripping works (Touched with Fire (1993), An Unquiet Mind (1995), Night Falls Fast (1999)). Any time spent with Jamison’s body of work is time well spent. She is also a Ph.D. psychologist and professor of psychiatry at the University of California, San Diego. She reports that she takes lithium and benefits from it. If one is thinking of suicide, homicide, self-harm or harming others, then “any port in a storm.” Take the medicine under the guidance of a properly trained physician. Live to fight another day. Do not overlook her guidance that each individual has to figure out what works best for her or him in cooperation with trusted professional advisers. Still, the relationship to powerful psychotropic medications to be used only in the case of an emergency is far from the way we relate to other emergency measures. The sense of this section is that the pendulum has swung way too far in the direction of Big Pharma. The tendency to medicate, the slide towards the bottom of the slippery slope to escape the tough issues and tough questions, needs correction based on each individual’s thoughtful examination, preferably with a trusted and empathic listener, of the issues and possibilities. Further details on the case against Prozac are reviewed in the dramatic narrative by David Healy in Let Them Eat Prozac (Healy 2003). Follow the advice of one’s trusted medical doctor regarding the risks of taking or stopping taking medicines (see Breggin 1991, 2008). In this chapter, an educational narrative about the author’s personal training as a psychotherapist emerges, not advice to take any particular action or not. The author’s commitment is to empathy and expanding empathy in the community, including the community of psychotherapy services. Mental illness is a possibility for human beings who are unable to express their pain and suffering in any other way, given the constraints of the community, the limitations of their personalities, and their powers of selfexpression. We do not want to idealize or romanticize the authentic emotional suffering and distress of the seriously confused, the unconventional, the socially awkward, or the insane. Many of these individuals are experiencing intense suffering, and the distress as such is neither instructive, edifying, nor entertaining. It is the breakdown and loss of life in its emotional and human dimensions. Yet in a manner of the playful attitude of W. D. Winnicott, and like him, we may discover more psychosis in our sanity and more sanity in our collective and individual psychosis. With anxiety now a qualifying criteria for disability benefits from Social Security in the USA (and parallel considerations in the European Union) mental illness is a growth industry. In any given context, we are all socially awkward.

128

Plato not prozac!

The lesson learned is that the process of conversation between two human beings, one of them a psychotherapist, can be as powerful an agent for reducing emotional suffering and creating possibility as any psychotropic medication, and the conversation will likely have fewer medical side effects. In a sense, the “method of choice” is what the prospective patient requests as she or he comes in the door. In another sense, the prospective patient needs to be well informed in order to make a choice and that may usefully include a trial course of psychotherapy. In any case, any medication has a cost-benefit and risk profile that requires careful consultation between patient and practitioner. The rumor of empathy in psychopharmacology remains a rumor.

A rumor of empathy on the inpatient unit As much unconditional respect as I had for the psychiatric residents, attending physicians and the director of the unit, this was nothing compared with the high regard, friendliness, and warmth with which I was greeted by the nurses on duty in the unit. These individuals were at the front lines—in the trenches so to speak—and running the enterprise. Their good will was essential. Who was I for them? I introduced myself as being in the program from the local psychoanalytic institute, the latter lending me a certain dignity, with an academic background and not an MD. Yes, you had heard right, I was the author of a book on empathy. That consistently raised an eyebrow and elicited an expression of interest. I mention this, not to exhibit my partially analyzed grandiosity but to highlight the response. The nurses said, “We need that—empathy. We need more of that. Let’s organize an ‘inservice workshop’.” I replied that it would have to be permissioned by the director, and I would ask. Here are the facts. I made the request. The answer was an unequivocal “no,” and “what are you thinking?” “Fergedaboutit.” “But why not?” I wondered. No reply. There was no debriefing about the negative answer. I am not proud to admit it, but it was at this point that I stopped referring to her in my own mind as “the Director” and started thinking of her as “Big Nurse.” My status—to use a charitable descriptor— was at risk of being persona non grata. I was in no position to escalate since I would have simply been sent home—rotation over. The resistance to introspection and empathy on the inpatient unit consisted in “being practical.” The facility was state of the art, but there was no place to close a door, hang out an “in session” sign, and perform psychotherapy one-on-one. The staff had periodic meetings, and one could always insert a note into a patient file. But, as far as I could see, no opportunity was available for the staff to debrief on their encounters with patients that raised difficult or troubling issues for the staff or the patient. Getting to an “emotional clearing” by having a confidential conversation with an experienced colleague was not a possibility for the staff, unless they separately hired a psychotherapist on their own time and dime. The policy that codified

Plato not prozac!

129

resistance to empathy was subtle but pervasive. The patients were counseled “not to think too deeply about what is bothering you.” However, the staff were interested in thinking. Human beings are designed as thinking beings. We can’t not think. Thinking happens and in spite of all efforts. The staff were hungry to obtain guidance regarding self-care, professional activities (such as a workshop on empathy), but it was not the approach or policy on the unit, which, more charitably redescribed, was oriented towards “being in the here and now.” The program was designed—I think properly—to keep the patients occupied without too much time for reflection. Given the overall low mood— it was, after all, an affective disorders unit—too much time for introspection was at risk of being elaborated into melancholy ideas and “negative self talk,” reflecting shaky self-esteem. For many of the patients, the glass was indeed half empty. For the staff, this resistance to introspection and empathy took the form of letting perfection be the enemy of the good. Be practical. Since one could not alter a person’s life through a few empathic conversations or a couple of weeks of work—a complete “cure” (whatever that would be)—it was judged best not to take the risk at all. Other than my conversation as a psychotherapist and the kindness of the residents and attending physicians during their visits to check on well-being and adjust medications, no evidence of talk therapy existed. A short-term course of psychotherapy could easily hit 10 or 20 sessions in a two-week period if undertaken in a suitable framework. It could be started on an inpatient basis and continued after discharge. The power of dynamic psychotherapy to access a pathogenic secret or at least a disruptive skeleton lurking in the closet is unsurpassed given the engaged presence of a gracious and generous listening. Even if empathy is defined not primarily as optimal responsiveness but merely as a method of accessing the experiences of the other person, the power of bearing witness, acknowledging, and recognizing suffering can make a profound difference in accelerating the process of recovery. In short, the opportunity presented by short-term psychotherapy was missed. The rumor of empathy on the inpatient unit was stymied by institutional resistance to empathy. Still, the following lessons learned were available. Clinical vignette: redescribing youthful indiscretion

So it is now my first day on the unit. I come at the assigned time. I check in at the nurse’s station. Of course, an entire group of new people are present from a different shift than the people to whom I was initially introduced, so I have to explain who I am yet again. However, a written record exists on the master schedule that some individual—in this case myself—will show up and please give this lost soul some guidance. So I check in with the nurse as to what patient might be open to and benefit from a conversation.

130

Plato not prozac!

No further goals are specified nor need they be defined since the conversation would work as a way of getting in touch with the here and now, relieving the boredom that is pervasive in such a milieu, or even working on what is really bothering you. Oops, I should not have called out the latter, but it seemed to pass unnoticed for the moment. The nurse recommends that I introduce myself to the women in room 203, Ms. G. So I am off to my training. So far, all this is the marketing brochure. The design and intention. Now the reality. Ms. G (a 50-something Caucasian woman with two grown children and a 30-year marriage) has just come back from having ECT and is flat on her back. I think to myself, “This is it. Find out if she wants to talk.” I introduced myself “Hi—my name is Lou Agosta, and I am in training to be a psychotherapist. Would you be interested in having a conversation?” It turns out that she is. Her first complaint is that she can’t remember things from one moment to the next. I definitely do not say, “Well, that is because they were just blasting your brains out with ECT and fewer functioning brain cells are now present than were present when you got up this morning.” Heck, that might not even be true. The chairman of the department, Dr. Al Prazolam (not the real name), one of America’s great psycho-pharmacologists, was explaining to me how the technology has come a long way from the time when this black box was plugged into the wall and the doctors would complete the circuit using the patient’s head. He did not quite put it that way, but that was the gist of it. Now the device delivers microbursts of electrical impulses on the order of six per micro second. This was a vast improvement over prior technology. Definitely. Dr. Prazolam explained that he was personally familiar with the case of Hemingway, another tortured soul if there ever was one, who did not take the recommended ECT therapy at the Mayo Clinic that Dr. Prazolam’s colleague had recommended. Hemingway was concerned it would inhibit his writing. He then went home and committed suicide with a shotgun. I acknowledged to Dr. Prazolam that not a lot of empathy was required— indeed, virtual insensitivity would suffice—to appreciate that the shotgun approach definitely did not do anything for Hemingway’s writing. Point made. Returning from my momentary reverie, I put on my most reassuring and soothing voice and say “Well, the memory issue is most likely a temporary side-effect of the treatment you have been having; and the memory will return in a matter of days, but given that I am not an MD but a Ph.D., check with your medical doctor.” Okay, so I pass my first test. I am not a complete moron. Ms. G is going home soon to a large house on the water in a prestigious resort community famous for its Old Money. Her husband is a successful entrepreneur. He works a lot. A real lot. They have grown children. Without further logical transition, she volunteers the information that early in her marriage, many years ago now, when her husband was a

Plato not prozac!

131

total workaholic, making the first of his many fortunes, she had an affair— a sexual encounter—now long past. So even if the short- term memory was temporarily an issue, deeper memories were still available. I got the distinct impression, though I could not prove it beyond a reasonable doubt, that everyone knew about this affair and this was far from being the “Pathogenic Secret.” In spite of the side-effects of her treatment, Ms. G had sized me up with remarkable rapidity, and she had decided that, rookie that I obviously was, I was still a decent fellow and she would be willing to train me. Her thoughts were in effect: “Let’s see what he does with this old saw, this old micro-narrative.” It was more like a well-worn, comfortable source of suffering that Ms. G trotted out when she was in a mind to justify the low mood she was already experiencing and find a further pretext to “torture” herself. It might also have been a form of compliance of someone wanting to relate as a “good patient” and give the rookie therapist the training to which he seems to aspire. The question that Ms. G posed for me right upfront was “When will I feel better? This ECT is supposed to tune up my brain chemistry. But I still don’t feel better. When will I feel better?” No pressure—and, by the way, let’s cut to the chase. The clock was ticking, the time was running out, other visitors were waiting to see Ms. G. Since she was going to go home soon. I might never see her again. The answer? “Well, Ms. G, I am kinda shooting from the hip here, but let me see: When you forgive yourself for your youthful indiscretion, you will feel better. You will feel better in proportion to your success in forgiving yourself.” An optimal response? An empathic narrative? I will never know. When in doubt, push back against the overly scrupulous, inner representations of punishing, punitive reminders of scolding parents, teachers, and authority figures of all kinds. When in doubt, push back against the superego. I had the feeling that she already knew that, and, once again, she was testing me, the rookie, and perhaps, in her generosity, giving the new guy—the trainee—some psychodynamically relevant material to chew on. However, now I am not so sure. Given the course of treatment that she was undergoing, she may never have heard the guidance before. No one even thought about the relationship. No one even asked. Notwithstanding the brevity of the encounter, it seemed to me to be straight out of Freud’s essay on “Mourning and Melancholia” (1916). The shadow of the object fell on the ego. There was perhaps a whole world of unexpressed communications, reproaches against the absent workaholic husband, reproaches against herself. Yet I had one data point—a youthful indiscretion. The long shadow of the past indiscretion, the incomplete and unexpressed upset over much financial wealth and limited emotional riches were a cliché, but a resonant one. Still, I got the distinct impression that my training was well begun. This individual had given me a significant lesson, a gift even, as she generously

132

Plato not prozac!

shared her experience with me and thereby unburdened herself in some small way. It is not like she had a lesson plan. Heck, she had just returned from ECT and was literally flat on her back. Nevertheless, I was in no position to run enthusiastically back to the nurse’s station and say, “Hey, guess what I learned?” In fact, Ms. G had thought deeply, even if only momentarily, about what was really bothering her. Perhaps I had unwittingly undone an entire treatment plan that focused on ECT and making the bothersome, albeit unacknowledged, thoughts return to the oblivion from which I had unwittingly invoked them. Yet such an accusation would be misleading and unfair. I had done nothing other than make present the possibility of empathy in the form of a conversation. Empathy occurs naturally. Empathy occurs spontaneously unless the people having the conversation actively take steps to squelch it. Ms. G’s memory of this indiscretion was persistent and survived many years and many treatments. It was waiting for someone to say merely, “Hey, I’m listening— wanna talk?” In spite of my ambiguous and edgy remarks about the policy actually codifying resistance to introspection and empathy—the policy being “do not think too deeply about what is bothering you”—everyone on staff whom I met on the inpatient affective unit, without condition or qualification, was professional and helpful—no exception. I get the distinct sense, “These good folks—such as Ms. G—could train me—in listening, in empathy, in so many things—if I let them do so, if the system let them do so.” Once again, Dr. Prazolam’s advice was first rate—concise and to the point—get out of the way of the patient and let her tell you the narrative. I later learn by chance reading that Freud had the same thought, referring to one of his early patients, Cäcilie M (Anna von Lieben) as his “former patient and teacher,” because she insisted that Freud stop being so active and simply let her tell her story, opening the way to using free association as part of the talking cure (see Appignanesi and Forrester 1992: 86–87). Reinventing the wheel is hard work; but in many cases—such as learning psychotherapy—there is no other way to do it. Clinical vignette: redescribing saying “good bye”

The next person I met was named “Ms. L.” She was a 20-something Caucasian woman who was hospitalized for a suicidal gesture that had reportedly been bloody, dramatic, and messy without rising to the level of a life-threatening injury. The back story was that she had escaped with her late mother from a regional conflict in the Third World just ahead of the paramilitaries. Ms. L was articulate and expressed herself well. Her education included the better part of the credits for a Master’s degree in education. Her manner of dress on the inpatient unit included a bathrobe and p-jays. However, for the first session with me her manner of dress was

Plato not prozac!

133

seductive with a high hemline, baby-doll style, and décolleté. I did not ask whether Ms. L was familiar with the writings of Nabokov. In answer to my inquiry about the occurrence of physical, emotional or verbal abuse, Ms. L reported that her mother practiced all three. Hardly a day passed that Ms. L was not called a devaluing name, hurtful swear words in her mother’s native tongue from the old country, and slapped, punched or kicked. In the most dramatic episode, Ms. L was reportedly pushed by her mother into a small space behind the stove and the wall and repeatedly kicked. Her mother’s behavior, the escape from the civil unrest in the homeland, and trying to build a new life in the USA, made it clear that Ms. L was a survivor. Significant somatic issues were presented. Two years prior to our meeting, Ms. L was hospitalized for a heart condition, including a racing heart beat, which reportedly required laparoscopic surgery to perform a coronary ablation. Complications occurred, including meningitis, requiring additional hospitalizations. Explaining that I was not an MD, I asked for clarification about the medical procedure. She made a gesture as if to unbutton her gown. In an instant my psychotherapy career passed in front of my eyes. I started imaging how I would try to explain the misunderstanding of the halfundressed patient in the meeting room to the nurses and the attending physician. I quickly rallied from my second long reverie and shouted: “Don’t undress! Just tell me about it!” As Ms. L subsequently explained verbally, the procedure required surgery to cauterize a spot on the heart related to the irregular (racing) heart beat. Ms. L reported that she had spinal hemoangiomas, which (she believed) were related to the many beatings administered by her mother, according to Ms. L, starting as early as age five and continuing to the late teenage years. Ms. L said that she was never knocked unconscious, though her ears would ring. Ms. L reported that she suffered from migraines on a daily basis, which, however, were successfully treated with a migraine medication. Though we will never know for sure, it is possible that there was nothing physically wrong with Ms. L’s heart and the cardiac intervention was due to a misdiagnosis of panic attacks related to untreated PTSD, which included the racing heart. By the way, the heart procedure did not fix the panic attacks. Obviously. Once again, I did not rush to the nurse’s station and call out what I hypothetically learned. I did, however, include this material in the case formulation that I presented in one of the classes that I was attending. In my case conference class, the professor and students were critical that my report was “too long.” I wondered if any had read it. No follow-up was ever performed as far as I know. Remarkably resilient in the face of so many dark and difficult experiences, repeated physical, emotional, and verbal traumas, left Ms. L uncertain about the proper boundaries in speech and basic behavior in her new homeland. Boundary issues in abundance occurred. Ms. L did not seem to sufficiently

134

Plato not prozac!

appreciate that she was entitled to be “safe and secure.” Ms. L had not been personally safe with her mother, who otherwise apparently did a satisfactory job in escaping from a terrible situation overseas and starting a new life in the USA. That is the devilish thing about abuse—the paramilitaries would have perpetrated far worse crimes on the victims, yet the least bad alternative was itself an abusive one where safety was compromised. Just because the suffering might have been worse is no reason to diminish the suffering that did in fact occur. Empathy leads us to distinguish exactly what happened = x—which was a series of traumas—from what the individual made it mean. The “decisions” about what it all means made in the context of a struggle for survival are the ones that are psychodynamically relevant. Judgments such as “I am not worthy,” “It is my fault,” “The perpetrator is loving, so I must be the bad one,” can be the equivalent of the pathogenic secret, surfaced and allowed to vaporize in the face of healthy common sense. As I listened to Ms. L talk, my associations were that Ms. L resembled the tough talking girl of Kevin Klein’s infatuation in the movie American Beauty. However, behind the bad language and seemingly worldly-wise behavior of this individual, was a vulnerable, inexperienced, fearful teenager. This case is rather more complicated and messy than Hollywood represented. Given the background of abuse and trauma, it was very “grown up” to have an affair with a married man, which was ongoing prior to the hospitalization. A modest amount of work in therapy about what are proper boundaries in a relationship and the distinction between devaluing language and proper respect, resulted in “saying good-bye” to the “questionable boyfriend material,” who was sent on his way. Yet it is hard to escape from the “mother within” who makes one feel guilty—bad and wrong—about transgressing conventional values and whose commitment seemed to be controlling and dominating. A moving narrative unfolded. Just as her mother was about to strike the then-teenaged Ms. L, raising her hand to do so, the mother paused. Without explanation either then or since then, she lowered her hand. She never hit Ms. L again. Ms. L never asked nor was further clarification offered. The mother passed away two years later of advanced lung cancer. “Due to smoking cigarettes?” To my surprise, Ms. L said that it was not. Ms. L said that many of her former countrymen are now dying from various cancers due to the voluminous fragments of uranium munitions used in the civil war, strewn randomly about the landscape—tanks shells, hand grenades, armorpiercing bullets, and fragments of bombs. Ms. L’s mother went into hospital for treatment, but was soon sent back home to spend her few remaining weeks, since the cancers were far advanced. At this point, the mother stopped speaking. The mother never said another word to anyone. Ms. L bemoaned that Mom and she had not said “good-bye.” The day before Ms. L’s mother died, an end that was expected without knowing the exact time, Ms. L and a friend of her mother, gave her Mom

Plato not prozac!

135

a relaxing hot bath. Ms. L asked her Mom to smile for her. Her Mom did. Ms. L asked her Mom to hold her hand. Her Mom did. Ms. L asked her Mom to kiss her. Her Mom did. The next day, her Mom died. Ms. L broke down and cried then and there as she realized that she had indeed experienced a good-bye with her Mom. They had not said the words—they had “said” the experience. They had indeed shared the good-bye. Let us take a step back. In at least three cases of the people with whom I talked on the inpatient unit (the third mentioned below), there was a significant history of physical abuse by a parent contributing to the affective disorder. The details were different. However, in each case, a presenting statement was made that “I just have a chemical imbalance that requires tuning up.” This “line” gave way in our conversation with remarkable velocity to details of repeated childhood or young adult physical trauma that had not been worked through and apparently not even mentioned. Now my incompletely analyzed narcissism causes me to think that these patients sensed my deep empathic abilities and spoke their unexpressed trauma into my gracious and generous listening. But I wasn’t born yesterday. The most probable reason that the matter of abuse had not come up before with these survivors—and my firm suspicion—is that no one bothered to ask. I repeat: No one asked. “But it is now the policy to ask.” Duly noted. If the caretaker had indeed asked—said the form of words, it was done in such a way to signal a negative response was required, implying: “Don’t bring it up unless you want to get out of your comfort zone.” In a context lacking empathic receptivity and responsiveness, the shame and guilt inhibit a complete reply. It simply was not a priority to bring it up. It was not a priority to engage with it. The policy on the affective disorders unit was an implementation of the resistance to introspection and empathy—do not think too deeply about what is bothering you. If that makes you angry, you are not alone. However, you are not in the majority of the decision makers down at the unit itself. No amount of ECT, medications, or CBT can cover it up or keep the lid on some kinds of trauma. An object-relational approach is an inviting formulation when the internalized parental representation (“imago”) is still “beating” up the individual emotionally. In fact, one patient explicitly said as much: “The voice I hear telling me I am ‘no good’ and ‘you are the cause of all the problems’ is that of my alcoholic father.” When the one describes the voice as exactly as possible—one might say “thinks deeply about it”— then it frequently begins to get quieter, smaller, and lose its power. Clinical vignette: cultivating the tree of one’s sorrows

An object-relational approach is welcome when some internalized parental representation (“imago”) is beating up on the individual. In this vignette, the death of a spouse of 50 years is closely aligned with the triggering of

136

Plato not prozac!

the onset of the depression; and the absence of the deceased person from the world is compensated for by the intensifying of the relation with the internal representation of the significant other in psychic reality. My association was: “This individual has been cultivating the tree of her sorrows.” This senior citizen has lost a beloved husband of many years and that is authentically sad. Yet the circling around and around the loss goes on—for five years. The micro-narrative? This person has been cultivating the tree of her sorrows, and to such an extent that it has become a carnivorous plant—as in the Broadway play about the man eating plant in the back of the flower store—and it is consuming her psyche and her life. It is true the husband had taken care of many things in their lives. The loss was substantial. He was socially awkward, or at least not very talkative, and was perfectly complimented by her extroverted manner. She had the ideas—he was the practical one, taking care of the logistics. She was the articulate one in their social interactions. In one way, she lacked certain practical skills around finance and logistics, but in another way she had externalized the social skills she required by marrying them in the form of her late husband. It is just that now her other half had literally gone missing. Hear me say it in spite of my reservation about CBT (cognitive, behavioral therapy): In this case, her lack of life skills in certain well-defined areas invite intervention based on CBT initiatives. She exemplified Gedo’s (1993: 519; 1988: Chapter 12) description of apraxias—literally “absence of practice,” a deficit of psychological skills that occasion lack of progress in spite of wellinterpreted transference repetitions. Such apraxias leave the patient at the effect of elaborations of her inner world. Not a negative therapeutic response, but no response at all—due to lack of competence. Unfortunately, this individual required more detailed attention and skills development than could be provided in the group setting of the inpatient unit (and in our three conversations). Too bad. It might have jump-started the process of integrating the component of her self, her late husband, that was now missing. Clinical vignette: a noticeable absence of trauma

In at least four of the cases that I encountered, the more of life’s riches and would-be happiness that was sent in the direction of the patient, the more the individual suffered. The paradox of depression was in evidence. The more life treated the individual with generosity and kindness, the worse the individual felt. Nothing really bad happened. The parents were not abusive. The parents were loving and kind. There was no evidence of alcohol or other street drugs. The micro-narrative? “A noticeable absence of trauma.” In one instance, a single instance of trauma was significant enough—a street mugging—yet the depression that it precipitated was all out of proportion and suggested some larger, latent issue was activated.

Plato not prozac!

137

One further vignette. A schoolteacher from a local high school checked herself in prior to the anniversary of September 11 (9/11). She had an ongoing life which was relatively uneventful in its externals until . . . one day until she was robbed at gunpoint. Thereafter, she suffered panic attacks. They seemed to escalate prior to going back to school for the upcoming term. Meanwhile, she was working on a children’s short story. She wanted to change career. She also had a long relationship with a gentleman from a different ethnic group that might have raised eyebrows in years gone by among the prejudiced, but which is common today. She was suffering from low mood and suicidal ideation without a specific plan. Once again, she described several stories in sequence of people being nice to her—a surprise birthday party, inclusive social invitations, a boss at school who was a source of understanding and concern. The nicer people were towards her, the worse she felt affectively. My statement to her that it seemed paradoxical that the nicer the people around her treated her, the more fragile became her mood, struck a chord. She commented on an experience she had when growing up. Her mother would never pick her up from school. However, one day her mother came to pick her up. The mother said, “There is something on the radio that I want you to hear.” Mom then turned into the swearing-in ceremony of the first woman Supreme Court Justice. The mother expressed the view that she (the daughter) could come and do whatever she wanted. I had the ironic thought, “No pressure here!” The daughter followed her muse, pursuing what she felt she could succeed at and liked well enough too. She became a schoolteacher, feeling all the while that she was not living up to her aspirations—actually her mother’s aspirations for her—and was not good enough. The patient is a would-be dramatist, working on a play. Drama is the order of the day— suicidal ideas and check into the psychiatric unit. One wonders whether the mother’s hidden and pervasive demands are robbing the patient of her life at gunpoint? Speculation, yet a useful beginning to an empathic narrative. It would be risky to launch such a deep interpretation based on three conversations, and I did not do so. Too big a risk of retraumatization—yet it might have shaken things up. In this instance, a perfectionist mother was a key player in the patient’s life, who, though nice enough as a mother, was never, ever satisfied in her high, yet unmet, aspirations for her daughter. The clock is ticking, thinks the patient in her preconscious, and I have not even begun law school much less made it through the nomination process required to serve on the Supreme Court. In the other cases, individuals checked into the inpatient unit with panic disorders or anxiety attacks on September 11th or within a week of the anniversary of the terrorist attacks. This date once was a date like any other date. Now it is a symbol of angst and stress. In no case was the terrorist attack called out explicitly as a source of anxiety or concern by the individual. I am still puzzling over this one. Robert Stolorow (2011: 54 n9) has called

138

Plato not prozac!

out the distinction “collective trauma” (see also Lear 2006). I hypothesize that psychiatric institutions across the country experience a spike in acute panic admissions or ER visits during this time. The cynic wonders: Starting around Labor Day, should they stock up on sedatives in anticipation? My interest in psychodynamic therapy showed that I was living in a bygone era, according to the unit director. The reality of insurance limitations meant “patch ‘em up and move ‘em out.” Without wishing to excuse the power trip of the insurance companies, the assertion that a patient needs to spend a year on the unit to benefit from a psychodynamic approach masks a vulnerability and deficit in the unit’s underlying capabilities—and is not accurate. Such statements were made to me—repeatedly—and they resonate as so much resistance to introspection and empathy. Much good work can be done in ten sessions. Persons are in the inpatient unit because they have issues in relating, working, and living. The issues can be addressed by looking for the meaning of symptoms in a context of chemistry or in a context of life. In the context of examining the unexamined life, the issues are as diverse and complex as the people themselves. The conversation enriches while shifting what troubles the individual to a relatedness with the therapist, which, in turn, can be examined for the patient’s contribution to her or his own struggles. The conversation alternatingly soothes and disrupts the complacency of life on automatic pilot while disclosing possibilities for development. In the context of chemistry, basically one size is made to fit all (though the medications are diverse). The meaning is: “The neurotransmitters are out of balance.” The commitment of this particular affective disorders unit was to provide the patient with methods of not thinking about (attending to) what is really upsetting him or her. This means the upset gets pushed down and avoided. While that is perhaps good for business long term, because the individual will be back when what has been suppressed inevitably returns, the recommendation is to get the staff (especially the nurses, starting with the director) the training they require to provide a gracious and generous listening. Absent that, call in Flash Gordon. Having spent some 14 months partnered in rotation with a dozen residents in psychiatry in their day jobs, I will never be the same. The dedication, commitment, hard work, and, it must be said, suffering, of the psychiatric residents due to long hours and minimal appreciation, was inspiring in every way and without exception. At the risk of laying it on too thick—but if not now, when?—I was particularly moved, touched, and activated by the example of the residents. The psychiatric residents were ministering to suffering humanity. They were engaging the struggling patients and would-be patients in community psychiatry. Community psychiatry is a context in which secondary gain is a significant obstacle to recovery. If one gets better, one’s disability payment is reduced. This implies a significant frustration factor to the

Plato not prozac!

139

would-be psychotherapist. In short, the conversation about how the patient is feeling and behaving ends with a conversation about a prescription for a medication. So here we have dedicated, caring psychiatrists who want to engage in a conversation for human possibility and are in a medical model putting them on a trajectory to writing a prescription. Yet the powers that be do not know who they let in the door when they admitted me. I will never be the same because I saw that one can tune up someone’s lithium, valproate acid, or fluoxetine, while still having no idea what is going on with the individual. I saw what the residents in psychiatry are doing. Which is? They are turning the crank as diligently as possible, consistent with 15- or 30-minute sessions, in dispensing medications to the target population. Yet they cared. Cared deeply and were dedicated to ideals of making a difference and making a contribution. From their example, I acquired a sense of how to get down to business and collect a case history, providing a gracious and generous listening, being kind and, yes, being empathic. Time and time again patients in one or another of the clinics would be questioned about their symptoms and an accurate description of mood or sleep pattern or pressured speech, and there would be no problem. “Everything is okay.” Then the psychiatric resident would acknowledge who the patient is as a possibility, express authentic concern, and display a readiness to listen. Then the difficult and dark material would come tumbling out— abuse, violence, darkness, boundary violations. And that is the good news. The lesson? Notwithstanding resistance to the empathy and introspection, the presence of empathy sets the limits for what will surface from the depths, emerge, come forth, and be explicitly thematized. I will never be the same because I saw first hand, I personally witnessed, that the secondary gains were nearly insurmountable. The uses of authority to cause adherence—the old term “compliance” told the truth—is pervasive and significant. The uses of suggestion and persuasion are critical path for getting results. The self-deceptions and undelivered communications are vast and deep. This is the front line against suffering humanity. For all the messiness, alternative readings, diverse interpretations, descriptions and redescriptions, it works. People get better, express satisfaction, and return to their lives energized and enlivened. Why would I never be the same? The residents set a high bar for delivering crisp reports encapsulating the patient’s history, symptoms, and behavior. They set a high bar in being respectful, courteous, and businesslike. They set a high bar for providing a gracious and generous listening, even amid the pager alerts, sadistic humor of the attending physicians, and personal struggle to accommodate conflicting double binds. Why would I never be the same? I had finally gotten an internship and clinical experience. There was no turning back the clock. The genie was out of the bottle.

140

Plato not prozac!

Note 1

This is the place to call out diverse “spiritual disciplines” that compete in the increasingly dynamic market for development and training without replacing the uses of psychotherapy. These extend from Dale Carnegie’s How to Win Friends and Influence People, through Eric Berne’s Games People Play. From a different perspective, an engaging implementation of language as speech acts with a philosophy of possibility is to be found in Steve Zaffron and Dave Logan’s The Three Laws of Performance (2009), also available commercially as an extended weekend seminar (see www.landmarkeducation.com). But a word of caution: This forum is not a lecture—speech acts are barely mentioned—and it is not short-term psychotherapy—the training is a fundamental ontological inquiry and conversation about the participant’s possibilities, by design raising as many questions as it answers. Most people find that it tests the limits of their comfort zones, an eminently useful thing to do.

Chapter 4

Treatment of domestic violence

The psychodynamic treatment of survivors of domestic violence has to navigate a delicate course between the risks of retraumatization and the impasse of interminable entitlement to corrective emotional experience. This chapter begins with a review of Freud’s position on boundary violations— called “seductions” in his day—and his account of trauma. It continues with a briefing on the distinctions required to engage with the difficult matter of domestic violence—also called “gender violence.” This includes questions that are asked and questions that are not asked, but need to be asked. Why do men abuse? What to do about it? What does a healthy relationship look like? What is the value of sensitivity training and leadership training? Although the phases in the psychotherapeutic treatment and recovery of domestic violence are simultaneous, they are engaged in sequence: establishing safety; distinguishing between acknowledgment of what happened and what the survivor made it mean; work with boundaries and the confrontation with shame, guilt, rage, and negative emotions; expectations (realistic or otherwise) of compensation for suffering; abuse survived that has been worked through and becomes a resource; access to emotional equilibrium, aspirations, ambitions, and ideals; reengaging with development and access to a productive future and relationships; risks of retraumatization, stuckness, endless looping, and isolation. Domestic violence is concisely situated in relationship to psychodynamic methods and clinical examples are engaged. Most families have a skeleton in the closet, but in this vignette, the closet is getting crowded.

Prelude Domestic violence is a subset of trauma. We may usefully engage with Freud’s approach to trauma, though this inquiry will not be limited to it. Freud’s first 18 patients experienced boundary violations—in those days, euphemistically called “seductions”—as one of the determining causes of the neuroses. Those recovering from domestic violence do not report symptoms of classic hysteria. Yet the consequence of abuse are diverse and

142

Treatment of domestic violence

often mixed in complex ways with hypochondria, somatization, diffuse anxiety, and classic conversion symptoms. The downstream sequelae can form a toxic amalgamation with the more typical features of post-traumatic stress disorder (PTSD) such as intrusive thoughts, nightmares, panic attacks, hyper-vigilance, etc. The relevance of Freud’s initial work with boundary violations needs to be better appreciated, though his scientific hypothesis of an invariant seduction was ultimately discarded. Freud had scientific ambitions to discover a single cause of hysteria analogous to the tubercule bacillus as the cause of tuberculosis. A single condition contrary to fact cause, enabling a definitive cure: “If there had been no X (bacillus/sexual trauma), then there would have been no resulting Y (tuberculosis/hysteria); whereby the removal of the X, also causes the Y to disappear.” Freud initially argued that a sexual trauma, and indeed one perpetrated by the father, was the cause of all cases of hysteria. Freud subsequently had to give up the account of a single cause in the face of compelling evidence that there were counter-examples. Sometimes the bait of falsehood catches a carp of truth. In some cases at least, the trauma was imaginary, fictional, and a part of the standard development of the moral conscience (i.e. superego). Multiple variables confounded one another—and confounded the hope of a single curative treatment. We saw above how Freud’s position evolved in the direction of studied ambiguity (see “A Rumor of Empathy in Freud” (Freud 1917: 370)) while allowing room for both real-world abuse as well as pathogenic fantasies. Freud’s second decisive engagement with trauma as a source of neurosis occurred in a different context. The First World War invented new horrors for civilians and soldiers alike. Individual soldiers were overcome with “shell shock,” an early version of the Second World War’s “battle fatigue” and today’s “post-traumatic stress disorder” (PTSD). The “treatment” of choice by the military, including army doctors, was to assume that the soldier was malingering and to threaten (and apply) punishments to enforce conformity to duty. In yet another compelling example of retroactive redescription (and an appalling breakdown of justice), we know that First World War soldiers suffering from PTSD were court-marshaled and executed by firing squad as an example to others not to shirk their duty to die for their county in the trenches (see Hacking 1995: 241). In contrast, a psychoanalytically inspired psychiatrist in the German Army, Ernest Simmel, found that talking to the shell-shocked soldier using psychoanalytic methods was effective in returning the soldier to duty with integrity and restored well-being. A conference was held in September 1918 with Freud and key psychoanalysts such as Ernest Jones, Karl Abraham, and Sándor Ferenczi at which government representatives from the German and Austrian governments were present. An ambitious project was envisioned at which clinics and hospitals would be set up using psychoanalytic methods for treating war neuroses. A real prospect emerged that psychoanalysis would “break out” to the general

Treatment of domestic violence

143

public. The collapse of these governments and the post-World War I political and economic chaos thwarted this vision. Freud went on to publish Beyond the Pleasure Principle (1921) in which the mastery of trauma through the repetition compulsion was on the critical path to dealing with aggression and overcoming neurotic suffering. Given that here in the USA in the year 2014 our community is dealing with the return of veterans from two wars, the use of psychoanalytic methods with “shell shock”—i.e. trauma—are more important than they have ever been before. However, it is not necessary to confront hostile foreign powers in the trenches to become a survivor of PTSD. Sometimes the “foreign power” is one’s own intimate partner— a family member, a husband, a boyfriend. Thus, psychoanalytic therapy has engaged in an inquiry into the pathogenic effects of trauma at its beginning and in its mature theory (Freud 1921). Kohut has engaged with the traumatic effects of emotional deprivation on the development of the self—strictly speaking, not domestic violence. Kohut hypothesized that non-traumatic failures of empathy were the mechanism of standard development by which the self-structure required for affect equilibrium and regulation is acquired, developed, and restored. The “nontraumatic failures” are “the optimal frustrations” (Kohut 1971: 64, 172, 197–199), in turn, invoking empathic responsiveness, explicitly entailed in the process of restoring empathic relatedness. More problematic is how the trauma relates to the inevitable psychic conflicts that emerge in the development of the individual. Virtually every survivor asks: “What did I do wrong? Why me?” Like any survivor, the survivor of domestic violence has an unconscious fantasy of causation and solution (e.g. Busch 2005: 27). The fantasy alternates between two distortions: blaming oneself for something that one did not do and blaming another for something that one did indeed do or intended to do. Even if the survivor does not have a particularly egocentric view of the world, it seems to be a design flaw in the human psyche to take responsibility for one’s own pain and suffering in an attempt to master one’s situation when it is out of control. Thus, the survivor of domestic violence imagines (in so many words): “If only I had dinner ready on time, he would not have hit me. I am to blame.” The value of making such an absurd fantasy explicit is that it is so nonsensical as to evaporate immediately, leaving the responsibility where it properly lies, i.e. with the perpetrator. Yet even after having escaped physically from an abusive environment, the abuse lives on intra-psychically. One survivor’s sense of being special at having survived and escaped was such that a series of minor miscommunications in relationships or at work would occur provocatively when she did not get what she believed she deserved. The minor misunderstandings eventually escalated to a big breakdown in which the other person was almost inevitably redescribed as an abuser, whereas he was more properly described as a struggling, clumsy fellow worker or boss. In the workplace, the further

144

Treatment of domestic violence

escalation to corporate human resources would result in the survivor getting a short-term victory prior to the elimination of her job—of both her complaint and her. More abuse? It does give one pause. Yet the survivor needs a job, not an interminable legal case. One must be careful not to blame the victim, and the number of variables makes it hard to say when suffering becomes one’s comfort zone simply because it is a familiar pattern. Habitual patterns are persistent, suffering is sticky, and survivors continue to fight their way through life, even after having escaped from danger, because fighting was so effective in surviving. Both extremes occur at one time or another in the treatment. The psychotherapist is challenged to navigate between the extremes of self-blame and projection. The short, initial version of the unconscious fantasy is of the form “I am to blame—I am not lovable” until enough of the capacity to reclaim feelings has occurred in psychotherapy. The tendency to flight diminishes. The inclination to fight expands. Then the latent rage kicks in, at which point the fantasy spontaneously flips and becomes “I am entitled. You are to blame, you abuser.” The treatment method and recommendation is to allow empathic breakdowns to be redescribed as micro-traumas that open the way for working through. The trauma survivor typically has additional issues besides the trauma. The trauma gets amalgamated with existing psychic conflicts. We saw one example above of an individual whose life prior to being mugged was characterized by a noticeable absence of trauma and an abundance of “normality” (see “Clinical Vignette: A Noticeable Absence of Trauma,” pp. 136–140). Yet further inquiry showed that there were subtle stressors and a pervasive requirement of perfectionism that set the stage for the mugging to have a disproportionate impact. When a mugging is inserted into a conflict between perfectionism and fragile self-esteem, the mugging may be associated with the perfectionist self-reproach, “I should have worn gym shoes to run away, instead of high heels.” Overlooked is that high heels do not justify muggings. Once the trauma gets amalgamated with the psychic conflict around self-esteem, self-confidence, etc., then any attempt to discuss the fantasy “I am to blame” can make the inquiry seem like the therapist is doubting the reality of the trauma as such. We are not on the slippery slope to blaming the victim, we are at the bottom of it. The trauma may itself be fuzzy and not fully delimited, though no less upsetting for all that. This only increases the patient’s vulnerability. The therapist may feel like a bull in a china shop—clumsy. In engaging with such survivors, the therapist’s empathy looks a lot like learning to live with ambiguity. Though rarely are survivors explicitly blamed in a psychotherapeutic context for what happened to them, language that unwittingly implies they contributed to their own suffering occurs. This is where the kid gloves are out. In the initial report of a boundary violation, perpetration, or abuse, almost any request for clarification that the psychotherapist issues can land like a cross-examination. I have found it useful to

Treatment of domestic violence

145

limit initial responses to recognition and acknowledgment that engaging with such difficult material is challenging. This often elicits further details spontaneously. Character and courage are required to talk about such material. “How did you feel about it?” is a ready response. And it can be instructive to discover that the more horrendous the events, the more likely the individual felt a noticeable absence of feeling—numbness. Patients can be deeply wounded when they accurately perceive that they are not believed or examined skeptically. The therapist’s head may nod up and down agreeably. But when it comes to the patient’s own authentic selfinterest, even supposedly out-of-touch patients can be exquisitely sensitive to the nuances and leanings of the therapist’s affective states, especially doubt and skepticism. Nor is the therapist necessarily bad or wrong for wondering to himself, after listening to a patient vent her anger about someone or something, perhaps including the therapist himself: “Is there a single fact here?” The therapist’s task of being empathic correlates closely with learning to live with ambiguity and letting the patient’s narrative live in the space of the therapeutic encounter as a welcome presentation of the patient’s experiences in the here-and-now. In the absence of a single reliable fact, the therapist is accustomed to learning to live in a disquieting uncertainty (Spinelli 2005: 114)—bracketing reality, quarantining his initial opinion for future reference, and investigating the meaning. The survivor has had to live with ambiguity, and continues to do so, even in insisting on a certain canonical interpretation of what happened. Such ambiguity is an empathic opportunity for the therapist, too. This discussion focuses on the psychoanalytically oriented therapy with survivors of domestic violence where the survivors are women and the perpetrators are men. While not exclusively a man-on-woman problem, that is the most common demographic subset and it shall engage us here. Perpetrators are primarily, though not exclusively, men (Centers for Disease Control 2010). The main approach to remediation in the state of Illinois, where this author writes, stresses a legal, and not necessarily psychotherapeutic, approach. Thus, perpetrators end up being constrained to undergo treatment after they have been held to account by the criminal justice system. Numerous issues of secondary gain, second guessing, moral evasion, and gaming the legal system to avoid punishment, make psychodynamic therapy with the perpetrator a problematic approach, though one well worth trying. As a result of these complexities, group processes are currently in vogue with a group leader, who, frankly, often resembles the drill sargent from central casting. There is nothing wrong with such an approach, but many debate its value as psychotherapy. It comes to resemble August Aichhorn’s work with wayward young people (1925), though the target is the child in the man, in some cases in the body of a big scary man. The paradigm of “tough love” and “scared straight” is applied, and, absent significant additional resources, such an approach seems to be the model favored by funding

146

Treatment of domestic violence

agencies for the foreseeable future. With that in mind, I do not report on one-on-one work with perpetrators here, as important as such work is. The irony is that the survivors—usually women—are often more ready and open to the approach of dynamic psychotherapy, though it is the abusers—usually men—who present the more troubling attitudes and ways of relating. Nevertheless, an account of why men abuse is reviewed concisely, whether or not they are ready to take responsibility for their actions individually or as a group. When the men request it, help will be available. Until then, get ready for boot camp.

Why do men abuse and what to do about it We will not review in detail all the correlations that are not causation in relation to domestic violence (e.g. Wilson 1996/2007). As is often the case, it is easier to say what is not the cause than what is. Domestic violence is not caused by alcohol, drugs, religion, bad up-bringing, mental illness, lack of civil rights, education or lack thereof, or criminality, though it can be correlated with all these. It is not even caused by lack of impulse control, though it is correlated with that too. Positively expressed, domestic violence is a maladaptive method of seeking power and control. It is about power and control.1 Hannah Arendt (1968) pointed out that power and violence are inversely related in any given community. The more power, the less violence. The less power, the more violence. The remarkable thing is that Arendt was referring to the politics of governmental organizations but her analysis also applies to domestic violence. When an individual (or organization) is experiencing loss of power, the risk is to resort to violence in order to regain power and control. The risk is of an escalating use of force. So, for example, as a woman is getting ready to leave an abusive relationship, and the man is experiencing a loss of power, this is the dangerous time for the would-be survivor, a time in which people get hurt or even killed. Even if an escalation to violence is ultimately self-defeating, the abuser tries to get the power back by means of force (violence). In no way does this mean accommodating some ideology of machismo or manliness. The violence erupts as the individual experiences a loss of power. The equation “power up, violence down” applies remarkably well even in therapy. When one of the participants experiences a loss of power or control, the risk of acting out increases. “Acting out” includes risky enactments of diverse kinds, including violence. Tactically, an experience of authentic, legitimate power reduces the risk of violence. If such an experience can be provided while maintaining respect for persons and integrity of boundaries, then all participants are likely to benefit. This is easier said than done, and it is where structured men’s psychodynamic and encounter groups can make a difference, in which men who have mastered such dynamics can present them to men who have not.

Treatment of domestic violence

147

For the purposes of this discussion, it is useful to take a position as to why men abuse, acknowledging that, in spite of the above-cited correlation of violence with loss of power, no easy explanation is available as to the cause of domestic violence. A one-size-fits-all approach is not workable. Although the focus in this chapter in on work with the survivors of domestic violence, we cannot allow the men who cause the problem to fall out of the equation and the debate, even if they rarely end up in psychotherapy. Why do men abuse? The reason why men abuse is because they can. The probable future is that a given abusive man will continue to relate abusively as long as men (and women) do not stop him. The optimal solution is when a man takes responsibility for his way of relating, seeks help, and changes. This rarely happens without intervention. One prominent micro-narrative is that the abuser lacks impulse control. I have my doubts. Rather the violent acting out is strategic and manipulative. Rarely is the violent way of relating a mere matter of lack of impulse control. This story is regarded with increasing skepticism, though after long practice, rehearsed lack of impulse control can become habitual. If the abuser’s mother or grandmother walked into the room as he was about to hit his intimate partner, he would stop. He would stop of his own accord and as an exercise of his freedom and power. Alas, matters often do not happen that way. By the time domestic violence has become a pattern, it has also, unfortunately, become a strategic way of relating. Even if not premeditated, the abusive behavior had become a preconscious way of relating that has a defined payoff—getting one’s way by throwing a temper tantrum. The lack of impulse control is a pretext, and well-rehearsed. Acting out violently is an effect, a consequence, a symptom, of defective self-regulation, not the cause of it. Sufficient impulse control is usually available, and the acting out is not an isolated behavior but a pattern of overall affective disequilibrium that manifests itself pervasively in relatedness (or lack thereof) across multiple situations in the family, at work, and in everyday life. Rarely, a man may abuse out of a sense of guilt because he wants to be caught. It is a way of asking for help—the wrong way. One can indeed get criminality out of a sense of guilt as in Freud’s penetrating article of the same name where the guilt precedes the acting out and is the cause, not the effect (Freud 1916b: 332). But this is a much less common scenario. Men abuse because they can. This may sound like a provocative and confronting statement. It is. What it means is that men who abuse have a choice. They are autonomous and accountable and are able to choose otherwise if they decide to do so. Men are responsible. The opportunity is for other men to confront men who abuse with a compelling case of their own responsibility in the matter—with reasons and motives not to do so. Providing the answer is deceptively simple. As usual, the devil is in the details. One proposal that has traction is that men abuse because of a failure of leadership—on the part of men. Not only the abusers, but all men. This

148

Treatment of domestic violence

is a bold statement. It needs to be better known. Explanation is required. Responsible men with power need to engage with—talk to, counsel with, empathize with, and confront—other men about proper, responsible, civilized behavior. Not just when they witness abuse ongoing in the moment (though obviously that too), but when men are together in situations in men’s culture and community not frequented by women. Empathize with the perpetrators? A high bar indeed, yet empathy does not mean “agree with,” “condone,” or “excuse.” Empathy may mean withholding judgment long enough to identify the triggers specific to a given individual and intervene in such a way as to empower the individual to make the responsible choice in his words and actions. Empathy is all about firm but semipermeable boundaries between the self and other; and empathy works best where firm boundaries are maintained, even amid a communicability of affect. Empathy means surfacing the fear that gets transformed into rage; surfacing the rage that leads to violence. Leadership has been missing, but fortunately is finally starting to emerge—admittedly all-too-slowly—as powerful men step up, speak up, man up, and address the issues. From the community perspective, a turning point is at hand. The conversation is ripped from the headlines. In an attempted honor killing of a young girl, Malala Yousafzai is shot in the head by the Taliban for advocating women’s education (Dhume 2012). The bullet reportedly travels around the side of the skull without penetrating it, damaging her hearing on one side. She survives to address the UN General Assembly. Along with Kailash Satyarth, Malala goes on to win the Nobel Peace Prize (2014). However, before getting too self-righteous about the atrocities perpetrated in foreign lands, we may usefully clean up our own mess. This mess includes the scandals erupting in major institutions such as the Catholic Church (Pashman et al. 2014), the football program at Penn State under Sandusky and Paterno (Wikipedia 2014), the Boy Scouts of American (McGrael 2010). Why do so many men rape boys and girls? The same system that results in men abusing women also produces abusers of boys. What about the boys and young men who have been traumatized by the violence perpetrated by men against their mothers and sisters? This is not changing the subject. It is the subject. It is a sobering fact that most victims of violence—of both genders —are victims of violence by a man. This is something that men and women have in common—both demographics are victims of male violence. That must give us pause. Jackson Katz (2013) has provided significant leadership in addressing gender violence (as he prefers to describe the set of issues), engaging with predominantly male communities such as major sports franchises, branches of the US Armed Forces, and selected major corporations. I rely on his contribution in the following. Note that while Katz prefers the distinction “gender violence,” much of what he has to say about the issues apply directly to “domestic violence.”

Treatment of domestic violence

149

According to Katz, gender violence has been seen as a woman’s issue with which some good men help out. It is fair to say that women have provided the leadership in standing up and confronting parts of men’s culture and men’s communities that ignored or reacted hostilely to trying to discuss gender violence. Women have been doing the work for a long time and have built momentum and movements. These movements have benefited women and children, including boys, who have been the victims of men’s violence. Yet gender violence is not seen as a men’s issue. It is. A paradigm shift is occurring. Defining and calling gender violence merely a “woman’s issue” is part of the problem (though it is indeed also a woman’s issue). Calling gender violence a “woman’s issue” gives men a pretext not to pay attention to it— as if “man” is not a gender. Under one redescription, the prevailing system of domination operates as if men do not have a gender, enabling the dominating group in power to remain invisible. Remarkably, men fall out of an equation that is basically about men. The really appalling thing is that the group that dominates—has the power—gets deleted from the equation— and does not get attention. Attempts are made to shout down the woman who has been bold enough to raise the issue, thus, in effect shooting the messenger. That is not to say that we may not also ask about women, and, for example, why suffering is sticky, and, some survivors keep returning to the abuser? This too does give one pause. Yet we need to ask first and foremost about the men. Hence, the value of—and need for—a paradigm shift. Men can go places in men’s culture that women cannot go. The stereotypes of the men’s locker rooms, poker games, sports events, and “man caves,” are the occasions for men-with-men conversations. There are locations and occasions—and they are pervasive—where men can say things to men and be heard that women cannot say and be heard. This is because locations and occasions exist where men are together and women are simply not granted access to the physical location or the community. Therefore, the men are responsible for stepping up and making a difference. The paradigm shift is from those involved in a dyad of abuse—perpetrator or victim—to the previously uninvolved bystander who speaks up and challenges the “business as usual” of devaluing talk (and devaluing ways of behaving) in relation to women. This has been considered a matter of men’s sensitivity. When men have been insensitive, further sensitivity training has been required. While there is nothing wrong with sensitivity training, it is not the main issue. The issue is leadership. The responsibility for interrupting devaluing ways of relating to women rests with adult men with power— leaders. Not boys. The men who were in responsible roles as the scandals were unfolding were not so much insensitive, they were inadequate, failed leaders. Their silence was not due to a lack of sensitivity. Their silence was due to lack of leadership. Their silence was accurately redescribed to their disadvantage and legal peril as aiding and abetting the boundary violations.

150

Treatment of domestic violence

Silence is particularly delicate where the proper approach of neutrality, anonymity, and abstinence can sometimes lead to silence. Under the abovecited interpretation, this can be redescribed as consent in the face of injustice and unfairness. Such would be a misdescription. Nor does this imply going to the other extreme, requiring the psychotherapist to issue an angry denunciation of social injustice whenever it rears its ugly head. What, then, is the guidance? Neutrality is different than lack of commitment. Neutrality is distinct from lack of psychological engagement. Neutrality is remaining equidistant from the id, superego, ego, and reality. The guidance is to set and adhere to firm boundaries. Just as the psychotherapist would not be expected to be non-committal upon learning that the patient’s home was robbed, so too he would not be uninvolved upon learning that the patient had survived assault and battery at the hands of an intimate partner. A crime is a crime. “Did you fill out a police report?” Kohut exemplified average expectable humane responsiveness (1971: 89ftnt.): “To remain silent when one is asked a question, for example, is not neutral but rude.” If the therapist is authentically shocked, there is little value in trying to disguise it, though one may usefully moderate any inclination to exaggerated response. “Betrayal oozes at every pore” (Freud 1905) applies not only to patients. Value exists in distinguishing between “what actually happened” and “what did the survivor make it mean” (to which we shall return in the like-named section). Under one redescription, silence is not neutral. Silence is a form of consent. The shift is to inspire men who are not abusive to challenge those who are. The shift is for men to challenge men, who, for any reason, use language and ways of relating that is devaluing of women, thus creating a context for violence. Martin Luther King said: “In the end we will remember not so much the words of our enemies as the silence of our friends.” The silence is the most hurtful. The goal is to create a peer culture of men where the abusive language and behavior is unacceptable and explicitly challenged so that the man is motivated to seek therapy. Those acting out devaluing agendas about women lose standing and status. If a son is present with the father, this shifts the socialization of boys in the direction of integrity and respect for women. Preventing abuse is a work in progress in institutions such as schools, community organizations, and the military. Progress with such work requires increased velocity. We know how to interrupt and deal with abuse if it does occur. These are the mother of all teachable moments. What has been missing is the leadership to take a stand and make a difference. Men as leaders need to break the silence of a complicity that gives permission for devaluing behavior. Men need to challenge one another. Yes, men owe it to women, but men also owe it to their sons and all the children, and men are emerging as leaders as the battle is joined against domestic violence. With the definitions of trauma and of leadership in hand, we now turn to a framework

Treatment of domestic violence

151

for the treatment of domestic violence in the context of psychodynamic psychotherapy.

Escape “Escape” is defined as “one no longer physically lives with the perpetrator (and the perpetrator does not have access to the living space) such that the use of force against her (or the children) is no longer an option.” The risk of financial manipulation also exists—a different kind of “force”– and other attempts at emotionally controlling, dominating, or manipulating. Psychotherapy can make a difference in the latter instances, too, though the results will be conditioned and qualified by the specific parameters of the situation. The point is that in the examples where the domestic violence is ongoing or immanent, psychotherapy is strictly limited in its effect as psychotherapy as such and is reduced to a set of related actions—taking steps to be or become safe, summoning emergency services to protect life and limb, planning for such contingencies, etc., and to reestablish boundaries by escaping. After the survivor has escaped from the physical abuse and is no longer in immediate danger, engaging with psychotherapy to address the emotional and psychic issues makes sense. Once escape has occurred, the battle for the recovery of emotional well-being can be joined in earnest. Having stated such a position, I hasten to add that the celebrity psychologist, Nancy McWilliams, the study of whose work is always a good use of one’s effort, provides an example of a case involving abuse where dynamic psychotherapy made a difference and was instrumental in promoting escape (McWilliams 2004: 197). Still, words of caution are appropriate: doing psychotherapy is not consistent with a situation of active, ongoing, or immanent abuse. After the individual has physically escaped from the abusive environment, then it makes sense to address the psychic and psychological challenges that the individual inevitably carries with her in leaving behind the physical abuse. One can escape the abusive environment physically, but the internal demons, the hostile introjects, the inward conflict, the stickiness of the suffering, are carried by the survivor with her (or him) to whatever geographic place of refuge is found. Having escaped physical danger, which is itself not a trivial matter, it makes sense to engage and accelerate the process of recovery through dynamic psychotherapy. Notwithstanding the caution that psychotherapy is not the best initial intervention (a safety plan is), if a victim or survivor reporting on-going intimate partner violence shows up at the door of a psychotherapist that does not mean turning them away. Depending on the details (and every individual case is different), it means understanding that the would-be therapist is going to be working on a safety plan, an escape plan, or related referral instead of doing psychotherapy in the narrow sense. Depending on the level of severity

152

Treatment of domestic violence

of abuse and the potential for escalating abuse, a safety plan consists in the would-be survivor having her government photo id, wallet, purse, bank/credit card, money, other essential documents such as passports and the children’s birth certificates and immunization history for school ready to go (this list is not complete) if she needs to exit her residence immediately to escape from an immanent threat of abuse. Similarly, when an individual decides that she or he has had enough abuse and finally wants to escape by moving out, then it is useful to network with family and friends whose confidentiality can be trusted to find a place to live temporarily while marshaling further resources. Picking up the phone and dialing the police, emergency services, or 911 is an option in the face of immediate danger or concern. Best to err on the side of caution—first responders are receiving expanded training and the leadership required to engage this difficult situation, especially in large metropolitan areas such as Chicago where this work is occurring. Tactics and responses that require the legal system such as orders of protection are a vast topic in themselves, not covered here. Since this is not a tutorial on escaping domestic violence as such, the reader is urged to consult the growing literature (see Wilson 1997/2006, which is a comprehensive start). Once escape occurs, the recovery process can be engaged. The tasks as depicted in Figure 4.1 are decidedly not sequential. They are all simultaneously present on day one. They are all potentially engaged in parallel.

acknowledgment of what happened

safety (trust)

escape

re-engage with development process/ access to a productive future and relatedness

survived, transformed abuse as a resource

acknowledgment of what the survivor made it mean

boundaries: confrontation with shame, guilt, rage, negative emotions

expectations (realistic or otherwise) of compensation for suffering

Risks

access to emotional resources, aspiration, ambition, ideals

Figure 4.1 Recovery cloud: transforming domestic violence

Retraumatization Stuckness Endless looping Conformity Isolation

Treatment of domestic violence

153

Without exception, the relations are many-to-many. For example, there should be an arrow from the upper right, “confrontation with shame guilt, rage” to the lower left, “access to aspirations, ambitions, ideals,” but it would be too hard to read with so many connectors. Hence, the binary arrows. Even such relatively advanced aspects as reengaging the process of development are present on day one. To be sure, it is rare to have a breakthrough in such an area on day one, yet hints and possibilities—slender tendrils of new development—the forward edge—are present and are usefully engaged if they show up.

Safety One survivor reported in psychotherapy that she would study the behavior of the abuser with whom she lived as a child. She would study him to make sure she was not alone with him and that there was someone else nearby. She would study him to assess his mood. She would take other measures to promote her safety. Being a thin 12-year-old, she would put on multiple layers of leisure wear, multiple tops, and an assortment of clothes that were hard to untie. This was more effective than one might think, though not a perfect defense, as it actually provided time to escape or fight back in critical situations. Yet the fact that such measures were needed shows how difficult, how amiss, how fraught, how totally unacceptable, was the entire situation. Finally, having escaped and become self-supporting, when under stress due to school or the job, this person would feel that she was being watched, though no one else was on the street. In a word, she would feel—unsafe. Small wonder. Much of the initial work in psychotherapy consisted in introspectively identifying the triggers to the feeling of unsafety. Typically, it would consist of encountering someone who reminded the survivor of the abuser in some detail, setting off a chain of associations, culminating in a hyper-vigilant sense of being watched. The triggers consisted in heightened stress in life due to job or school or relationships—or a pending vacation of the therapist—which would unleash an acerbation of the symptom. The symptom began to shrink as the working through process continued, until it was barely distinguishable from looking over one’s shoulder as one approached one’s car on an isolated urban street. In a short but significant article Sandler (1960: 355) makes the nice point that the mechanisms of defense (Anna Freud 1936) contribute to the person’s feeling of safety in that they potentially protect the ego against anxiety. Defense is self-protection against being overwhelmed by anxiety in its various forms—from the external world, from internal desires or aggression, and from the conscience or community. Without safety nothing works. Without safety the ego is overwhelmed. At the level of perception, perceptual filters are required to reduce the stimulation to a level that is manageable by secondary processing of input

154

Treatment of domestic violence

and without which we would indeed be overwhelmed by a tumultuous influx of confusing data. We know the specific feeling of safety when we lose it. One is walking through a darken room and stumbles over an obstacle in the path. One is driving the auto and suddenly hits a deep pot-hole that had not been perceived. One transfers to a new high school and the kids are not exactly welcoming. The rush of adrenaline tells us that we are in a “fight or flight” moment. The “amygdala hijack” tells us that momentarily we are no longer in charge of our organism, which has automatically activated bodily reaction. After the tornado in The Wizard of Oz, Dorothy expresses a famous micro-narrative to Todo: “We’re not in Kansas anymore.” Indeed not. A developmental narrative is available here too in which a definition of trauma is implied as sudden or persisting lack of safety. Hyper-vigilance— scanning the environment for early warning signs of danger—is the order of the day. Such hyper-sensitivity can be useful as protection against a dangerous world. But it can also be maladaptive when it leads the survivor to engage in elaboration and over-reaction against the small discourtesies of everyday life according to a template of protection against abuse. Never was it truer that our strengths become our weaknesses. It bears repeating: without safety nothing works. The same can be said of trust and integrity. If the process of psychotherapy works, the psychotherapist becomes a special kind of intimate partner in the matter of the patient’s deepest thoughts and emotions, albeit with conditions and qualification about the therapist’s boundaries. Since abusers and would-be predators typically start by saying things like “Trust me,” the value of such explicit assurances on the part of the therapist is doubtful. In the listening of someone whose trust has been violated by an intimate partner such assurances can sound like a false pretense if not a set-up for a perpetration. One of the reasons the patient is in therapy is precisely that her safety has been betrayed with traumatic results. The therapist has to earn the trust of the patient. Such trust initially looks like being firm about the therapeutic framework and agreement. Schedule, fee, and attentive listening are important to all patients, but they are especially critical path with survivors who may be hyper-vigilant about details of the process. This applies to the patient’s inclinations to test the boundaries of the process by bringing her (or his) own storm of emotional confusion and distress to the scheduling dynamic. In no way should the therapist be moralizing or punitive, yet requests for exceptions may usefully be made the subject of mutual understanding. In order to get the benefit of the process of psychotherapy, one must honor one’s word rigorously about scheduling, fee, and engaging in the work at hand. Thus, when transportation breakdowns, illness, and scheduling challenges arise, as they inevitably do, the response may usefully be: “I know that I said I would be there by now. . . . And I am stuck, etc.” The value of repairing breakdowns in communication—and empathy—is high. That is what the work itself looks like on a day-to-day basis.

Treatment of domestic violence

155

The facts are fragile

People who present themselves seeking psychotherapy as survivors of sexual or physical trauma—or indeed as struggling from something less dramatic but equally painful—have to deal with distortions of the historical facts in addition to the pain and suffering. The alleged perpetrator frequently says: “It never happened.” “It wasn’t like that.” Such situations are fraught with uncertainty because, in addition to the boundary violation, the perpetrator often insists on a narrative of what happened at odds with alternative accounts of the facts. “There was no abuse. You must be dreaming” (e.g. Noël and Watterson. 1992). Where the victim is in a position of dependence on the abuser—due to age, finances, or emotional vulnerability—the emotional and physical damage escalates rapidly. The psychotherapist initially encountering such a situation associates to the white elephant sitting in the middle of the living room that is visible to all, but unacknowledged. Moreover, even when there are no boundary violations that rise to the level of abuse, human beings in a state of emotional upset are susceptible to processes of distortion. They seriously maintain “It is raining cats and dogs” even when the sun is shining outside. This capacity for self-deception is taken to a high art in the cases of self-interest—and self-interest has a disturbing way of occasioning selfdeception. Here description and redescription are not so innocent. In anticipation of the next section on “Acknowledgment of What Happened,” we may usefully work on the empathic dimension of learning to live with ambiguity. Not necessarily on the part of the patient who was present at the trauma and experienced what happened even if in a way that is hard to formulate, rather on the part of the psychotherapist. History is clinically relevant here. Facts are much more fragile than truths of reason. If all the copies of Euclid’s Geometry had been burned in the destruction of the library at Alexandria, mathematicians would still have been able to recreate the truths of geometry out of the a priori forms of space and time, spatial relations and the definitions of point, line, and plain. However, knowledge of a contingent, transitory facts such as that a person named “Trotsky” existed— or that a death camp near Auschwitz existed—are much more at risk of oblivion. For example, after Stalin succeeded in having Leon Trotsky assassinated, Trotsky’s picture and all references to him simply vanished from historical accounts of the history of the Soviet Union. Trotsky never happened. Vanished in a puff of editorial deletion in history books and archives. In spite of being the architect of the Russian Revolution and a famous revolutionary, Trotsky became a non-person. This is parallel to the abuser’s “you must be dreaming—no abuse occurred.” This is a speech act to try to construct a fact, not an assertion of a fact.

156

Treatment of domestic violence

The Rat Man quotes Nietzsche to Freud: “My pride says ‘it happened’; my memory says ‘it did not.’ Memory yields.” Hannah Arendt (1954) makes a similar point that “Belgium invaded Germany” is above all a speech act to persuade, not inquire into a fact. “Belgium invaded Germany” attempts to construct a fact, even in the face of a condition contrary to fact. If a compelling enough psychic reality is created, historical truth yields. A stern warning to all. A similar warning can be made about the challenges faced by survivors of abuse that seek help in psychotherapy and the psychotherapists committed to making a difference for them. Thus, it is tempting to speculate that every therapist must walk the path trodden by Freud as he advanced from his initial, so-called seduction theory to that of the entanglement of psychic reality and fact—and back again. Having abandoned the idea that an actual, factual boundary violation (“seduction”) was the sole cause of hysteria, Freud explicitly acknowledged fantasy alone is not the sole cause either—that children are misused sexually and that is a problem: “You must not suppose, however, that sexual misuse of a child by its nearest male relative belongs entirely to the realm of phantasy” (Freud 1917: 370). This over-determination lacked the elegance of providing a single cause for hysteria that would guarantee the fame that Freud fervently desired, but it was what the data showed, and Freud’s fame came through other means. This is all very well when we are dealing with relatively simple and straightforward historical events. The mother really did wear a gas mask, which looked extremely scary to the child, according to Niederland’s patient (1965). The analyst really did schedule a vacation (Spence 1982). Waelder’s patient really did have a stillborn sibling, who was mourned deeply by his mother (Guttman 1987). Viderman’s patient’s father really was dying of liver disease—the six roses (or cirrhosis) of the dream (Viderman 1979). There is a form of development—chronology—that is satisfied with the plain recitation of the sequence of historical events in time. But what about the majority of cases where the events that happened are not nearly so definite or clear? Clinical psychoanalysis engages with phenomena that closely resemble that in which post-modern historians are really interested. Motivation. Intention. Desire. Grandiosity. Self-deception. Disruption of the canonical metanarrative. A person’s beliefs are not nearly so available as we imagine, even in the person’s written journal, and the psychodynamic investigations of these beliefs are a thorough preparation for writing a dramatically gripping historical account. The network of beliefs, desires, and intentions forms a background against which historical facts take on human significance and relevance. This is also the case in any psychodynamically relevant clinical inquiry. Acknowledgment of what happened and what the survivor made it mean are inextricably intertwined. We now try to disentangle them.

Treatment of domestic violence

157

Acknowledgment of what happened If the survivor can feel safe enough to express what happened into an empathic receptivity in the context of a trusting environment that does not retraumatize by skepticism and cross-examination, then the abuse, the boundary violations, and the perpetrations, begin to lose their force. Even if accompanied initially by strong emotions, as the survivor expresses her feelings and thoughts into the empathic listening of the therapist, the upsets begin to shrink. They start to shrink, and continue to do so with each iteration. The events begin to morph and change into something less confronting, monstrous, or compulsive. Even though language does not create what happened, language allows access to what happened. Language allows the speakers to capture the experience. And if the person can capture the experiences, including imaginary and psychic ones, the person can eventually release and lose them too. This is because describing and redescribing the event itself uses language that is semantically rich and ambiguous— inherently structuring and creating distances and distinctions. Though the violations may never entirely disappear, they becomes less menacing, intrusive, and disruptive. This section focuses on what happened, and the issues of “what the survivor made it mean” will be engaged in the next section. Cognitive scientists have observed that selected mental pathologies— traumas, including related psychic conflicts—can be broken up by making explicit the complex of context and attitude through a process of introspection, usually undertaken in the context of psychotherapy (Metzinger 2003: 33): “[B]y introspectively attending to ‘conflict generating’ (i.e. functionally incoherent) parts of one’s internal self-representation, additional processing resource are automatically allocated to this part and may thereby support a positive (i.e. integrative) development. . . .” Allocating additional attention—both primary and secondary processing resources—to a problem allows for integrating the functionally incoherent aspects of the individual’s experience into a coherent whole. Paying attention to something causes it to shift, especially if one feels empathically held by a gracious listening. Possibilities open up for regaining equilibrium and self-soothing. This is a corollary to Freud’s (1910: 148) observation that the process of making explicit what was unconscious occasions its disappearance like the evil spirit in the fairy tale when you call out its name. Thus, the survivor comes in and has a story to tell—a narrative to relate. The presenting issue, symptom, or problem is described. Sometimes the survivor can relate exactly and precisely what happened. Sometimes the person knows well enough that something happened but the words are hard to formulate. Nevertheless, the abuse is often in the nature of the two-ton elephant sitting in the middle of the living room. Family members know about it, but no one talks about it. In other instances, the survivor and the perpetrator knew about it. The survivor was there, and, was subjectively

158

Treatment of domestic violence

certain that she knew what happened. But then she tried to tell someone and was invalidated. She was betrayed by a person she trusted. She was shouted down by another parental figure—in one case, a beloved grandmother: “Stop telling such lies!” An atmosphere of denial, invalidation, and disbelief was laid on top of the survivor’s attempt to tell about it. Such cases are prognostically good only in the sense that once the survivor realizes that a non-judgmental, empathic listening is available, the events often come pouring out in a torrent, usually accompanied by powerful affect. Typically, there will be a test—of the psychotherapist. The survivor may report on the abuse in the most improbable and amazing descriptions. What to do about it? Acknowledgment is useful on the part of the listener that it is not easy for the speaker to engage such difficult material. Acknowledgment that courage is required to talk about such shame, guilt, and rage-inspiring material is a form of empathic interpretation. Frequently the abuse is available to the patient’s recollection and able to be described in detail. However, not always; and even when the abuse is readily available, it may get emotionally entangled and telescoped with genetic upsets from childhood, regardless of whether or not that latter rise to the level of abuse. The debate on recovered memories of childhood molestation (a form of abuse) is a difficult issue for any psychodynamic engagement with the topic. The work already done on “Narrative Truth and Historical Truth Revisited” and “The Facts are Fragile” may usefully be reviewed at this point. Suffice to say that abuse takes many forms. Recovered memories do occur (e.g. Viederman 1995; Hacking 1995), albeit more rarely than some previously believed. Viederman’s (1995) case is exemplary. The patient and Viederman were not looking for molestation, but a trail of metaphorical breadcrumbs starts showing up, culminating in significant images and words in context. Something = x emerges on its own in the course of the work of free association. The patient provides the leadership. The patient was the primary actor in the reconstruction which was accompanied by powerful affects and a re-experiencing that was of a different quality than intellectualization (1995: 1187). In the case of Viederman’s patient, an incident of molestation, reportedly occurring twice, is a source of suffering and becomes the source of additional suffering as the adults to whom the child turns for help—the nanny, the beloved grandmother, the father—all “circle the wagons,” so to speak, to protect the feelings of the mother against the information that her own dear brother was a child molester. Everyone was privy to the information—everyone except the mother. The child was told: “Stop all the ridiculousness. Pull yourself together” (Viederman 1995: 1184). Other clues emerge. Being offered ice cream is innocent enough. But being offered ice cream by the uncle not to tell. Tell what? It could be an innocent misdemeanor—but it isn’t. The atmosphere of disbelief, betrayal by the beloved grandmother—and requirement that the mother remain ignorant—

Treatment of domestic violence

159

becomes as significant as the two episodes of molestation—and more damaging in its traumatic consequences to the patient’s self-esteem and selfconfidence. Viederman’s patient has a rare opportunity to test the recovered memory against a measure of reality provided by one of the adults present at the time: “Years after the analysis, a conversation with a now dying, extremely aged friend of the grandmother, confirmed that she knew of the event that had occurred years before” (1995: 1185). Though this conversation arguably provided evidence of the truth of the molestation, the friend’s report presented “the same problem as the truth value of memory and is theoretically unresolvable in the psychoanalytic situation” (1995 1192). There is no guaranteed outcome. The patient might have become the bitter victim, the narcissistic exception, or the accuser of now long deceased relatives. However, she had a usable psychoanalyst. She recovered and flourished. There is no one else who can make the “tough call” except the person who is in the presence of the patient’s transference relationship and the narrative. Viederman addresses the issue: Each of the reviewers of this article commented on this issue but in markedly divergent ways. The first indicated that my supportive behavior manifest by touching the patient [on the shoulder], asking her to sit up, giving her my telephone numbers, checking on her in the waiting room, and my direct reassurance, were puzzling and required a discussion of their rationale and impact [. . .] The second reviewer believed that I was too apologetic about this behavior and that I was “backing away from a fuller exploration and possible reappraisal of traditional concepts of neutrality and abstinence in working with patients who have suffered sexual abuse,” a view with which I concur. The third viewed these behaviors as parameters and wondered whether they were subjected to analytic scrutiny. It is clear from these contradictory views that psychoanalytic technique is changing and is the subject of vigorous debate [. . .] (1995: 1180ftnt) Naturally, this is only one pattern. Just as forms of abuse are many, so are the patterns of responsiveness. When the abuse takes on expanded emotional and physical damage—violent penetration, accompanied by physical injury, occurring repeatedly and over a long period of time, in an environment of constant or intermittent threat—then the abuse may well be less likely to be forgotten, though not necessarily less vertically split off or less confusing in its details or meaning. That is why trying to give an account of what the survivor believes happened is the critical path. If one can say exactly what happened, the meaning and impact of the events start to transform. Affect is constellated and released. Catharsis does occur.

160

Treatment of domestic violence

Abreaction has value. But catharsis and abreaction are not the only value and perhaps not even the main one. The value lies in saying what happened in order to engage the process of integrating what happened into the personality (i.e. the self or ego, depending on one’s perspective). Painful as it may be, when the abuse is confronted with reality and acknowledged— acknowledged as unacceptable and as bad and wrong—then it starts to lose its power. It starts to lose its power to cause intrusive thoughts, repetitive traumatic state dreams, hyper-vigilance, and related symptoms. As noted above, it is a useful rule of thumb that if one can say exactly what happened from the perspective of a safe place and a non-retraumatizing relatedness, then the traumatic material spontaneously begins to morph, shrink, and lose its toxic force, even if it does not ever entirely disappear. Stating exactly what happened as factually and accurately as humanly possible is like bringing up a strange sea creature in the ocean from 12,000 feet below sea level. You do not ever really get to see what it looks like in its original form. The pressure differential is too great. It ceases to be what it previously was. It explodes. Survivors suffer from not being believed. For years. There is the abuse— the slap, the molestation, the violation, the beating. Then there is the ongoing secondary abuse of invalidating the survivor’s experience by describing the individual as “exaggerating,” “making it up,” “out of touch,” accusations of what would psychodynamically be called a failure of “reality testing.” Nor does this mean that all the details of what the survivor recounts have a privileged accuracy just because the survivor has come through the refiner’s fire of abuse. Inevitably, the issues migrate into the room—into the transference. But now they relate to the person of the psychotherapist. According to the patient, the therapist does not get it—does not believe it—cannot relate to the extent and depth of the patient’s suffering. This is where the filtering power of empathy works to deliver to the therapist a sample of the patient’s suffering, a signal affect, not the entire mass merger of suffering. This enables the therapist’s empathic responsiveness to rise to the occasion in meeting the patient where she or he is at. “I was late, and it was momentarily similar to being abandoned again to the perpetrator.” Rarely are matters so direct, but do not overlook the obvious—the patterns can be disarmingly simple. Not being believed by the other, non-abusing friends, relatives, or wouldbe helpers is a function of the bystander (friend, etc.) being stubbornly defended against what is occurring. The bystander has her or his own selfinterest in actively knowing and not knowing at the same time—maintaining a split in place in which the bystander literally does not experience what is before his eyes (see “A Rumor of Empathy in Freud,” pp. 82–83 (Freud 1893a: 117)). Otherwise, she or he would have to do something about it such as breaking up the unhappy home or filling out a police report and risk being abused herself. The latter in particular should not be forgotten. There is

Treatment of domestic violence

161

indeed a “should” here—or at least a recommendation. Psychotherapists should not second-guess the tough decisions that survivors and bystanders had to make as they were in complex situations of danger and as these situations unfolded. Courageously fighting back does occur—and sometimes it works. The prognosis for a therapeutic outcome is significantly enhanced if the survivor fights back (and survives). However, sometimes courageously fighting back just increases the body count. Sometimes we are left to infer the courageous fight, because the victim does not survive. That the individual is sitting there, narrating her or his story, probably means that at some point, the individual prudently decided to placate, pretend to cooperate, go along with the perpetrator in order to live to fight another day. This is where the psychotherapist’s acknowledgment and recognition can provide a balanced, even-handed response: “I acknowledge you for engaging with such difficult material, events, recollections. This is not easy work.” The patient’s fear is a powerful motivator—to courageous action in spite of fear, but also to do nothing—to freeze—to become “the deer in the headlights.” The deer usually does not survive. It is tempting to say, “Well, psychic reality can be just as good as factual reality for purposes of therapeutic working through.” And given that victims and survivors of abuse often suffer from the intentional or unwitting collusion of family and friends not to acknowledge the abuse, to deny it for their own defensive purposes, the prudent therapist allows an expansive listening to the survivor’s narrative of events. Psychotherapists are often literally shut up in their response to reports of abuse because the one thing they do not want to risk is blaming the victim. While learning to live with ambiguity, the empathic therapist distinguishes himself from the non-involved, uncommitted bystander by acknowledging the effort needed to do the work of engaging with such challenging material. However, there is the small, quiet, barely audible voice of those who just are gripped by an authentic spirit of rigorous inquiry and want to know: “Psspt. What happened—really?” The dynamic psychotherapist usually does not have to provide expert testimony in a forensic process. Compelling inquiries that meaningfully engage the suffering of the survivors and the suffering of those righteously and falsely accused are available in Hacking (1995) and Rabinowitz (2003). The example of the literary hoax of Benjamin Wilkomirski (in Maechler 2001) is a cautionary tale. Wilkomirski had a seriously disturbed mother (herself a survivor of abuse), spent years in unempathic foster care, including being in an asylum with Jewish child survivors of the Holocaust, and arguably had an overactive psychotherapist. This individual, Benjamin Wilkomirski, was not a liar. He fooled a lot of people, including himself. His emotional distress was long and deep. He suffered greatly. However, he was never in Auschwitz (as he claimed to be). Winner of the Israeli National Book Award (later withdrawn), he was not even Jewish (see Maechler 2001). A cautionary tale indeed.

162

Treatment of domestic violence

Once again, facts are fragile. For example, a Holocaust survivor of the uprising at Auschwitz testifies: “All of a sudden we saw four chimneys going up in flames, exploding” (cited in Felman and Laub 1992: 59). At an interdisciplinary conference on the Holocaust years later, historians point out that the testimony was not accurate—only one chimney was destroyed (1992: 59). The correction stands, but is it relevant? The historians point out that it is relevant to be accurate and precise so as not to give Holocaust deniers a pretext to generalize that the entire genocide was itself a fiction. This is yet another compelling example of the fragility of historical facts. Therefore, the integrity of the witnessing must be beyond reproach. Nor should this be taken as criticism in any way devaluing the testimony of the survivor, for whom the key event was the uprising itself—that the prisoners managed to fight back against all the odds. Point taken. This is yet another powerful example of the entanglement of historic fact and psychic reality. The initial dose of historical fact is susceptible to psychic elaboration; and psychic elaboration is capable of bringing forth initiatives that impact history as when the prisoners imagined, planned, and executed the actual uprising that made history. Now shift this discussion in the direction of psychodynamic transference. Memories do get repressed; and, yes, the repressed does return. However, the return of repressed memories is far rarer—and this is a position not the truth with a capital “T”—than the most enthusiastic proponents of recovered memories asserted during their most influential time. Wilkomirski was arguably a survivor, but not of what he factually claimed to survive as he elaborated his narrative in working with his psychotherapist. Just “talking about it” is effective, but not enough, because the unexpressed, unacknowledged abuse lives in a context of meaning of which the survivor is both aware and unaware. As with the chimney, whether Uncle Jim said “Don’t tell and I’ll give you ice cream” or “Don’t tell or I’ll kill you” on a given occasion may not be critical path outside a forensic process. Yet the subtext of the promise of ice cream may be a threat of bodily harm. That something was said and how it was heard by the survivor is what is significant. Thus, this already points towards the important distinction—what happened versus what did the survivor make it mean? To that we now turn.

Acknowledgment of what the survivor made it mean At this phase, the therapy consists in the steady drum beat of distinguishing between “what the survivor believes actually happened” and “what the survivor made it mean.” The distinction between “what happened” and “what the survivor made it mean” is exemplified in the following clinical vignette. One abuser, who periodically exploded in “temper tantrums” of hitting and verbal abuse, had his eight-year-old son persuaded of the idea that the boy

Treatment of domestic violence

163

had to “get his act together and behave.” As the abuser’s rage cycled down, he would talk nicely to the boy about the boy’s behaving himself, though the required behavior was indistinguishable from not committing the narcissistic slight that caused the father to explode in the first place. Walking on egg shells—tip toeing around hyper-vigilantly—being solicitous in the extreme are “meaning-making” results that attempt quasi-magically to ward off the next explosion and round of abuse. Here the damage done was to self-esteem, self-confidence, and by internalizing the hostile introject. Much work in therapy was required to surface and shift the low self-esteem: “I made it mean—I was to blame for what happened. I caused it.” Not so. Recurring phases of psychotherapy consisted in the steady drum beat of descriptions of physical and emotional upsets, traumas, and empathic interpretations the punch line of which is the statement: “You know, one of the things that survivors tend to do is blame themselves for the abuse to which they were subjected even if they did not cause it.” Remarkably enough, today’s survivors of diverse forms of abuse may be in the position of the entire community prior to 1962. Yes, they know the shocking statistics about abuse displayed in public service announcements. Yet they do not appreciate that it applies to them. The survivor thinks, “This is simply the way all families live.” The child in the adult thinks, “This is the way my family was—get over it.” But she or he does not. One can take the child out of the abusive environment; but one cannot take the abuse out of the child (or grown-up child). After a certain amount of habituation, the abuse lives on in the individual. The hostile introject has been interiorized and endures. The fragile, vulnerable self survives, but sometimes just barely. Thus, the psychodynamic treatment of survivors of domestic violence has to navigate a delicate course between the risks of retraumatization and the impasse of interminable entitlement to corrective emotional experience. Empathy directly addresses the first. Being well listened to by someone (the therapist) can itself be a deeply satisfying, if not corrective, emotional experience. Yet empathy has its risks—and resistances. It can unwittingly increase the patient’s sense of entitlement. The exploration of this resistance confronts the obstacles to owning negative affect, and the power of such affects and beliefs in engendering intrapsychic conflict, including the distorted beliefs that the survivor was an accomplice in the abuse, deserved the abuse, or is now entitled to compensation from a third party (such as the therapist). If the survivor believes that she or he has been complicit in the abuse, because the survivor was threatened with grave bodily harm and decided to cooperate (or because the individual momentarily enjoyed the experience), then the survivor may feel that she has made a deal with the devil. Yet paradoxically if the survivor tries to eliminate this darkness from her psyche, as one survivor reported, by “having only pure and noble thoughts” in a kind of obsessional ritual of repetition of mental meditative self cleansing, then

164

Treatment of domestic violence

the abuse seems to continue to come at her from the outside as shady characters whose behavior invites being described as provocative if not abusive. She really is that suffering, authentically and all the way down. She really is that impurity. She did not do anything to deserve it, but that is what got encoded in the neurons and transcribed in her psyche. When she accepts it in all its messiness, repossessing the projections, then they start to lose their power and force. The upsetting feelings becomes less intrusive. The images and memories become less forceful. The conflict due to vain struggles and attempts to force oneself not to think about something—which only increases the intensity of the obsessive thought—starts to remit. The upset shrinks. She must own the darkness in order to overcome it, and move from survival to flourishing. At the same time, the conflict between who one is and what one might have been requires mourning one’s losses—that one does not have the wonderful partner or parent that everyone deserves. In another clinical vignette, the perpetrator made a credible threat that the survivor, in her mid-teens at the time, would be sent back to the homeland and an “honor killing” arranged. Apparently, this survivor had been living with this information for years as a 20-something adult. It was definitely not a recovered memory. The events had always been available in memory. This survivor had been torturing herself with guilt that she had done things that made her feel impure (though she had done them under duress to save her own life). Finally, she thoughtfully reflected on the obvious fact that a person may decide that she wants to go on living—that every person is entitled to have a life—and the person does whatever the person has to do to survive (even under duress). It was as if an enormous burden of guilt was lifted from the shoulders. It was perhaps an obvious point, but a relationship with the therapist of mutual trust and communication about the abuse had to be in place for the recollection of the threat to “surface” from the preconscious and become available for discussion. Human beings and the human psyche are “meaning-making machines.” Empathic understanding and empathic interpretation are on the critical path for distinguishing near delusional elaboration from a validly and accurately perceived trauma. That one survivor decided to fight back against the violence and threats of violence means that he or she is fighter. That another person decided to cooperate to preserve their life and limb means that he or she is a survivor. Other times, it is as if the survivor is “cursed” with the tendency to blame herself or himself for the abuse that occurred. This is not an occult process. It is a process of owning one’s projections and projective identifications. Intuitions, educated guesses, and elaborations are replaced with empathy and openness to relatedness in the here and now. The forward edge of the patient’s experience replaces the intuition of elaborating in fantasy about what others might be thinking or intending with empathic receptivity to what the other’s are experiencing in the moment, including what was actually said

Treatment of domestic violence

165

and done. This is a capability that requires practice. Even introspective survivors, who display significant self-understanding, after engaging in thoughtful reflections on how they know—really appreciate—that they are not to blame, will end up saying: “I wonder what I did wrong?” They go on to express the views: “I am broken—in need of fixing. I am defective. I am morally corrupt. My sex organs are misshapen or a source of shame. My appearance is shameful. My nose is too big, my ears stick out too much. My hair is the wrong color. I am the wrong color. I am just plain wrong.” A modest dose of “normalization” of the dark impulses we all harbor is useful. “You know, given your father’s actions, no one would blame you for occasionally thinking you were cursed.” Nevertheless, the feelings of impurity were “burned into” the psychic by repeated perpetrations and it took much work for that to start to shrink. A first step was taken at that moment that she realized she had acted “under duress.” If domestic violence started in childhood, the adult may take over from the child the goal that she must try to fix the parent so that the parent can do his or her job—be a parent and take care of the child, who after all needs the parent in order to survive. At this point, insert almost every imaginable unconscious fantasy. “I caused Mom/Dad to act this [upsetting] way.” “If I were smarter/dumber, more good looking/less good looking, shorter/taller, then this never would have happened.” Even people who were not abused have such fantasies about causing the behavior of significant others in the environment. Treatment consists in surfacing and watching such fantasies blow up. Clinical vignette: redescribing the skeleton in the closet: it’s crowded in there

Ms. S was a 30-something woman, who spent the first 12 years of her life being raised by her maternal aunt in a relatively safe and secure, if unconventional, setting in a foreign country along with a cognitively challenged sister and her own mother, who suffered from debilitating PTSD. Hard working, outgoing, even extroverted and of an overall cheerful disposition, Ms. S was subject to periodic “breakdowns” of an empty lethargic (“depressive”) nature in which, as she said, “it took all the energy I had even to drag myself into bed” where she would stay for a couple of days. Also, behind the scenes was a smoldering rage about what had happened, an intermittent sense of entitlement, hyper-vigilance, and suspiciousness of other people that reflected a home life that included significant abuse. Ms. S initially came to therapy with a “situation” in her place of employment involving on-the-job conflict with a fellow worker. She was hungry for strong role models, preferably but not exclusively female, but there had not been many of those in recent memory. The prospective models that had

166

Treatment of domestic violence

shown up turned out to disappoint—severely. When a would-be role model disappointed her, a series of small misunderstandings added up to a large, dramatic upset and rupture. The rupture included accusations that the other person was behaving abusively, like her father and brother, and that she (Ms. S) was surrounded by emotional “leeches.” Ms. S initially communicated that she was struggling with relationships with her coworkers. She spoke of these coworkers in devaluing ways. After hearing the details, my own associations were to a work cohort of immature coworkers behaving like “mean girl” teenagers at the local junior high school. However, initial, tentative attempts to explore what Ms. S’s unwitting or unintentional contribution to her own difficulties were rebuffed. Tentative suggestions that “her meaning machine might be working overtime” were not useful. Speculations that people were sometimes common and petty but, with notable exceptions, not really abusers, were not appreciated. This was likewise rebuffed with protests: “You don’t get it.” Indeed I did not. Weeks of long, patient listening to the narratives of injustice that were being perpetrated at the workplace were needed to attain a measure of calm that enabled recognition of the underlying pattern of struggle in defining and navigating boundaries—boundaries in the workplace and in relationships. Furthermore, a pattern emerges that when Ms. S was made to feel humiliated—narcissistic slights often related to boundary issues at work or lack of immediate, empathic understanding on the part of the therapist— then she escalates into angry and aggressive verbal denunciations, nor is she shy about the use of profanity. In the meantime, background data pointed to a dramatic and moving struggle at home for freedom, self-expression, and contribution. Typically, the patient would escalate towards angry denunciations of the way she had been treated at various of her work assignments where she ended up becoming entangled in boundary issues. In one instance, she tried to engage in an office romance, the very definition of which is a lack of clarity about boundaries. Perhaps a risk worth taking if one has the necessary skills in dealing with boundary issues, but in this case the result was a chronic upset. In another, she engaged in an intense personal relationship with the supervisor outside the job, not romantic, but yet another boundary issue, this time involving an idealization of a supposedly successful professional woman with whom identification occurred. This woman was herself struggling with boundary issues that made it impossible for her to respond appropriately. The result was not just disappointment but conflict as the patient responded ragefully to the deidealization. Empathy is a competence that requires significant navigation of boundaries. One must be open to the other in empathic receptivity, yet distinct from the other in empathic responsiveness. A definite step forward occurred when I interpreted a breakdown in my own empathic relatedness. After acknowledging how badly the patient had been treated at the job for the

Treatment of domestic violence

167

umpteenth time, I wondered aloud again whether the patient had thought about how she might be contributing to the difficult situation. While perhaps accurate enough as an inquiry, this question was not the optimal nurturing response. This triggered an angry tirade, displaced onto “the losers and leeches” who surrounded the patient. (I wondered, was I not one of those, too?) I reflected how there was more going on than met the eye. “This is really about us—you and me. A lot of energy is being aroused by my not being nurturing in my response. When you do not get the nurturing—one might also say ‘empathy’—you feel you deserve, then you get a lot of energy—a lot of angry energy.” The patient’s response was to reflect on how her Mom had never been able to be there for her. The patient reflected on how her Mom had been abused and was often not fully present. She broke down and cried, reflecting on how she had wanted to help her Mom but that both of them needed rescuing. The patient reflected on how she wished for someone to show her how to manage the boundaries at the job. To myself I thought that one thing that was missing was the affect regulation that mothers provide. This also points to an alternative forward-edge redescription of the therapeutic transference as not limited to reenacting abuse but also providing guidance around mentoring and boundary setting going into the future. In the period that followed, I ventured to respond to the patient that she had a kind of “mother hunger” that caused her to look for powerful women in the work environment from whom she might get recognition, mentoring, and approval. Unfortunately, a couple of the figures on whom she had pinned her hopes turned out to be disappointments. This only increased the patient’s rage at the unfairness of life, which had already been so unfair. When people are not nurturing—where “nurturing” became another way of saying “empathy”—then the disappointment soon escalated into anger and rage. The next session Ms. S came in furiously enraged about the treatment she had received, including the treatment from me in asking how she might have contributed to her own difficulties. “Well, that was a clumsy moment. Not my most empathic one, to say the least. However, there is good news— I think we have found your energy.” Ms. S continued reflecting on the annoying things a prospective, new woman friend, Maria, had done. Not exactly confirmation, but not refutation either. Maria had criticized a fellow worker, behaving like a bully. Ms. S felt compelled to come to the rescue of the fellow worker against the perceived “bullying.” We are getting warmer. I try again. “There is nothing wrong in sticking up for a friend. However, this back-and-forth will be less of an energy drain when you own your own critical tendencies instead of discovering them outside yourself.” Own the critic within, and it will have less of a tendency to be projected and come at one from without. Another challenging question is why did we seem to fall through a timewarp, back into second year of high school? Ms. S is engaged—one might

168

Treatment of domestic violence

say “fixated” in a technical sense of arrest at a stage of development—upon the kind of competition that one sees in junior high school. Boys might throw a punch, but girls tend rather to channel their aggression into devaluing talk, hurtful gossip, and cliquish behavior that arbitrarily excludes the one designated as shy or socially awkward. If empathy is used, it is only used by the bully the better to control or dominate the would-be competitor. The literature on the competitiveness of “mean girls” is eye opening and disturbing (e.g. Piper 1994; Simmons 2002; Kulish and Holtzman 2008). This is not to say that Ms. S is in any way mean or ill-tempered. Far from it. She is kind, considerate, even self- sacrificing to a degree only possible if one is motivated by a self-protective, defensive reaction formation against meanness. The relationship with me alternates between my being one of the gossip girls (with whom to share confidences) and one of the bullies, maybe even an abuser. The distinction between “what happened” and “what the survivor made it mean” is ready to hand and gets frequent use. I try to substitute empathy for intuition and inference. The results are mixed. The results are that Ms. S is vulnerable to the kind of competitiveness that has girls gossiping about one another in devaluing terms. Ms. S senses that such a thing is going on at work and wounds her deeply when she senses, occasionally accurately, that she is the target of it. In a sense, she is a “clearing for it,” since she wears her heart on her sleeve, yet is hyper-vigilant about devaluing or critical comments. What is meant by saying “a clearing for it” is as if she had a sign on her backside, as in the sadistic high school prank, that said “kick me”—or, in this case, gossip about me in a devaluing way. The problem is that the reference of the gossip is invariably that everyone else knows that she was abused—abused in the most humiliating and degrading way. The problem is taken up a level in that Ms. S cannot say for sure whether or not the gossipers had met a member of her extended family—the nephew of a cousin, and something about one of the many skeletons in her closet got out in that way. At this point, Ms. S’s “meaningmaking machine” is working overtime. The ambivalence is deep. She is proud of having come through the refiner’s fire and survived; yet she does not want to be perceived as “broken.” She credibly denies having discussed the darkest aspects of her personal history with anyone but me, yet acknowledges that she has let it be known that she has certificates of completion in training as a rape advocate and domestic violence advocate. People may draw their own inferences. The result is a near-delusional narrative about who knows what about Ms. S and when did they know it. Narrative truth and historical truth are entangled. Disentangling the narrative is challenging. This causes Ms. S to shut down interpersonally and isolate herself. Interactions are too messy. Isolation seems like an increasingly attractive alternative. People disclose to Ms. S that they, too, had suffered abuse. This happens without any initial “confession” on Ms. S’s part. Every family seems to have a skeleton in the

Treatment of domestic violence

169

closet, but Ms. S’s family is so large that it is getting crowded in there. As noted, in an attempt to understand her own experience, she takes training as a domestic violence advocate. She just seems to be a “clearing” for the conversation about it. Ms. S offers to refer them to counseling, but she has not yet transformed her own abuse into a resource, and her guidance is not always appreciated by the survivor to whom it seems dismissive. Repeated conversations about boundary setting, navigating boundaries, boundary issues occur as Ms. S engages relationships with halting but increasing competence. The work goes on.

Boundaries: confrontation with shame, guilt, rage, negative emotions Empathy is all about boundaries. Empathy fails by not maintaining firm boundaries between self and other. Empathy fails in the form of merger— over-identification with the other, emotional flooding, or excessive intervention. Empathy fails by maintaining too rigid and inflexible boundaries between the self and other in the form of emotional distance—lack of relatedness to the other, lack of identification, or over-intellectualization. Empathy is all about keeping one’s emotional balance. Once you get the hang of it, you never forget. But riding the bike “hands free” is reserved for the circus—most practitioners still need to keep both hands on the handlebars to maintain equilibrium and balance. The power of Kohut’s definition of empathy as data gathering through vicarious introspection lies in importing a certain “distanced relatedness” into the heart of the process. The “distanced relatedness” that such a formulation implements creates a significant distinction between empathy (as receptivity, understanding, interpretation, and responsiveness) and merger-like phenomena that become a source of compassion fatigue, emotional burnout, or mystical over-identification with suffering. If one experiences the latter, one is doing it wrong. One is over-identifying or overintellectualizing. Thus, the multidimensional process of empathy forms a protection—one might say “defense”—against such burnout and compassion fatigue because empathy takes a sample of the suffering of the other without over-identifying or merging with the other’s suffering. As a form of relatedness to the other individual, empathy provides a trace affect of the other’s experience. Yes, the empathy is open to the negative experience that the other individual is enduring, but as a trace and a sample, not the full weight of the suffering. Yes, one suffers, but, unconventional as it may sound, one suffers only a little bit. Survivors of domestic violence want to be known for who they authentically are—courageous survivors of difficult trials and tribulations. They want to be known for having come through the “refiner’s fire” of the difficult ordeals they have survived. They want to make a contribution,

170

Treatment of domestic violence

realizing their own aspirations and contributing to the well being of others. This segues with the “what I made it [the abuse] mean” moment, but in a positive way. It is a “what does not kill you makes you stronger” moment, where “stronger” means “more human,” “more resilient,” “more empathic,” “better able to make a difference.” Survivors are proud, or, at least, are willing to consider being proud. But there is a “but.” They are proud, but they are also not proud. What happened—the abuse—is a source of ambivalence. How could it be otherwise? It is a source of shame that the survivor often would prefer to forget. For the survivor what happened is a bottomless pit of negative emotions, painful memories, and maladaptive patterns of relating. As soon as a survivor considers sharing her experiences with a fellow traveler, she is confronted—confronted with ambivalence and shame. This is so even though the survivor knows she did nothing of which to be ashamed. The abuse can be redescribed in a way that is devaluing to the survivor, and the abuser has often done just that. The survivor confronting being selfexpressed about her experiences to therapists, friends, etc., wonders: Will the other person get the wrong impression? What is the right impression? Will the other person wonder why I was treated so badly? “What did you do to deserve such treatment?” “You must have done something wrong.” Well, not really. Thus, the survivor is inhibited in her or his communications. All of a sudden, even the individual who has engaged in working through, integration, and transformation of their traumas can find herself momentarily back at squire one wondering, “Maybe I really am to blame after all. There must be something wrong with me!?” In this next clinical vignette, the survivor arrived to live with different members of her family, leaving a caring matriarchal milieu in a land geographically far away only to find herself in a dangerous situation of physical and sexual molestation. “How did it feel?” Numb. She felt emotionally numb. She still felt that way ten years after having escaped the physical environment. From the moment she entered the home where locks had curiously been removed from the bedroom and bathroom doors, she was in a near-continuous state of quasi-trauma that started to shrink only with psychotherapy. Feelings started to return as she became accustomed to being in a safer milieu. Where empathy lives, can narcissistic rage be far behind (e.g. Kohut 1972)? Then explosive, stormy, confrontational sessions occurred. When things got too hot and the patient threatened to walk out the door, the response was: “Given what you have been through, it is to be expected, quite natural, that you would feel the way you feel.” “I acknowledge your commitment in engaging in the tough work that needs to be done.” Detailed accounts of what happened, and what the survivor made it mean came tumbling out. The introduction of the distinction “boundary violation” to the survivor can unleash a flood of new emotional material about what happened. If this

Treatment of domestic violence

171

is education, make the most of it. A “boundary violation” is defined as a transgressing of limits that compromises the person’s physical, emotional, or moral integrity (see also McWilliams 2004: 101 on limit setting). Living in a community requires extensive negotiations, conversations, and interactions about setting and navigating limits and boundaries. Here the distinctions of description and redescription are clinically relevant. What seemed business as usual—locks are removed from the bedroom doors, walking on eggshells so he does not “go off,” the smile that masks heartbreak —gets redescribed as what it was or really is—that is, a boundary violation, perpetration, criminal wrong doing—along with a challenging wealth of affects, emotions, and hyper-vigilance. One survivor had compensated for confusion about boundaries caused by an abusive environment by developing a “Don’t you mess with me!” talk and way of relating. If narcissistically injured, the risk was that she would work herself up into a righteous indignation and “go off,” launching a verbal tirade of considerable energy and impact. I had a sense that she was rehearsing it on me, which was perhaps permissible enough within a formulation that some cathartic expression of rage had its uses in restoring and maintaining emotional equilibrium. Thus, venting had its uses; but sometimes venting is just venting. She would invoke it when she felt threatened by the ambiguities or assertiveness of coworkers—and my own intermittent empathic lapses. But there was a cost and an impact. It did not make friends, and it created a void around her and increased her painful loneliness and not being included. It established a boundary in the moment, and became visible when it migrated into the therapeutic relationship. Instances of correlating my occasional empathic failures—which to her were not minor at all—with the “don’t you mess with me moment” were needed before her contribution to the dynamic began to be visible to her. Even when the survivor of boundary violations—physical, emotional, sexual, all of the above—escapes and discovers some families are loving and non-abusive, the survivor may not believe the evidence of her or his senses. The family from which the survivor has escaped maintains a façade of normalcy in presenting itself to the “outside” community. This survivor found that any kind of hypocrisy, for example, on the part of coworkers, aroused a disgust in her so strong as to be transiently incapacitating. Even years after having escaped the violence and molestation of her father, the two-facedness and deception of the abuser, who was a respected pillar of the community in public but a monster with his own family, laid down a pattern hard to overcome. She suffered from a keen sense of hyper-vigilance in relation to double standards in the corporate world and among her 20something friends. The hyper-vigilance required engagement in therapy to recover a sense of normalcy about petty human failings by those who were in no way abusers. If the extended family still dwells in the same neighborhood or community, chance encounters on the street with the survivor can

172

Treatment of domestic violence

become a trigger for retraumatization, upset, and breakdowns in the feeling of being safe. Back to square one? The role of empathy is to provide a non-judgmental context into which to speak the shameful and confronting perpetrations and meanings into which the survivor was forced. If one cannot help but blame oneself, empathy acknowledges that people initially tend to do that. The rush of emerging, erupting material can seem like a tidal wave. Throughout such a process of draining the emotional swamp, it is a valuable rule of thumb, previously stated but worth repeating, that if one can say exactly what happened and what one made it mean from the perspective of a safe place and a non-retraumatizing relatedness, then the traumatic material spontaneously begins to morph, shrink, and lose its power, even if it does not ever entirely disappear. Clinical vignette: redescribing honor

Ms. S had significant energy tied up in reflecting on the agonizing task of ferreting out the hypocrisy of abuse in the world at large. She was finely tuned into double standards, and she would often attribute the least charitable intention to others whose way of relating was merely self-serving. One thinks of a Kohut-like genetic interpretation and phrase, saying “Well, given your difficult experiences with your family, it is quite natural that you would think [feel, behave] in that way. Nothing wrong with that. Meanwhile, what are the facts? What happened? What did he actually say?” During the initials month of the unfolding story of abuse, perpetration, and molestation, the psychotherapist’s main approach was acknowledging the patient’s commitment in sharing—narrating—the difficult material. The emotional pendulum swung back and forth between alternating cycles of loss and anger. It is questionable whether there is such a thing as a “baseline” against which such difficult experiences can be measured, but if there was a baseline, it was that the work was being courageously engaged. It was to be expected that the emotions aroused would be strong and upsetting, especially given that the main emotion experienced during the traumas themselves were the absence of emotion—pervasive numbness. The numbness was soon replaced by intermittent towering rages and fits of crying over the loss. All prognostically positive signs. Ms. S periodically raises her hands to the sky asking, “Why me? What did I do to deserve such a heartless brother and father?” She then speaks movingly about wanting to make a contribution as a doctor to serving women and children who do not have access to proper healthcare. What has sustained her through these challenges has been her aspiration to become a medical doctor, like her cousin—at last a good object—and make a contribution at the cousin’s Clinic for Women and Children back in her country of origin.

Treatment of domestic violence

173

Ms. S’s father was teaching in the local school system and being a “martyr” who had to take care of his supposedly schizophrenic wife and his delinquent daughters who were “ungrateful bitches.” The wife’s condition may more accurately be redescribed as PTSD with psychotic features, and the so-called “delinquent” sisters may be redescribed as “acting out in selfdefeating ways” and “in a towering rage.” One wonders, what might have happened to get them so angry? The father is grooming them to provide him with sexual services with a narrative all too familiar: “You know, I get nothing from your mother.” The three sisters plan an escape, though, ultimately, not quickly enough. The eldest sister rents a place. They secretly remove essential belongings out past the doorman, who is “bribed” by the father to keep tabs on them. Ms. S writes a long angry letter denouncing father’s high crimes and misdemeanors, and, using the spiritual language that has helped her to survive, invoking the wrath of the Lord upon his soul in no uncertain terms, leaving it where he is sure to find it. The sisters escape. Disappear. The father discovers the letter. He bemoans the ingratitude of his delinquent daughters. In a turn of events that would not have been believed if it were fiction and that Ms. S speculates was divine intervention— the father goes back to the homeland to marshal family and friends as allies. One cannot help but wonder—perhaps to arrange an honor killing? His trip occurs in the hottest part of the summer. He is drinking heavily. He has an unscheduled cardiac event. He passes away before emergency services arrive. The brother accuses Ms. S of killing their father with the letter. She does not believe it for an instant, yet she suffers greatly from the accusation, because at another level she believes it. Interpretations prove useful: molestation that occurs under duress—and is there any other kind?—the explicit threat of an honor killing—cause impure feeling and shame, but that is so only in taking the perpetrator’s point of view. Empathic interpretations attempt to shift perspectives, showing just how readily the survivor unwittingly slips into taking the point of view of the abuser. The time spent in compulsive cleansing rituals—five showers a day—diminishes and returns rarely if the patient is under extreme pressure in school or work. A single instance of a recovered memory occurs. Ms. S experiences it after we discussed the threat of the honor killing and how the person does what she has to do to save her own life—to survive in the face of a death threat. (I hypothesize that this reduced the guilt enough to allow the recollection to return.) Ms. S remembers what happened the next day after she literally stabbed the father in the back with a small sharp tool that lay ready to hand. In the back, because he was on top of her trying to undo the tie on her trousers. The recovered recollection? Ms. S was walking into the kitchen and out of nowhere her mother came at her with a large knife and cut her on the face. She recalls there being a lot of blood. She faints. She wakes up in the emergency room. She recalls the father was looking angry all the while. The brothers said that maybe it would be a good thing if she got cut more often.

174

Treatment of domestic violence

As bad as all of this was, the final straw occurred when the father took Ms. S out of school, reportedly for holding hands with a boy. But that was a pretext. The actual reason was for threatening to tell a teacher what was going on at home. Being pulled out of school placed at risk Ms. S’s plan of using education to escape the abusive behavior of the men in the family. This precipitated the escape plan and the escape. Ms. S planned, worked, networked with her sisters, and they literally ran away from home with the help of the drug-dealer boyfriend of one of the sisters. Applying the principle of “any port in a storm,” they get away. In short, Ms. S got a job; completed her GED; put herself through college, earning a bachelor’s degree in business administration and credits towards an MBA. She has been self-supporting ever since the age of 17, including contributing financially to the support of her sister’s children, her Mom, and her mentally challenged older sister. Thanks to a well-paying position at a Big Six consulting company, she was able to put aside money for her education, though she reports that she is “unfortunately not rich, except in spiritual blessings.” Upon reflection, Ms. S believes that the threat of an honor killing was credible, though as a teenager she cannot say what it meant—just that she felt numb. At one point the father pinched her, called her a “bitch” in their native language, and said that he was sorry he had not yet arranged an “honor killing.” Still, Ms. S felt guilty, as do most victims, that she was coerced into becoming an accomplice to however limited a degree in the boundary violations that were enacted upon her. This gets telescoped with her brother’s accusation that Ms. S’s angry letter of denunciation caused the father’s death. These vulnerabilities are carried by the survivor intrapsychically even after physically escaping. One can take the survivor out of the abuse; but the abuse lives on in the survivor. The narrative of the threat provided an opening to push back against the many hostile introjects. The description of the so-called father was not that of someone relating like a parent. Ms. S used the word “monster” without any prompting. “Criminal” also occurred. Although there was nothing funny about the situation, and perhaps as a signal of my own vicarious suffering, brief comic relief was provided as I wagged my finger in the caricature of a parent saying “First do your homework; then go out to the mall.” This was so painfully at odds with the reality of the boundary violations that just how unsafe home had been was dramatically demonstrated. After this encounter with reality testing, I saw a significant diminution in her feelings of guilt. She made fewer excuses for her father. She disassociated less. She quoted me back to myself that she had been making excuses for inexcusable behavior, but mainly as an attempt to understand why. She wondered aloud persistently, addressing God, “Why did you send such bad people to me? What did I do to deserve this?” No answer. I reflected aloud that as a certified domestic violence advocate she knew that victims and

Treatment of domestic violence

175

survivors regularly blame themselves as part of an attempt to understand and take control of an out-of-control, traumatic situation. The traumatic events transpired before I met Ms. S. She is now continuously employed, working hard, putting herself through school and earning two bachelors degrees—one in a business field and one in a science field. As noted, she periodically experiences a hit-the-wall, vegetative lethargy that prevents her from crawling out of bed for several days at a time. She consulted an energy healer—an individual who is some kind of “natural empath” with significant intuitive skills. Ms. S was persuaded that a former boyfriend had used black magic to put a curse on her. Ms. S later reported that she was putting on weight and losing energy because of the curse. She turned to the energy healer for help. Ms. S paid her hundreds of dollars to remove the curse, which coincidently was the amount that the energy healer was in arrears on her rent. Ms. S can only do things for herself by helping others. Ms. S wished that she could take better care of her sisters and mother—the energy healer seemed like one of those. Ms. S experienced relief (as the depression spontaneously remits) and got her energy back, though not her money. Her weight-gain did not come off. Given that Ms. S was struggling to pay her psychotherapy bill, my countertransference was activated, even though the scam occurred in the past, prior to our meeting. Nor did I like the idea of her being taken advantage of by an “energy healer” who explained to Ms. S that there were vulnerabilities in her aura. Yet I came around to thinking this “healer” had a certain talent—and was not totally off the mark. I sensed that Ms. S was abused—financially, this time—again. Using the admittedly unprofessional language of the natural empath, the problem is that the counter-magic was only partially successful. The counter-magic might have removed the black magic. But the larger part of the “curse” remained. Removing the curse did not work. It did not work on the shame, guilt, and rage. My countertransference is such that I tend to normalize to keep the patient in touch with everyday reality. I tended to agree that she was cursed—not by black magic but by what we might scientifically redescribe as enormous random bad luck in being born into her family of origin. The shame, guilt, and rage at the way the patient was treated by the men in her family lives on. To remove that part of the “curse” the recommended method of treatment is psychotherapy. At this point, the treatment of shame, guilt, and rage aligns with the standard practice of psychotherapy. The usual amount of hard work and working through of shame, guilt, and rage get the job done. That is not to say it is easy, but it is no longer an occult process; it is a psychotherapeutic one.

Expectation (realistic and otherwise) of compensation for suffering At selected points in the process of recovery, any survivor confronts the realization that life is not fair. One survivor even said to me, “We all know

176

Treatment of domestic violence

that life is not fair. It is the purpose of society to create fairness where fairness would otherwise not exist.” In the USA, the “right to petition for redress of grievances” is guaranteed by the US Constitution. Now that can mean many things, but it can also mean extra therapeutic actions on the part of the patient such as filling out police reports, applying for orders of protection within the legal system, and filing legal complaints when financial abuse has occurred. Such is a legal process, not a psychodynamic one. That points to the possibility of retraumatization by an indifferent and unempathic legal system whose mission is definitely not to promote emotional healing. One must be cautious about too much early cross-examination about the details of the trauma to avoid retraumatization and an early flight out the door. The legal system knows no such caution. Cross-examination occurs early and often. Retraumatization is ever present. Yet if a person is angry enough, diligent enough in marshaling the evidence of wrong doing, and—most importantly—committed enough to getting a hearing—the language is significant, “hearing”—principles of autonomy and neutrality counsel against any therapist ultimatums to proceed or not to proceed. Psychodynamically this is the area of “enactments.” It may also mean a forward-edge expansion of agency in a positive sense. Never was it truer that concerned inquiry is appropriate into the cost and impact of a legal process on the psychodynamic process (and vice versa). “Don’t hurt yourself” is a micro-narrative and an empathic response in the face of any risky undertaking such as trying to get justice for a financial inheritance that was unethically or illegally appropriated by an abuser. Yet the matter is fraught. Sexual and financial predators wear suits. One client would send an email—a form of acting out—to a sexual predator, who had used a daterape drug to rape her on a date. The email asserted that he was going to pay, demanding financial compensation. This would happen when life’s stresses became extreme for her. She was risking retraumatization by behaving in a way that might formally be redescribed as blackmail or extortion. The risk was that she would be the one who would hear from the authorities. A significant part of her low mood and energy—her depression—was tied up in fighting this battle. After a certain point—but who could say what that point was?—she could either continue trying to get justice or move on and engage with life. Yet who is to say that the therapist is supposed to be the “voice of reality”? One time when I asked “Did you fill out a police report?” it was not appreciated. I was not being “nurturing enough.” Indeed I was not. How clumsy of me. The alternative is the “college of hard knocks.” We both spent some time matriculating there, too. Thus, the tough issue. What to do with the demand to recover a sense of justice? When the abuse is shrouded in the mists of the past and any statute of limitations is long expired, survivors still want to get their own back. Survivors still long for compensation for suffering. Survivors still want

Treatment of domestic violence

177

justice. Fortunate the survivor who is willing to accept acknowledgment as a form of repair and compensation. Fortunate the survivor who writes a short story, blog post, or poem to recover a sense of completeness. Fortunate the survivor who is able to find recognition in being known as someone who has “had one’s mountains to climb,” and, whatever the confidential details, is known for having come through the “refiner’s fire” as a whole and complete person. Truth be told, the survivor was never anything but whole and complete, yet it did not seem to be so as the abuse was occurring. When the abuse is not shrouded in the mists of the past but is relatively better known yet still complex, entangled, and messy, then survivors (and therapists) have to choose their battles wisely. If the survivor is one of those who fought back and continues to battle her or his way through life, then the “suck of the game” is to continue the fight. It can be a breakthrough to realize that the battle is another form of the stickiness of suffering, another form of stuckness to the past, another form of the repetitive return of the incomplete in an attempt to master the upset. The battle is another form of “return to the abuser,” though not due to a micro-narrative about “love,” but one about “compensation,” i.e. getting one’s own back, revenge. We read above how survivors lapse into returning to the abuser because of a caricature of “love.” It needs to be better known and made the target of therapeutic inquiry that survivors also reestablish contact with abusers because the survivor harbors the fantasy—usually unconscious—of getting justice, whether as retribution, compensation, or out-and-out revenge. One of the scenarios that drives to distraction the people who work with survivors is the enactment whereby the survivor proposes to return to the abuser—and then actually does so. The forces causing a return to the abuser are many. She needs a place to live. She needs a place for the children to live. It may be better than being homeless, even if not by much. Our empathy warns us not to be judgmental. Once again, suffering is sticky. The past is sticky. The emotional entanglements have not been dealt with or sufficiently dealt with. Nor should it be forgotten that some version of reality is often recruited to justify such a misguided course of action. Yes, “she loved him” is cited as a rationalization by the survivor as well as bystanders. As noted, do not underestimate the possibility that she maintains an unconscious fantasy of being compensated by the perpetrator for her suffering. She maintains a dimly sensed plan of “getting her own back,” “getting revenge,” or “getting even.” That too is sticky. Empathic receptivity can give one access to these inclinations and barely sensed emotions. Empathic understanding recognizes the possibility of gain or loss, enabling one to rise above an initial impulse to blame or even intervene with prohibitions that imply blame. Empathic interpretation acknowledges that there is nothing wrong with wanting to be treated fairly. Empathic responsiveness asserts that two wrongs do not make a right.

178

Treatment of domestic violence

The internal conversation in the survivor’s psyche becomes a conflict about what one should have done, might have done, did actually do, with the perpetrator. If one can “listen in” on the conversation in the survivor’s psyche as the conflict unfolds, one can learn a lot. This conflict is a significant drain on emotional energy and related personal resources. The conflict remits when the survivor struggles her way to an emotionally laden “The matter is complete.” This can indeed be a communication saying, “This is what happened [regardless of what happened] and I am owning my struggle and moving on with it.” Even if a survivor would be justified in pursuing a criminal or legal case and even if she had a case, an argument could be made for walking away from the emotional morass based on what one needed to do to get a good night’s sleep—the “gold standard” of peace of mind. If the survivor has the resources—emotional and financial—and can get by on a few hours’ sleep, then autonomy dictates that the survivor is empowered to make the decision. This section is no discourse on forgiveness, but neither is it one on retributive justice. Emotional resources are needed to live life and have a future. Forgiving oneself makes sense, and is often the point aimed at by well-intentioned discourses on forgiveness. But unless it restores power to the survivor, forgiveness is over-rated. We are not operating a truth and reconciliation commission. But if we were, perpetrators would have to apply for forgiveness and be required to tell the truth in all its horrendous detail so that the survivors could say whether the request was close enough to the truth for the survivor even to consider forgiveness (e.g. Tutu 1999). (See the above section on “The Facts are Fragile,” pp. 155–156.) This approach lines up with Kohut’s recommendation that the psychoanalyst should not be moralizing or try to be the voice of reality when presented with the unrealistic aspiration of the grandiose self. Rather, the empathic approach acknowledges, given what you have been through, it is to be expected that one would want “to get one’s own back,” that one would want some kind of “compensation for suffering.” Indeed, it makes perfect sense in its own way. Is this the retributive justice of the law of the talon of the five-year-old child or the justice of the categorical imperative that allows that the consequences of our autonomous actions sometimes escape us? For empathic responsiveness, a main concern is that one should not hurt oneself or be retraumatized as one reaches out to a sexual predator, or a remote relative in denial, etc. Such empathic understanding of possibility engages unconscious fantasies as a part of “what the survivor is makes it mean” that she keeps sending emails, etc. to the perpetrator. An empathic interpretation can shift the therapeutic conversation from the trailing to the forward edge of the process by asking what she hopes to gain. If it is money for education or therapy, better ways are available to attain those. Notwithstanding the stickiness of the past, the survivor may find it more rewarding to engage with productive pursuits with career, relationships, or education.

Treatment of domestic violence

179

Abuse survived and worked through as a resource Working through abuse that has been survived is one of those processes that indicates a point on the horizon towards which infinite progress is possible. If the survivor is in the presence of the psychotherapist and communicating coherently, then, by definition, she or he has come through the abuse in one physical piece, albeit psychically vulnerable. However, the confrontation with emotional consequences still awaits. The patient’s assertion, “You don’t know the challenges I’ve faced. You don’t know my life—you don’t get what I am up against” is an assertion that every therapist has confronted. It is true by definition. Even if we are all connected thanks to mirror neurons, even if we all resonate together, even if we all share the same DNA that is now traceable back to a small hominid nick-named “Lucy,” living on the savannah in East Africa a half million years ago, still we do not have the direct experiences of the other person’s experiences. We do not experience the other’s suffering—except vicariously through empathic receptivity. We do not experience the other’s possibility— except through empathic understanding. Yet the answer to the “you don’t know . . .” is direct. “Okay, but I have had mountains to climb, too. It is true that all the details are different. Your suffering and whatever I have experienced are not identical or substitutable. And when one is hanging from a cliff, all mountains look pretty much alike up close. I have had mountains to climb too; and we will understand this challenge together.” An example will facilitate what it means to transform abuse into a resource. Clinical vignette: redescribing emotional balance

We have earlier engaged the example of Mr. A’s crashing the bike in the section of that title. Strictly speaking, this is an example of domestic violence, not gender violence. Here we go into more psychodynamic detail to show how abuse that has been survived can be transformed into an emotional resource, engaging the forward edge (Tolpin 2002). Mr. A’s career as a psychotherapist began, even though he did not realize it at the time, when he was eight years old. He had just gotten a new 24-inch, two-wheel bicycle. It was red and white with chrome trim; it was cool; it was slightly too big for him. His feet did not quite touch the ground. His next-door neighbor, Georgie, was his best friend and a tad older, though in the same grade as him. Georgie had gotten a two-wheeler that was just the right size for him, 20 inches, and he was having fun exhibiting his prowess riding assertively around the neighborhood. You see, feet touching the ground meant being able to stop, maneuver, and turn with considerable ease and in a tight situation—how shall one put it delicately?—not getting jammed in the crotch while trying to jump on or off as the bike slowed and losing momentum tipped over. Feet being able to touch the ground meant gravitational equilibrium. Feet being able to touch the ground meant equilibrium. Period.

180

Treatment of domestic violence

However, like many well-meaning parents who saw the bike as both expensive and a potential risk that the boy was going to kill himself by riding into the street—“Watch out! You’re gonna kill yourself!”—the boy’s parents made a choice based on the logic “he will grow into it.” Duly noted. Quite true. The less empathic choice? Perhaps that too, though even with retrospective redescription, one cannot doubt the love. Nevertheless, it was harder to steer and navigate, and maintain one’s balance, anticipating turns and starting and stopping. Balance—that is the key dynamic here—in both physics and psychodynamics—it is also the key metaphor for what the bike came to mean. The problem was that A’s feet did not touch the ground while sitting firmly in the seat, so he had trouble mastering starting and stopping. As a beginner, his control and balance were an issue. In short, he needed practice. As the young A and his Dad engaged in an activity on the weekend, while Mom worked retail, this was an opportunity. On this particular Saturday, father and son took the bike to the bike path near the “big hill” at Wilson Avenue near Lake Michigan. He got on, pushed off and was going well enough. Now the bike path divides into two roads prior to going into an underpass that leads beneath the street. At that point, there was a pole with a street sign on it indicating the direction of the bike path. The boy was nervously biking along trying to figure out how to turn around. He fixed his gaze on the pole. Unfortunately, if one looks at a pole, one steers toward it. That is what happened. Even though he braked, he clipped the pole and “wiped out.” No problem—except perhaps a bruised shin and scraped knee. But that was not the worst of it. There was something about the whole scene of the loss of control, the mechanically steering towards the pole due to inexperience, the appearance of being magnetically attracted to the obstacle, and comically clipping it and doing a clownish crash and fall. It might even have been funny—again except for the bruised shin and pride. But it was not. It meant something to Dad. It meant something = X. It meant something to which the boy did not have visibility and will never know. Perhaps Dad made it mean that he was not a good teacher. Perhaps he made it mean that the boy was not a good student. Perhaps he had no idea of the meaning himself, but was himself quasi-hypnotically drawn into a semi-altered state of consciousness based on the fact that he did not get a bike when he was boy. His parents, the boy’s grandparents, were poor, struggling immigrants— no bike. Heck, the story in the family was that they could not even afford a toothbrush. However, that is doubtful. Grandma just did not have the distinction “dental hygiene,” and the Dad suffered from poor teeth his whole life long as a consequence. However, back to the bike. The boy’s crash set Dad off. It enraged him. The boy was picking himself up and literally dusting himself off, feeling physically bruised and ashamed that he was so clumsy. Meanwhile, the Dad approached, but not with words of comfort or encouragement. He flew into

Treatment of domestic violence

181

a rage and berated the patient for being so stupid as to run into the pole. Again, in retrospect, the boy allowed that crashing the bike was not one of his better moments. But that is what happens when one is learning. So instead of being comforted, the boy was insulted and punished by being slapped and spoken to in a devaluing way. It went on for awhile. The boy was ashamed, unhappy and embarrassed. Many of the details are quite clear to him. He was called names, made fun of, hit. It was pathetic—tears were streaming done his face. He was told to stop crying—or, you guessed it— he would be given something more to cry about. He couldn’t help it. So he was. In retrospect, the boy concluded then and there that he was stupid. He decided that he could not do anything right. He believed that he was hopeless. That is what he made it mean. He also decided he would be smarter than everyone else. No surprise when he eventually graduates with a Ph.D. in philosophy—and a dissertation on empathy and interpretation (Agosta 1977). But as a youngster, he was surely disappointed in himself, since he wanted to master biking, but was obviously having trouble maintaining his balance. Balance is the key, and he did not have balance at this point. Balance turns out to be the central symbol in the micro-narrative of crashing the bike. At another level, the boy was simply scared since the father was so angry at him, so harsh and punitive. The father actually slapped him and shook him. Finally, the boy must have begun to wonder what kind of a father is this person who treats a son so harshly. What makes a parent a parent is that the parent treats the child like a child who deserves parenting. Although the boy did not have the distinction “abuse” until years later, whatever it was, this was not proper parenting. The was the opposite of a good enough, much less optimal response. This was an example of antipathy, not empathy. Years later in psychoanalytic therapy, this would come to symbolize for Mr. A his father’s ultimate unempathic moment. Instead of getting guidance in restoring his physical balance and emotional equilibrium, he was—for want of a better word—traumatized—spoken to harshly, called stupid, shaken, and slapped. Mr. A repeats himself—but it happened repeatedly. And then made to get back on the bike and try and steer through his tears. Here Mr. A, the boy, would greatly have benefited from friendly encouragement to get back on and keep at it. There was nothing friendly about the father’s approach. It was strictly drill sergeant Dad, and the patient was an eight-year-old recruit. What kind of a father behaves in this way towards a son? The young Mr. A learned to ride that bike just as soon as his feet could touch the ground while at rest still on the seat. He never again suggested going out with the bike and with Dad. This was not the Dad’s only tempter tantrum. He was a regular enfant terrible, not only toward the young Mr. A, but toward other members of the family, too. Mr. A spent years working through the details in psychoanalytic therapy. However, this single event—crashing the bike—came to symbolize

182

Treatment of domestic violence

the impact on Mr. A and his task of gaining the psychic structure needed to maintain emotional equilibrium. The symbolism of crashing the bike is even more significant when, years later, the 17-year-old hauls off and hits the Dad back. The young Mr. A then leaves home and doesn’t look back, except for years of psychodynamic therapy, working his way through college with a series of well-paying factory and constructions jobs, which were still available to students in those days. The father’s psychological imbalance, lack of empathy (not to mention common courtesy), and the function of psychoanalytic therapy for Mr. A in providing a context for what had been missing—empathy—provide a powerful example of abuse worked through, brought forward, and transformed. The abuse had become a resource to Mr. A in understanding himself, maintaining emotional equilibrium, and relating to others in an empathic way.

Access to emotional resources, aspirations, ambitions, ideals The confrontation with shame, rage, and other negative emotions provides an opening for regaining emotional equilibrium that has been lost. The confrontation with abuse survived and reclaimed as an emotional resource provides an opening for building self structures that regulate affect. This in turn opens the way to accessing emotional resources for productive, forward-edge engagements (Tolpin 2002). The other individual’s empathy for oneself provides the possibility of selfsoothing. When the other is aggressive, hostile, or violent, the capacity for self-soothing is inhibited. Without the other’s empathic regard for the person, she or he cannot get back the emotional balance that has been disrupted. The person may, indeed must, “crash the bike” emotionally until he is able to comfort himself enough to regain his composure. The other’s intervention in being open to the experience as a vicarious experience that hits one palpably, that makes the difference in recovering emotional composure. Stepby-step in growing up with an empathic parent or recovering one’s capacity as an adult for self-soothing in a process of psychotherapy where empathic relatedness is available, the recovery of emotional equilibrium—selfsoothing—is fundamental to an account of recovery from domestic violence. Equilibrium is a dynamic process. In the clinical vignette above, the survivor endured by fighting back—reaching for the sharp instrument to defend herself, writing the “tell all” letter. The survivor continues the pattern, now fighting her way through life. She finds herself setting boundaries at work by enacting a “Don’t you mess with me!” moment with coworkers, bosses, and customers. This is similar to situations at home when the other was an abuser, not merely a clumsy and all-to-human coworker. Small misunderstandings add up to a complaint on the part of the survivor to corporate human resources (HR) about alleged mistreatment. HR then acts

Treatment of domestic violence

183

like all bureaucracies. After soothing over the ruffled feeling to avoid litigation, steps are taken to eliminate the complainer’s job—and the complainer. The survivor is now unemployed. That is a setback, noticeably lacking in equilibrium. Temporary fee adjustments in the psychotherapy process must be made with an intrusive reality in the background. The process of psychotherapy consists in introducing to the survivor the possibility that, even though she was not treated fairly, she may be contributing to her own challenges. The psychotherapist then risks becoming the “perpetrator” of further unfair treatment of the survivor—by billing for services. Yet the therapist knows the patient to be a person of integrity—at least one instance occurred where an insurance reimbursement came her way and might have been pocketed by the patient, but she turned it over to the one entitled to it. He calls out the act of integrity, reestablishing the forward edge of the transference. The arrears are remedied. She keeps her résumé current while improving future job prospects by going back to school. She volunteers to work in a community organization. There she meets someone in class who is able to offer her a job, and thanks to working through her tendency to struggle with boundaries, she is able to navigate the job offer and the first weeks at work well enough to sustain her commitment. In the struggle to survive, aspirations and ambitions are among the first things to be discarded, thrown overboard as excess ballast, in the attempt to stay afloat—to survive physically and emotionally. It can be a great comfort just to be left alone in peace and not abused. Nor is the value of basic security and safety to be underestimated. Yet the risk of isolation is significant. “Being left alone” is not what is meant by “flourishing.” It is not what is meant by contribution to community. It is not what is meant by a person’s experiencing satisfaction and rewarding activity in the direction of excellence. There is nothing wrong with survival as a goal. But ultimately, survival is just survival. Something is missing—flourishing as a human being among other human beings in the proper sense of the word. The reawakening of a survivor’s aspirations, ambitions, and ideals can be an indication that the process of recovery has traction and is moving forward. This is the empathic moment par excellence. For veterans of the domestic violence struggle, a deeply cynical thought occurs: It would be useful to know what a healthy relationship between a man and a woman looks like just in case it were to show up. Less cynically, having the description of a healthy relationship represents a “forward edge” towards which to strive (Tolpin 2002). Thus, what does a healthy relationship look like? A short description is at hand. A healthy relationship includes: 1 2

keeping one’s word and acting with integrity; respect for boundaries, and asking and negotiating permission for crossing boundaries when applicable;

184

3 4 5

Treatment of domestic violence

contributions from both individuals to the relationship; treating the other person as a possibility and an end in her- or himself and not a mere means; community and sharing, not isolation.

In a marriage or other committed, intimate relationship, we also need to be able to say something about what healthy sex looks like too. All the distinctions noted above—integrity, respect, permission, relatedness, sharing—apply to the sexual dimension, too. Especially in those relationships in which gray areas abound and which are merely problematic and do not rise to the level of criminal behavior from which escape is imperative, one should be on the lookout for such delicate, fragile tendrils of well-being and healthy relatedness as indication of a forward edge. Improving a troubled relationship versus abandoning an irretrievably broken one is a tough judgment call on which survivor and therapist need to collaborate. Sadly, some survivors of domestic violence may rarely or never have seen a healthy relationship. Our aspirations and ideals are what sustain us in the face of setbacks in relationships and work. One survivor was sustained in the face of many trials and challenges by keeping alive the dream of becoming a medical doctor, and helping women and children back in the homeland from which she had escaped. The example of an experienced cousin who was a medical doctor—the cousin was also a survivor of abuse—sustained this patient through the struggles of her own suffering until she was able to escape her toxic physical surroundings and start the process of recovery. This was neither simple nor straightforward. The intensity of the abuse was such that it left behind intrusive thoughts and negative fantasies that often erupted inconveniently as soon as she sat down to concentrate. As the working through process got traction and moved forward, these eruptions diminished in frequency and shrank in intensity as she necessarily decathected the ego in order to engage in the process of merging with the desk work at hand. Survivors are drawn to work with and make a contribution to the recovery of those who have “had mountains to climb” that resemble the ones they have confronted. Such an approach becomes a resource that shifts personal suffering in the direction of becoming a reservoir of positive emotional energy. However, access to aspirations and ideals is distinct from getting into action and re-engaging with the development process. To that we now turn.

Re-engage with the developmental process Empathic understanding creates an opening for taking action and implementing the possibilities of development where previously there had just been the struggle with vulnerabilities of the self. By engaging and remediating

Treatment of domestic violence

185

vulnerabilities and fixations through empathic interpretations and empathic responsiveness to the survivor’s humanity, the development process interrupted by life’s setbacks is able to be reengaged. Marian Tolpin (2002) makes the case for engaging with delicate “healthy tendrils” of forward-edge expressions of the patient. Tolpin presses the point with a near-polemical intensity (that I consider justified) that many such positive expressions of well-being are redescribed by conservative conformists in such as way as to pathologize, devalue, and make them into trailing-edge phenomena, expressing “suspiciousness towards health as resistance” (2002: 170). I dare ask: “Resistance to empathy?” The strivings of tendrils towards health are not recognized and valued for what they are in a therapeutic milieu that privileges “tough love” and debunking of naive confidence over empathy and creation of possibility. The encouraging thing is that, even amid the worst abuse and violence, evidence is available that it is the strivings for well-being that make the decisive difference in treatment and recovery. For example, the abuser pulled the daughter out of school because she threatened to go to the authorities about the situation at home. Obtaining an education was on the critical path for the survivor to escape from the situation at home. When this delicate tendril was thwarted, then and only then did the survivor take decisive action to escape, enlisting her sisters (who were also targets of abuse) in plans and actions that got them out of the physical milieu of abuse. It is a sobering thought that repeated acts of molestation, which were inexcusable, were insufficient to drive the survivor to act to escape. In no way does this excuse or account for what happened. Rather it points to the power of the forward edge. When the fragile tendril of well-being, the forward edge of education, was endangered, it is as if mountains were moved and with velocity to restore the possibility of having a future life. In short: the provocation inspired “reanimation and resurgence of what the patient unconsciously legitimately needs, strives for, seeks, and hopes” (Tolpin 2002: 188). To be sure, plenty of pathogenic material was available all around. However, the forward-edge transference of mentoring and formal study as a means of pulling oneself up by one’s bootstraps was a source of sustaining engagement in the treatment though numerous challenges and setbacks. This also points to an alternative redescription of the therapeutic transference as not limited to reenacting abuse but also providing guidance around boundary setting and formal school attendance. Under one description, human development unfolds naturally and spontaneously unless something interferes with it. Violence is a disruptive event that activates self-protective methods, fixations, and patterns that are appropriate to protect the vulnerabilities of a core aspect of the would-be survivor’s self—and humanity. Having escaped physically from the abuse, some of these patterns of survival persist but, in a context of safety, they are less adaptive. They are maladaptive. Hyper-vigilance, conformity,

186

Treatment of domestic violence

overly placating or overly aggressive patterns, are examples of templates of relating that invite attention and transformation. By removing the sedimented obstacles and resistances, development restarts. At least that is the theory and paradigm. Real life rarely corresponds exactly to the theory. That is one reason why the relationships illustrated in Figure 4.1 are many-to-many, not sequential. In another vignette, the survivor was recovered enough to be in action around concretely implementing her aspirations of becoming a doctor. One thing any would-be medical student needs are door-opening MCAT scores. She had good enough grades in biology, a compelling narrative of survival, which could be spun at a proper level of generality, and several powerful written recommendations from professors who saw value in her contribution. But due at least in part to intrusive and distracting thoughts, images, and feelings that continued to assail her with near hallucinatory intensity when she sat down to study, the MCAT score was disappointing—very disappointing. This disturbing image of the angry faces of her father and brother had not remitted when engaged using methods of EMDR, CBT, or EBT—all attempted prior to psychoanalytic therapy. If ever there was a situation in which it made sense to lie back on the couch and describe the images that spontaneously emerged to distract the would-be student, this was it. Reminiscent of Freud’s case of Elizabeth von R (1893) where she was assailed by the angry face of her employer, the disturbing images of the survivor’s angry brother and father began to shrink and lose their power and force when the survivor was finally able to summon the courage to describe them in as much detail as she could. Though they never completely disappeared, they were no longer disruptive enough to interfere with studying and related cognitive functions that required loosening the grip— “decathecting”—of inhibitions on disturbing ideas in order to concentrate attention on one’s studies. Though multiple variables are in action simultaneously, such improvement on the MCAT is a rare occurrence. The difference? One was the creation of an atmosphere of a gracious and generous listening—empathy—that enabled a breakthrough in undisturbed attention and concentration. This applied not only to the specific symptom, but to the survivor as a whole person whose well-being and emotional equilibrium were a vital concern. Thus, while it might be too much to claim that empathy improves one’s MCAT score, do not rule out the possibility that emotional equilibrium enables one to study, and that improves one’s score. The alleged beneficial consequences of empathy have become a matter of controversy. Kohut famously reported that in one of the cases he was supervising the analysand complimented the analyst, saying: being listened to by the empathic listening provided in the sessions was like sinking back into a warm bath. Relaxing. Soothing. Equilibrating. Stress reducing. The critic might object that, properly speaking, the benefit of empathy can be redescribed (and not

Treatment of domestic violence

187

altogether flatteringly) as a trip to the spa. Symptom relief? Escaping from the stresses and dynamics of the work-a-day world, one takes a relaxing bath, perhaps gets a massage, enjoys a specially prepared diet. The result? The person feels better. All well and good. But the symptom relief does not last. The cynic might say, “No good deed goes unpunished.” That is because the punisher lives on and lives within. I believe Kohut would agree with the critic up to a point. For someone who is suffering in emotional distress, symptom relief has its uses. A person is able to take distance from the issues and engage her problems in a way that makes possible envisioning a long-lasting solution. However, a permanent solution requires change in the structure of the self. Kohut was consistent and definite that the effect of empathy on the function and structure of the self occurred (as Kohut expressed it) as a result of phase-appropriate, non-traumatic failures in empathy that were then empathically repaired. These optimal frustrations provided opportunities for empathic interpretation and working through that enabled the analysand to take over empathic functions that were being provided temporarily by the analyst in the transference. Kohut aligned this process with normal development. For example, the toddler at play in the playground ventures forth to engage with the other child and slide set, returning to his or her Mom to get assurance and emotional recharge. Her caretaker functions as a part of the toddler’s self, providing emotional balance and equilibrium, and personal validation that life is good. As the toddler grows up, he takes over this function of selfregulation and seeks out the caretaker less frequently or not at all. The teenager needs fewer reminders to turn off the TV and do his homework or pick up his stuff as he takes over the functions of organization that someone else has been performing for him. Likewise, the analysand has benefited from occasional symptom relief provided by the empathic relatedness of the analyst; but when the analyst is not available due to vacations, etc., or, even more importantly, due to breakdowns in understanding, then the opportunity is present for the analysand to take over the functions of empathic integration, regulation, and balance for himself. This enables him to perform for himself and go forward for others with an entire set of empathic functions that were previously unavailable. The skilled analyst will provide a gracious empathic listening to provide symptom relief, knowing full well that the inevitable course of life will occasion phase-appropriate breakdowns in empathy on his part, in turn offering opportunities for the kind of interpretation and working through on the part of the analysand that develops improved functional integration of the self and resilient self-structure. But even in Kohut, though the optimal frustration is the start of structure building, it is not the only method. In the end, Kohut marshals evidence that “empathy per se, the mere presence of empathy, has also a beneficial, in a broad sense, a therapeutic effect—both in the clinical setting and in human life, in general” (1982: 397). The Kohutian parent’s “gleam in the eye” is.

188

Treatment of domestic violence

explicitly called out as inherently structure building and in a positive way (see above “From Empathic Narrative to Optimal Responsiveness,” pp. 105–108, and Bacal 1985: 17). At another level, the toddler, adolescent, or patient looks back to the other person (whether parent or analyst) and sees himself proudly mirrored in the gleam of the other’s eye building selfstructure directly without a preliminary breakdown by way of what Tolpin elaborates as the forward edge of development. Development in the self occurs naturally unless it is traumatically interrupted. Remove the obstacles and resistances. Get out of the way and let development occur. The same can be said of the development of empathy. Empathy assumes the function of the “gleam in the eye,” becoming synonymous with the work of psychoanalytic therapy at large as Kohut writes: “[I]t is in the long run the task of the analysis to allow the analysand to become sufficiently empathic with himself” (1977: 125). The self-soothing that expands in the well analyzed can be redescribed as a form of empathy with oneself. If empathy is “vicarious introspection,” then is introspection reciprocally describable as “vicarious empathy” and what would that be? Empathy for oneself is a way of relating to oneself as another. An example will be useful. The shoemaker’s daughter eventually came to the realization that she was colleting notches in the equivalent of her feminist pistola with a series of slacker boyfriends, who, as she eventually realized, “were just not good boyfriend material.” Then the moment of empathy with “oneself as other” occurred as she applied the lesson to herself, painfully acknowledging: “Hey, I am just not good ‘girlfriend’ material in certain ways.” That was beginning of struggle and effort around taking responsibility for relating in ways that created meaning and productive possibilities instead of dissatisfaction. For survivors of abuse, the moment of vicarious empathy comes in the form of acknowledging the narrative to which the individual is attached. That one is unworthy, broken, unfixable, beyond repair, in need of being returned, is often taken over by introjection of the abuser. But other times it seems to arise spontaneously out of a design defect of the psyche of human beings that we tend to blame ourselves when we are unwittingly caught up in painful circumstances that live on in spite of our conscious efforts. When psychotherapy works well the distinction between narrative and historical truth develops in the direction of the future, not the past. It unfolds in the direction of a “history” of the future. That is, the narrative of past abuse is rewritten as one of living into the future as possibility, productivity, and relatedness. Though the loss and suffering never completely disappear, they shrink and become less powerful as the constraints of the past fall away and possibilities call forth the initiatives of the self to reengage with life in a full and satisfying sense. But such initiatives are not without risks, which indeed have accompanied the entire process of recovery from the start. To those we now turn.

Treatment of domestic violence

189

Risks: retraumatization, stuckness, endless looping, isolation The risks of retraumatization are pervasive. As noted in a previous clinical vignette, during times of stress in her life and in the therapy, one survivor repeatedly reached out to the perpetrator of a drug-facilitated date rape via email and social media. One might as well have said “acted out.” Yes, sexual predators wear suits and dine at fine restaurants. Her message? “You are going to pay. One way or another—you are going to pay.” Psychodynamically she expressed the need to get her own back. While there is value in emotionally completing any experience that leaves the survivor whole and complete emotionally, yet this approach was too risky. The rape occurred seven years ago. The statue of limitations was expiring. Though she did not “know” that, the unconscious was tracking the calendar, even though the unconscious was “timeless.” “Did you fill out a police report?” I naively asked. This did not go well. “How can you be so insensitive? You don’t know what it is like to be raped. I would expect a psychotherapist to be more nurturing.” “Granted. I was not there. Granted, it was a clumsy question.” I had my mountains to climb, too, but perhaps I’d better not bring that up just now. Anyway, she had heard it already. It just landed too much like blaming the victim. The issue is that, due to the date rape drug, she wasn’t exactly there either. She had not fully grasped what had happened to her, as she said, “waking up from being unconscious in this guy’s bed with my pants off.” Then losing consciousness again. In order to get a handle on her experience, she took community training as a rape and domestic violence advocate. She realized what had happened to her—date rape. I was concerned. More than concerned. My thoughts ran rampant: “You are at risk if you reach out to this perpetrator and ask for money. I am not saying whether you should fill out a police report or not. You got the rape advocate training. You know what the policewoman behind the desk will say. She will probably take the report. What I am thinking is that ‘If you demand money from this guy, you will be the one at risk. Extortion or blackmail is not a valid revenue model. You know the word ‘retraumatize’? All of a sudden we will be having a conversation about this sexual predator making a counter-accusation of extortion. You will go from survivor to victim again.” I do not say any of this. I do not look anything like the policewoman behind the desk, but I am willing to relate, willing to engage, willing to listen. Instead, I borrow a micro-narrative called out after me as a boy by my Mom as I go out to play, and I say three words: “Don’t hurt yourself!” As I take a step back and examine my empathic receptivity, I experience the shame, guilt, and rage of walking into the police station and saying that I want to fill out a police report from seven years ago, and I can tell you the month and year, but not the exact date. The empathic understanding is

190

Treatment of domestic violence

engaged as the possibility of recovering the power of being an agent. Being an agent, a source of initiative, who acts on her own behalf, actively not passively, and, in that limited sense, getting her own back. The empathic interpretation is exact but incompletely expressed. “Don’t hurt yourself” is not a bad start but the prospect of acting out a return to the abuser—this time in order to demand money—is the source of an almost overwhelming therapeutic nihilism. Nevertheless, “don’t hurt yourself” seems to work. Maybe the empathy was good enough, even if incompletely expressed. The survivor comes into the next session displaying an uncharacteristic light-heartedness. She seems somehow more together, more coherent, more articulate, more engaged, more up-to-something. It comes out at the end of the session—given the shellacking I had taken, I don’t ask—she has indeed filled out a police report. This entirely symbolic act—seven years later there is no evidence, no DNA, etc.—is a dramatically empowering gesture. I hypothesize that it has contributed to recovering a sense of agency, self-expression, and perhaps getting one’s own back, however tentatively. It is not a breakthrough—it is a first moment of a turning point at which shame, doubt, rage, do not rule the survivor’s life. She is at the point at which she says “I get to say. . . .” She is at the point at which stuckness, the risk of retraumatization, and return to the abuser, are engaged and surmounted. No one wants to risk blaming the victim. Therefore, the kid gloves are out. Absent an empathic stance, the risk of a retraumatization escalates. Still, the strength and resilience of survivors should not be underestimated. Neither should they be taken for granted. The ever-present risk of retraumatization, even with the most delicate and empathic of approaches, is one that has to be carefully managed. We circle back to the beginning of the process of recovery. While the question “Why didn’t she leave the abuser?” may result in taking the focus off the perpetrator, it is still a significant question. The reasons given that the victim does not leave—escape—are as varied as the individuals. Yet suffering is sticky. Once again research that consists in talking to survivors anecdotally suggests that the top reasons actually expressed by survivors for not leaving the abuser include: 1 2 3

Economic challenges—who is going to pay the rent? Her credit may already have been damaged by his financial misbehavior (another form of abuse). Fear of death—he threatens to kill her or her children or family or all of the above and seems crazy enough to do it—and even if not crazy, one does not want to find out otherwise. Language barriers—since the survivor may be an immigrant from a foreign country and does not have sufficient command of the language (related to, but different than economic variables).

Treatment of domestic violence

4 5 6 7

191

Does not have knowledge of resources available to women in large urban areas such as a domestic violence shelter. Is so traumatized—numbed—by a pattern of abuse that she is chronically emotionally or psychically paralyzed. Rationalizes that he’s just like that or he gets that way only when he drinks or all men are like that. Unconscious or barely conscious hope that the relationship will “turn around” and fulfill a dream of satisfaction.

Finally, the top reason given that she did not leave the abuser: 8

Love—she loves him.

But wherever there is love can hatred be far behind? Under the above section “(Un)realistic Expectations of Compensation for Suffering,” pp. 175–178, we also engaged with (9) the hope of getting one’s own back—of which there are many forms including a hope for revenge. In any given life situation, all of these are realistic reasons, capable of robust reality testing, as well as unconscious fantasies, capable of lurking behind the scenes are in need of surfacing and working through. According to Freud, love is aim-inhibited sexuality; according to Eric Fromm, love is the overcoming of alienation and unfolding of personal possibilities in productive human relatedness; according to St. Paul love (agape) is God’s concern for mankind in the Christian community; according to Carl Rogers, love is unconditional positive regard, i.e. empathy; according to Bob Dylan love is just another four-letter word. We struggle to understand why suffering is sticky, and survivors sometimes cause those around them to despair by returning to the abuser. Empathy is a high bar. I have already suggested that a micro-narrative that “she loves him” can mask a subtext that a less socially acceptable idea of enacting revenge lurks behind the manifest behavior. A description such as “masochism” is risky, politically out of fashion, and potentially devaluing and retraumatizing the survivor. The psyche is supposed to be governed by the tendency to find pleasure in discharging tension and returning to a pleasurable state of relaxed equilibrium. From the perspective of psychic equilibrium, classical psychoanalysis finds that the enjoyment of overstimulation presents a significant problem. Into this dynamic play of forces, the distinction “sadomasochism” emerges as the enjoyment of pain and of inflicting pain. Given the basic economic principle that the discharge of tension is pleasurable, the economic problem of masochism—also the title of a classic article by Freud (1924)—is the paradox that an increase in stimulation is experienced as pleasurable. From another perspective, the experience of enjoyment when “a child is being beaten”—again echoing the title of Freud’s paper (1919)—becomes

192

Treatment of domestic violence

fundamental and is traced back to a basic, in-born aggression—a “death drive”—that is as wide and as deep as the erotic drives. When aggression gets recruited by the conscience—the superego—then a culture of selfpunishment emerges. This is redescribed as “moral masochism” and encompasses the various forms of self-defeating behavior that typically show up in the offices of psychotherapists. The turning against the self of the aggression is what distinguishes a neurotic from the sadistic acting out in inflicting physical pain as part of the process of sexual climax. Thus, the famous maxim that neurosis is the negative of perversion (1905: 165). Those who act out their perverse sexual fantasies do not become neurotic. Those who repress their fantasies find that the fantasies live on beneath the threshold of awareness and then emerge symbolically as compromise formations— symptoms. Until the abuse results in hospitalization or proves fatal, the cost to the victim of separating from the abuser often shows up to the would-be survivor as greater than the pain caused by the abuse. The risk of stickiness looms large. The temptation is strong for the therapist to over-identify with and take over the anxiety of the patient. When skillfully applied, the empathic stance is actually a defense against such a merger, since empathy discloses a trace affect, a sample of the other’s distress, not a full-blown merger with it. Empathy enables the therapist to feel a sample of the other’s pain and upset as a vicarious experience—a signal affective, a trace sensation— without becoming submerged in it. Thus, the therapist is able to say with integrity, “I sense that what you are going through is hard; and it must be extremely upsetting.” However, it also enables the therapist to keep enough distance to prevent taking on the patient’s distress and being emotionally flooded by it. The more the therapist’s over-identification expands, the less the patient is able to do anything about the situation, since the therapist is the one doing the suffering and worrying. If the therapist is worrying, feeling anxious, the patient does not have to do so, according to a quasi-magical “conservation of anxiety.” Short-term relief is available in having displaced the distress onto the therapist, but it just results in spinning matters out until the next go around with the abuser. If the therapist can give back to the patient some of her own worry and distress in a modest and manageable amount, then it opens a wedge into the mutual, deep attachment of the wouldbe survivor to the abuser. The stuckness abates. At the moment, this wedge encapsulates the value of the entire therapeutic process. The patient experiences a new found intolerance of her own willingness to put up with suffering. Aim-inhibited energies, including anger, because available for productive endeavors. The therapist may usefully inquire about a worst-case scenario, mixing confrontational with empathic methods. Nancy McWilliams (2004: 209) suggests that the therapist inquire whether the would-be survivor has a legally binding Last Will and Testament naming her children (if she has any) or

Treatment of domestic violence

193

other close relative rather than the abuser. The “misery loves company” of the emotionally wounded is not a position of power, and power is what is needed by the would-be survivor. The implication is that she is at risk of getting killed. In this context, safety planning (e.g. Wilson 1997/2006) is more likely to be heard receptively—practical suggestions about having one’s cell phone, wallet, keys, etc. readily available to make a quick escape. The stickiness of the past redescribes the compulsion to repeat. Likewise, the stickiness of suffering. The suffering is not past but is aroused in such a way that, even if originally experienced in the past, it lives again in the present. When an upsetting experience is not integrated and tamed by being organized and structured into a coherent meaning, then something exists in the person’s experience that inherently continues to call forth the upset in an attempt to master it. Although not an infantile wish (unless amalgamated with one), traumatic experiences share with unacknowledged wishes the distinct characteristic that they are aroused by resemblance to associations and contiguities to patterns acting as triggers in the present. As Freud notes, the force of the trauma is transferred to the present like the ghosts in the underworld of the Odyssey—“ghosts which awake to new life as soon as they tasted blood” (Freud 1900: 553n.). This original meaning of “transference” is closely associated with the repetition compulsion and points the way to decoupling the person from the stickiness of the suffering by articulating and integrating the previously unformulated experience. To the extent that the suffering is owned, articulated, and integrated, it becomes less sticky. It loses power, becomes less forceful, less intrusive, diminished in its disruptiveness, and shrinks, even if the memory of it never completely disappears. Each of the distinctions in Figure 4.1 is an opportunity to engage with the survivor in the context of empathy. Each of the distinctions is an opportunity to generate a breakthrough or risk a breakdown in empathy in relating individually to the survivor. Indeed, a breakdown is often a precursor to a breakthrough, though seeing how is not easy when in the midst of the struggle. For example, empathic receptivity to the experience of the loss of power is a vicarious experience of fear, signaling the possibility of escalating violence. Whenever there is a loss of power, then risk of violence goes up. This applies to scenarios of self-harm and other harm in psychodynamic situations. Violence and authentic power are inversely related. Empathic receptivity also surfaces righteous indignation about domestic violence, a transformation of anger in the direction of relationally useful, aim-inhibited emotional energies to take action in the face of suffering. Empathic understanding engages breaking out of the perpetrator–victim cycle to engage the possibility for survivors to have power in relationships with the others in their lives. Empathic understanding grasps the possibilities of mutual respect and contribution to family and community. Empathic interpretation— distinguishing what happened from what the survivor made it mean—points

194

Treatment of domestic violence

toward the articulation of leadership in the matter of mutual cooperation, relatedness, and engagement with possibilities for satisfaction, meaning, and productivity. The empathic narrative that emerges is one of building community based on empathy.

Note 1

Alice Dreger has pointed out to me that sometimes the motive for rape may actually be sexual attraction combined with the prospect that the victim would never willing consort with the perpetrator. That “sex, not power” is now a “politically incorrect” position has forced prosecuting attorneys to discover a motive other than sex in prosecuting the perpetrators of rape. See Alice Dreger (2014) Galileo’s Middle Finger, New York: Penguin Books: 121–126. When social justice agendas collide with scientific facts, unintended consequences for both science and social justice are the inconvenient result.

Conclusion

The very idea of a rumor of empathy can be confronting, even anxiety inspiring. Maybe empathy is a mere rumor—only a rumor—and not a vital presence that makes an enlivening difference in one’s relationships. Maybe the rumor is mistaken. Maybe a rumor is a scandal of empathy as when Strachey mistranslates “empathy” or Lipps substitutes “projection” or one person’s empathy becomes another’s countertransference. If empathy is missing, what then of the vitality, aliveness, and warmth that empathy brings forth in one’s relatedness to others? If empathy is missing, what then of the humanness—the humanity—in one’s relatedness to others? Yet from another perspective, a rumor of empathy restores power to empathy. The very rumor itself restores power. How so? It puts empathy in the foreground and at the foundation of relatedness. The anxious reaction to the prospect that empathy is a mere rumor, not a reality, provides compelling evidence of the significance of empathy. It provides compelling evidence that empathy makes a difference, is sought after, even coveted. Its absence is felt. It is missed. If empathy is oxygen for the soul (self), then the pervasive shortness of breath abroad in the land is not only due to air pollution. Granted this is a provocative metaphor, but one that is of the essence. So many are short of breath. Positively expressed, if without empathy the psychic life of man (persons) is unthinkable (as Kohut asserted), then empathy is foundational, showing the way forward, enlivening, vitalizing, and inspiring—literally “in-spiriting.” Without repeating in detail the argument of this work, connecting the dots between an initial situation of resistance to empathy and the natural unfolding of empathy requires removing the resistances to let empathy flourish, navigating the labyrinth of empathic receptivity, empathic understanding, empathic interpretation, and empathic responsiveness. In spite of resistances to empathy—institutionally, individually, therapeutically—few would are deny the value of empathy. Everyone endorses empathy with the possible exception of a few contrarians whose contribution is precisely perceiving the hypocrisies of the lip service to a superficial ersatzempathy in the marketplace. Yet if empathy is so widely endorsed, why is it not more common? If empathy is so easy, why is it not more available?

196

Conclusion

Why is there so little of it in the world? There is so little of it precisely because our naturally given empathic abilities are left undeveloped by educators, parents, therapists, peers, politicians, leaders, and the systems they govern—but most of all are left undeveloped by ourselves. There is so little of it because introspection and self-knowledge are hard, requiring confrontation with one’s own inauthenticities, blind spots, and limitations— and such confrontation arouses resistance. To be empathic one must be other-centered, not self-centered. The resistance to empathy exists precisely because empathy is a transformation of narcissism that wounds one’s narcissism. Freud points out the pattern in his article on difficulties in the path of psychoanalysis (1917a): Man’s planet earth is not the center of the solar system, the sun is (Copernicus). Man is not the crowning creation of God, but the product of random variation and natural selection in evolution (Darwin). The ego is not master in its own consciousness, the unconscious is (Freud). While empathy perhaps falls short of the blows to narcissism of the discoveries of Copernicus, Darwin, and Freud, the dear self is wounded in its grandiosity and would prefer to receive empathy, not give it away. A rumor of empathy restores power to empathy because it proposes to undertake an open-minded inquiry into empathy. A rumor of empathy wonders that wonderful as empathy is, it is not more common. A rumor of empathy implies that one would know empathy if one encounters it, and proposes to go looking for it. This evokes the association of Diogenes’ madman with a lit lantern at noon, looking in the marketplace for an honest man. Is it madness to speak of a rumor of empathy, of resistance to empathy, of developing empathy? Yet one has to wonder—so many are short of breath. A rumor of empathy restores power to empathy because it puts empathy in charge of the inquiry. To be sure, we honor and study the exact words of such great thinkers and enactors of empathy such as Socrates, Freud, Kohut, and others too numerous to list here; but we take our guidance from empathy, not Socrates; empathy, not Freud; empathy, not even Kohut. There is a rumor of empathy in one’s relationships, community, training program, school, or psychotherapy practice, and one proposes to inquire into the rumor. One proposes to inquire into empathy’s presence or absence, and say whether the rumor is valid or invalid. In fact, once one knows about the rumor, then it can be validated (or not) using the same constructive methods identified by Freud (1937) for testing any construction or interpretation. Does it yield additional analogous, confirming examples? Does it yield additional empathy? Is empathy advanced or constrained? Does empathy flourish or languish? Deep is the well of human suffering. Who can plumb it? The motivation for another inquiry into empathy is to engage suffering and relieve it. Even if suffering is ultimately an illusion, it is a compelling one, and much work is required to overcome it. But is this realistic? Is this practical? Don’t think too deeply about what is bothering you. Life is tough, and then you

A rumor of empathy

197

die. Get over it. Is this one of the consolations of the examined life? Is this back-sliding into the unexamined? Yet, empathy is a bridge over troubled waters. This work is filled with “big ideas” and invites an equally large-scale response; yet none is available here. Instead, the invitation is to a rumor of empathy—“rumor” because, as an inquiry, empathy shows up as a possibility of relatedness in receptivity, understanding, interpretation, and responsiveness. Empathy takes place at the margin, at the boundary, at the limit. “Rumor” is that of which there is a faint sound—an echo—a trace—a mere possibility. As a rumor, empathy takes place just below the limits of consciousness. The rumor struggles to emerge as emotional contagion, synchronization of bodily postures, vicarious experience, communicability of affect, none of which rise to the level of full-blown, adult empathic receptivity. The rumor struggles to emerge as the possibility of a shift in a person’s way of relating, shift in the person’s way of engaging with her or his own character, or manner of engaging with other individuals. The rumor is that of a new possibility of empathic understanding that “gets” the other as who the other really is as a possibility. The rumor struggles to emerge as an empathic interpretation of the other individual from a first person, second person, or third person perspective, none of which are commensurable with one another, but which converge on empathy as on a point of infinite progress towards the horizon of accomplishment and satisfaction. The rumor of empathy struggles to emerge as a responsiveness to the other that includes listening and responding, based on reciprocal humanity. This takes us back to the beginning and to an optimal response that demonstrates to the other that the other’s humanness is acknowledged. The rumor is ultimately an inquiry into what it is to be human, and the inquiry itself humanizes. Thus, a rumor of empathy is not psychotherapy, it is a clearing for human relatedness in the context of an inquiry into being human, engaging emotional disorder and transforms it into possibilities of productivity and relatedness; it is not psychoanalysis, it is a clearing for the possibility of finding meaning and self-knowledge amidst absurdity and significance amidst suffering; it is not humanism, it is a clearing for the possibility of being human; it is not existentialism, it is a clearing for the possibility of human possibility; it is not morals, it is a clearing for integrity, respect, and generosity; it is not community, it is a clearing for acknowledging one’s neighbor and expanding community; it is not theory of beauty, it is a clearing for the communicability of affect; it is not narrative, it is a clearing for being optimally responsive through language and listening to the humanity of the other individual; it is not teaching, mentoring, or parenting, it is a clearing for the possibility of leadership in diverse roles in community. In short, the rumor of empathy is the initiative of lighting a single candle in the form of empathy against the darkness of human suffering.

References

Agosta, L. (1976). “Intersecting language in psychoanalysis and philosophy,” International Journal of Psychoanalytic Psychotherapy, 5: 507–534. ––––. (1977). “Empathy and interpretation.” Ph.D. dissertation. Philosophy Department. University of Chicago. ––––. (1980). “The recovery of feelings in a folktale,” Journal of Religion and Health, 19(4): 287–297. ––––. (1984). “Empathy and intersubjectivity,” Empathy I, eds J. Lichtenberg, M. Bornstein and D. Silver. Hillsdale, NJ: Lawrence Erlbaum Press. ––––. (2010). Empathy in the Context of Philosophy. London: Palgrave/Macmillan. ––––. (2011). “Empathy and sympathy in ethics,” The Internet Encyclopedia of Philosophy, a peer-reviewed online resource. Available at: www.iep.utm.edu/emp-symp/ (checked 2015-04-20). ––––. (2013). “A rumor of empathy in psychology (the movie).” Available at: http://empathyinthecontextofphilosophy.com/2013/04/28/a-rumor-of-empathy-inpsychology/ (checked 2014–07–14). ––––. (2014). “A rumor of empathy: Reconstructing Heidegger’s contribution to empathy and empathic clinical practice,” Medicine, Healthcare, and Philosophy, 17 (2): 281–292. ––––. (2014a). “A delicacy of empathy: The many meanings of ‘sympathy’ in Hume,” Psicologia em Pesquisa, 8 (1): 3–14. ––––. (2014b). A Rumor of Empathy: Rewriting Empathy in Philosophy. London: Palgrave Macmillan. Aichhorn, A. (1925 [1965]). Wayward Youth. New York: Penguin Books. Alexander, F. (1950 [2007]). “Analysis of the therapeutic factors in psychoanalytic treatment,” Psychoanalytic Quarterly, 19: 482–500. Reprinted (2007) Psychoanalytic Quarterly, 76: 1065–1083. Anscombe, G. E. M. (1959). Intention. London: Blackwell. Anthony, E. J. (1961). “A study of ‘screen sensations’,” Psychoanalytic Study of the Child, 16: 211–245. Appignanesi, L. and J. Forrester. (1992). Freud’s Women. New York: Basic Books. Arendt, H. (1954 [1961]). Between Past and Future. New York: The Viking Press. ––––. (1968). On Violence. New York: Basic Books. Ariès, P. (1962). Centuries of Childhood. London: Jonathan Cape. Arlow, J. A. (1979). “The genesis of interpretation,” Journal of the American Psychoanalytic Association, 27S: 193–206.

References

199

Atwood, G. E. and R. D. Stolorow. (2014). Structures of Subjectivity: Explorations in Psychoanalytic Phenomenology and Contextualism, 2nd edn. New York: Routledge (Taylor & Francis). Bacal, H. A. (1985 [1998]). “Optimal responsiveness and the therapeutic process.” In Optimal Responsiveness: How Therapists Heal Their Patients. Northvale, NJ: Jason Aronson: 3–34. —— (ed.). (1998). Optimal Responsiveness: How Therapists Heal their Patients. Northvale, NJ: Jason Aronson. Baron-Cohen, S. (1995). Mindblindness: An Essay on Autism and Theory of Mind. Cambridge, MA: MIT Press. ––––. (2011). The Science of Evil: On Empathy and the Origins of Cruelty. New York: Basic Books (Perseus). Basch, M. F. (1976). “Psychoanalysis and communication science.” Annual of Psychoanalysis, 4: 385–421. Basch, M. F. (1983). “Empathic understanding: A review of the concept and some theoretical considerations,” Journal of the American Psychoanalytic Association, 31 (1): 101–126. Batson, C. D. (2012). “The empathy-altruism hypothesis: Issues and implications.” In Empathy From Bench to Bedside, ed. Jean Decety. Cambridge, MA: MIT Press: 41–54. Beres, D. and J. A. Arlow. (1974). “Fantasy and identification in empathy,” Psychoanalytic Quarterly, 43: 26–50. Berliner, B. (1958). “The role of object relations in moral masochism,” Psychoanalytic Quarterly, 27: 38–56. Breggin, P. R. (1991). Toxic Psychiatry: Why Therapy, Empathy, and Love Must Replace the Drugs, Electroshock, and Biochemical Theories of the ‘New Psychiatry.’ New York: St. Martin’s Press. ––––. (2008). Medication Madness. St. Martin’s Press. Breuer, J. and S. Freud. (1893). “On the psychical mechanism of hysterical phenomena” from Studies on Hysteria. SE, Volume II: 1–17. Buie, D. H. (1981). “Empathy: Its nature and limitations,” Journal of the American Psychoanalytic Association, 29: 281–307. Busch, F. (2005). “Conflict theory/trauma theory,” Psychoanalytic Quarterly, 74: 27–45. Centers for Disease Control. (2010). National Intimate Partner Sexual Violence Survey. Available at: www.cdc.gov/violenceprevention/nisvs/ (checked 2014–01–26). Chused, J. F. (1996). “The therapeutic action of psychoanalysis: Abstinence and informative experiences.” Journal of the American Psychoanalytic Association, 44: 1047–1071. Clark, A. (1989). Microcognition: Philosophy, Cognitive Science, and Parallel Distributed Computing. Cambridge, MA: MIT Press. Crews, F. (1980). “Analysis terminable,” Commentary, July: 25–34. Darwin, C. (1872 [1965]). The Expression of the Emotions in Man and Animals. Chicago, IL: University of Chicago Press. Daston, L. and E. Lunbeck (eds). (2011). Histories of Scientific Observation. Chicago, IL: University of Chicago Press. de Waal, F. B. M. (2009). The Age of Empathy. New York: Harmony Books (Random House).

200

References

Decety, J. and P. L. Jackson. (2004). “The functional architecture of human empathy,” Behavioral and Cognitive Neuroscience Reviews, 3 (2): 71–100. Decety, J., C. Chen, C. Harenski, and K. A. Kiehl. (2013). “An fMRI study of affective perspective taking in individuals with psychopathy: imagining another in pain does not evoke empathy,” Frontiers in Human Neuroscience, 7: 489; published online September 24. Deutsch, H. (1926 [1953]). “Occult processes occurring during psychoanalysis.” In Psychoanalysis and the Occult, ed. G. Devereux. New York: International Universities Press: 133–146. Dhume, S. (2012). “The Taliban’s latest target: A 14-year-old girl,” The Wall Street Journal, October 11. Available at: http://online.wsj.com/news/articles/SB100008723 96390444799904578050451861386588 (checked 2014–06–08). Dreger, A. (2014). Galileo’s Middle Finger. New York: Penguin. Edelson, M. (1985). “The hermeneutic turn and the single case in psychoanalysis,” Psychoanalysis and Contemporary Thought, 8: 567–614. Ekman, P. (2003). Emotions Revealed: Recognizing Faces and Feelings to Improve Communication and Emotional Life, New York: Henry Holt. ––––. (2008). Conversations With History: Paul Ekman. Available at: YouTube: www.youtube.com/watch?v=IA8nYZg4VnI (checked 2012–10–04). Ellenberger, H. (1970). The Discovery of the Unconscious. New York: Basic Books. Erikson, E. H. (1958). Young Man Luther. New York: W.W. Norton. ––––. (1975). Life History and the Historical Moment. New York: W.W. Norton. Fagin, L. (2001). “Therapeutic and counter-therapeutic factors in acute ward settings,” Psychoanalytic Psychotherapy, 15: 99–120. Farrow, T. and P. Woodruff (eds). (2007). Empathy and Mental Illness. Cambridge: Cambridge University Press. Felman, S. and D. Laub. (1992). Testimony: Crises of Witnessing in Literature, Psychoanalysis, and History. London: Taylor & Francis (Routledge). Ferenczi, S. (1949). “Confusion of the tongues between the adults and the child,” International Journal of Psycho-Analysis, 30: 225–230. Fliess, R. (1942). “The metapsychology of the analyst,” Psychoanalytic Quarterly 11: 211–227. Frank, J. D. and J. B. Frank. (1961 [1993]). Persuasion and Healing: A Comparative Study of Psychotherapy. 3rd edn. Baltimore, MD: The Johns Hopkins University Press. Frederickson, J. (1990). “Hate in the countertransference as an empathic position,” Contemporary Psychoanalysis, 26: 479–495. ––––. (1936 [1966]). Ego Psychology and the Mechanisms of Defense, trans. Cecil Baines. New York: International Universities Press. Freud, A. (1966–80). The Writings of Anna Freud. Vols. I–VIII. New York: International Universities Press. Freud, S. (1976) The Standard Edition of the Complete Psychological Works of Sigmund Freud, XXIV Volumes. Translated under the guidance of James Strachey. New York and London: W.W. Norton. Hereafter abbreviated as SE. ––––. (1893a). “Fräulein Elisabeth von R, case histories from Studies on Hysteria.” In SE, Volume II: 135–181. ––––. (1893b). “Miss Lucy R, case histories from Studies on Hysteria.” In SE, Volume II: 106–124.

References

201

––––. (1896). “The aetiology of hysteria.” In SE, Volume III: 187–221. ––––. (1898). “Letter from Freud to Fliess,” August 31, 1898. In The Complete Letters of Sigmund Freud to Wilhelm Fliess, 1887–1904: 325–326. ––––. (1900). The Interpretation of Dreams. SE, Volume IV: ix–627. ––––. (1905). Fragment of an Analysis of a Case of Hysteria. SE, Volume VII: 1–122. ––––. (1905a). Jokes and their Relation to the Unconscious. SE, Volume VIII: 1–247. ––––. (1908). “On the sexual theories of children.” In SE, Volume IX: 205–226. ––––. (1909). Notes Upon a Case of Obsessional Neurosis. SE, Volume X: 151–318. ––––. (1909a). Analysis of a Phobia in a Five Year Old Boy. SE, Volume X: 1–150. ––––. (1910). “The future prospect for psycho-analytic therapy.” In SE, Volume XI: 141–151. ––––. (1910a). “‘Wild’ psycho-analysis.” In SE, Volume XI: 219–228. ––––. (1912). “On the universal tendency to debasement in the sphere of love (Contributions to the Psychology of Love II).” In SE, Volume XI: 177–190. ––––. (1912a). “The dynamics of transference.” In SE, Volume XII: 97–108. ––––. (1912b). “Recommendations to physicians practicing psycho-analysis: The dynamics of transference.” In SE, Volume XII: 109–120. ––––. (1913). “Totem and Taboo.” In SE, Volume XIII: vii–162. ––––. (1913a). “On beginniang the treatment (further recommendations on the technique of psycho-analysis I).” In SE, Volume XII: 121–144. ––––. (1913b [1955]). “Zur einleitung der behandlung,” Gesammelte Werke, Volume VIII. London: Imago Press: 454–478. ––––. (1913c). “The claims of psycho-analysis to scientific interest.” In SE, Volume XIII: 163–190. ––––. (1914). “Remember, repeating, and working-through (further recommendations on the technique of psycho-analysis, II).” In SE, Volume XII: 145–156. ––––. (1916). “Mourning and melancholia.” In SE, Volume XIV: 237–258. ––––. (1916a). “Some character-types met with in psycho-analytic work.” In SE, Volume XIV: 309–333. ––––. (1917). Introductory Lecture on Psychoanalysis, trans. James Strachey. New York: W. W. Norton, 1977. ––––. (1917a). “A difficulty in the path of psycho-analysis.” In SE, Volume XVII: 135–144. ––––. (1918). “From the history of an infantile neurosis (the Wolf Man).” In SE, Volume XVII: 1–124. ––––. (1919). “‘A child is being beaten’. A contribution to the study of the origin of sexual perversions.” In SE, Volume XVII: 175–204. ––––. (1921). Beyond the Pleasure Principle. SE, Volume XVIII: 1–64. ––––. (1921a). “Group psychology and the analysis of the ego.” In SE, Volume XVIII: 69–143. ––––. (1923). The Ego and the Id. SE, Volume XIX: 1–66. ––––. (1924). “The economic problem of masochism.” In SE, Volume XIX: 155–170. ––––. (1926). The Question of Lay Analysis. SE, Volume XX: 177–258. ––––. (1933). New Introductory Lectures on Psycho-Analysis. SE, Volume XXII: 1–182. ––––. (1937). “Constructions in analysis.” In SE, Volume XXIII: 255–270. Friedman, L. J. and A. Schreiber. (2013). The Lives of Erich Fromm: Love’s Prophet. New York: Columbia University Press.

202

References

Gadamer, H. G. (1960 [1975]). Truth and Method, trans. Sheed & Ward. New York: Continuum/The Seabury Press. Gallese, V. (2007). “The shared manifold hypothesis: Embodied simulation and its role in empathy and social cognition.” In Empathy and Mental Illness, eds T. Farrow and P. Woodruff. Cambridge: Cambridge University Press: 448–472. ––––. (2001). “The ‘shared manifold’ hypothesis: From mirror neurons to empathy,” Journal of Consciousness Studies 8 (5–7): 30–50. Garbarino, J. (1999). Lost Boys. New York: Anchor (Random House). Gedo, J. E. (1988). The Mind in Disorder. Hillsdale, NJ: Analytic Press. ––––. (1993). “Empathy, new beginnings, and analytic cure,” Psychoanalytic Review, 80: 507–518. Gehrie, M. (2000). “Forms of relatedness: Self-preservation and the schizoid continuum.” In Progress in Self Psychology, ed. A. Goldberg. New York: The Analytic Press, 14–32. ––––. (2011). “From archaic narcissism to empathy for the self: The evolution of new capacities in psychoanalysis,” Journal of the American Psychoanalytic Association, 59 (2): 313–333. Glover, E. (1931). “The therapeutic effect of inexact interpretation: A contribution to the theory of suggestion.” International Journal of Psycho-Analysis, 12: 397–411. Goldberg, A. (1995). The Problem of Perversion: The View from Self Psychology. New Haven, NJ: Yale University Press. ––––. (1999). Being of Two Minds: The Vertical Split in Psychoanalysis and Psychotherapy. Hillsdale, NJ: The Analytic Press. ––––. (2011). “The enduring presence of Heinz Kohut: Empathy and its vicissitudes,” Journal of the American Psychoanalytic Association, 59 (2): 289–311. Greenson, R. (1960). “Empathy and its vicissitudes,” International Journal of Psychoanalysis, 41: 418–424. Grosz, S. (2013). The Examined Life: How We Lose and Find Ourselves. London: W.W. Norton. Guttman, S. A. (1987). “Robert Waelder on psychoanalytic technique: Five lectures,” Psychoanalytic Quarterly, 56: 1–67. Hacking, I. (1995). Rewriting the Soul: Multiple Personality and the Sciences of Memory. Princeton, NJ: Princeton University Press. ––––. (1999). The Social Construction of What? Cambridge, MA: Harvard University Press. Halpern, J. (2001). From Detached Concern to Empathy: Humanizing Medical Practice. Oxford: Oxford University Press. Halpert, E. (2007). “The Grafs: Father (Max) and Son (Herbert a.k.a. Little Hans,” Psychoanalytic Study of the Child, 62: 111–142. Hanley, M. H. (1996). “‘Narrative’ now and then: A critical realist approach,” International Journal of Psycho-Analysis, 77: 445–457. Healy, D. (2003). Let Them Eat Prozac. London: James Lorimer Press. Herder, J. G. von. (1772/1792 [2002]). Philosophical Writings, trans./ed. M. N. Forster. Cambridge: Cambridge University Press. Hickok, Gregory. (2014). The Myth of Mirror Neurons. New York: W.W. Norton. Hojat, M., M. J. Vergate, K. Maxwell, G. Brainard, S. K. Herrine, and G. A. Isenberg (2009). “The devil is in the third year: A longitudinal study of erosion of empathy in medical school,” Academic Medicine, 84 (9): 1182–1191.

References

203

Huxley, A. (1954 [1990]). “The doors of perception.” In The Doors of Perception and Heaven and Hell. New York: Harper Perennial. Jamison, K. R. (1993). Touched with Fire: Manic-Depressive Illness and the Artistic Temperament. New York: The Free Press. ––––. (1995). An Unquiet Mind: A Memoir of Moods and Madness. New York: Random House (Vintage). ––––. (1999). Night Falls Fast: Understanding Suicide. New York: Random House (Vintage). Iacoboni, M. (2005). “Understanding others: Imitation, language, and empathy.” In Perspectives on Imitation: From Neuroscience to Social Science, eds S. Hurly and N. Chater. Cambridge, MA: MIT Press: 76–100. ––––. (2007). “Existential empathy: The intimacy of self and other.” In Empathy and Mental Illness, eds T. Farrow and P. Woodruff, Cambridge: Cambridge University Press: 310–321. Janicak, P., J. Davis, S. Preskorn, F. Ayd, Jr., S. Marder, and M. Pavuluri. (2006). Principles and Practice of Psychopharmacotherapy. 4th edn. Philadelphia, PA: Lippincott Williams/Walters Kluwer. Kafka, F. (1919). “Letter to the father.” Available at: www.almaclassics.com/excerpts/ dearestfather.pdf (checked 2014–05–31). Kant, I. (1781/1787 [1997]). The Critique of Pure Reason, trans. P. Guyer and A. Wood. Cambridge: Cambridge University Press. Katz, J. (2013). “Violence against women: It’s a men’s issue.” Available at: YouTube: www.youtube.com/watch?v=KTvSfeCRxe8 (checked 2014–01–23). Kempe, H. C., F. N. Silverman, B. F. Steele, W. Droegemueller, and H. K. Silver (eds). (1962). “The battered child syndrome,” Journal of the American Medical Association, 181 (1): 17–24. Kirby, M. D., M. Darusman, and S. Biserko. (2014). “Report of the detailed findings of the commission of inquiry on human rights in the Democratic People’s Republic of Korea.” Available at: www.ohchr.org/EN/HRBodies/HRC/CoIDPRK/Pages/ ReportoftheCommissionofInquiryDPRK.aspx (checked 2014–03–03). Klein, G. (1976). Psychoanalytic Theory: An Exploration of Essentials. New York: International University Press. Kleinman, A. (2006). What Really Matters: Living a Moral Life Amidst Uncertainty and Danger. Oxford: Oxford University Press. Kohut, H. (1959). “Introspection, empathy, and psychoanalysis,” The Journal of the American Psychoanalytic Association 7 (July): 459–483. ––––. (1966). “Forms and transformations of narcissism.” The Journal of the American Psychoanalytic Association, 14: 243–272. ––––. (1971). The Analysis of the Self. New York: International Universities Press. 1971. ––––. (1972). “Thoughts on narcissism and narcissistic rage,” Psychoanalytic Study of the Child, 27: 360–400. ––––. (1977). The Restoration of the Self. New York: International Universities Press. ––––. (1979). “The two analyses of Mr Z,” International Journal of Psycho-Analysis, 60: 3–20. ––––. (1982). “Introspection, empathy, and the semi-circle of mental health,” International Journal of Psycho-Analysis, 63: 395–407. ––––. (1984). How Does Analysis Cure? Chicago IL: University of Chicago Press.

204

References

Kramer, P. (1993 [1997]). Listening to Prozac: The Landmark Book about Antidepressants and the Remaking of the Self. Revised edn. New York: Penguin. Kris, E. (1956). “The personal myth—A problem in psychoanalytic technique,” Journal of the American Psychoanalytic Association, 4: 653–681. Kulish, N. and D. Holtzman. (2008). A Story of Her Own: The Female Oedipus Complex Reexamined and Renamed. New York: Jason Aronson. Kulka, R. (1988). “Narcissism and neurosis—An opportunity for integration in psychoanalytic theory and technique,” International Journal of Psycho-Analysis, 69: 521–533. Lacan, J. (1953). “The function and field of speech and language in psychoanalysis.” In Ecrits, trans. Bruce Fink. New York: W. W. Norton, 197–268. Lachmann, F. M. (2008). Transforming Narcissism. New York: The Analytic Press. Lane, C. (2007). Shyness: How Normal Behavior Became a Sickness. New Haven, NJ: Yale University Press. Lanzoni, S. (2012). “Empathy in translation: Movement and image in the psychology laboratory,” Science in Context, September, 25 (03): 301–327. Laub, D. (2005). “Traumatic shutdown of narrative and symbolization,” Contemporary Psychoanalysis, 41: 307–328. Lear, J. (2006). Radical Hope: Ethics in the Face of Cultural Devastation. Cambridge, MA: Harvard University Press. Lichtenberg, J. (1981). “The empathic mode of perception and alternative vantage points for psychoanalytic work,” Psychoanalytic Inquiry, 1: 329–355. Lichtenberg, J., M. Borstein, and D. Silver (eds). (1984). Empathy I & II. Hillsdale, NJ: Lawrence Erlbaum Press (Taylor & Francis (Routledge)). Lipps, T. (1903). Ästhetik. Hamburg: Leopold Voss Verlag. ––––. (1909). Leitfaden der Psychologie. Leipzig: Wilhelm Englemann Verlag. Lipton, S. D. (1977). “The advantages of Freud’s technique as shown in his analysis of the rat man,” International Journal of Psycho-Analysis, 58: 255–273. Loewald, H. (1957 [1980]). “On the therapeutic action of psychoanalysis.” In Papers on Psychoanalysis. New Haven, NJ and London: Yale University Press: 221–256. Lunbeck, E. (2011). “Empathy as a psychoanalytic mode of observation: Between sentiment and science.” In Histories of Scientific Observation, L. Daston and E. Lunbeck (eds). Chicago, IL: University of Chicago Press, 255–276. McGrael, C. (2010). “Sexual abuse scandal rocks Boy Scouts of America after $18.5m payout,” The Guardian. Available at: www.theguardian.com/world/2010/apr/29/ boy-scouts-sexual-abuse-dykes (checked 2014–01–23). McWilliams, N. (1999). Psychoanalytic Case Formulation. New York: The Guilford Press. ––––. (2004). Psychoanalytic Psychotherapy: A Practitioner’s Guide. London: The Guilford Press. Maechler, S. (2001). The Wilkomirski Affair: A Study in Biographical Truth. New York: Schocken Books. Margulies, A. (1989). The Empathic Imagination. New York: W.W. Norton. Marinoff, L. (2000). Plato Not Prozac! New York: Quill. Metzinger, T. (2003). On Being No One: The Self-Model Theory of Subjectivity. Cambridge, MA: MIT Press. Modell, A. (1996). Other Times, Other Realities: Towards a Theory of Psychoanalytic Treatment. Cambridge, MA: Harvard University Press.

References

205

Newman, K. (1984). “The capacity to use the object.” In Psychoanalysis: The Vital Issues, Vol. II. New York: International Universities Press. Niederland, W. G. (1965). “The role of the ego in the recovery of early memories,” Psychoanalytic Quarterly, 34: 564–571. Noël, B. with K. Watterson. (1992). You Must be Dreaming. New York: Simon & Schuster (Poseidon Press). Ogden, T. (1992). “Comments on transference and countertransference in the initial analytic meeting,” Psychoanalytic Inquiry, 12(2): 225–247. ––––. (1994). “The analytic third: Working with intersubjective clinical facts,” International Journal of Psycho-Analysis, 75: 3–19. Olden, C. (1953). “On adult empathy with children,” Psychoanalytic Study of the Child, 8: 111–126. Orlinsky, D. E. and K. I. Howard. (1978). “The relation of process to outcome in psychotherapy.” In Handbook of Psychotherapy and Behavior Change, S. Garfield and A. Bergin (eds), 2nd edn. New York: Wiley: 283–329. Orlinsky, D. E. and K. I. Howard. (1986) “Process and outcome in psychotherapy.” In Handbook of Psychotherapy and Behavior Change, S. Garfield and A. Bergin (eds), 3rd edn. New York: Wiley: 311–385. Orlinsky, D. E. and M. H. Rønnestad. (2005). How Psychotherapists Develop: A Study of Therapeutic Work and Professional Growth. Washington, DC: American Psychological Association. Palmer, R. W. (1969). Hermeneutics. Evanston, IL: Northwestern University Press. Pashman, M. B., C. Gutowski and T. Lighty. (2014). “Papers detail decades of sex abuse by priests: Secret files hid archdiocese’s mishandling of scores of cases,” Chicago Tribune, January 21. Available at: http://articles.chicagotribune.com/201401-21/news/chi-chicago-priest-abuse-20140121_1_abusive-priests-secret-churchdocuments-john-de-la-salle (checked 2012–01–25). Patten S. B. (2004). “The impact of antidepressant treatment on population health: synthesis of data from two national data sources in Canada,” Population Health Metrics, 2 (1): 9. Pigman, G. W. (1995). “Freud and the history of empathy,” International Journal of Psycho-Analysis, 76: 237–256. Piper, M. (1994). Reviving Ophelia: Saving the Selves of Adolescent Girls. New York: Ballantine. Plato. (n.d.). Theaetetus. In Collected Dialogues (1963), ed. E. Hamilton, Princeton, NJ: Princeton University Press: 845–919. ––––. (n.d.). Apology. In Collected Dialogues (1963). ed. E. Hamilton, Princeton, NJ: Princeton University Press: 3–26. Rabinowitz, D. (2003). No Crueler Tyrannies: Accusation, False Witness, and Other Terrors of Our Times. New York: Free Press. Racker, H. (1957 [2007]). “The meanings and uses of countertransference,” Psychoanalytic Quarterly, LXXVI: 725–777. ––––. (1968). Transference and Countertransference. New York: International Universities Press. Renik, O. (1996). “The perils of neutrality,” The Psychoanalytic Quarterly, 65: 495–517. Ricci, W. and F. Broucek. (1998). “Optimal responsiveness and neutrality, abstinence, and anonymity.” In Optimal Responsiveness: How Therapists Heal Their Patients, ed. H. A. Bacal. New York: Jason Aronson: 35–57.

206

References

Ricoeur, P. (1965 [1970]). Freud and Philosophy, trans. Denis Savage. New Haven, NJ: Yale University Press. ––––. (1973 [1976]). Interpretation Theory: Discourse and the surplus of Meaning. Fort Worth, TX: Texas Christian University Press. ––––. (1977). “The question of proof in Freud’s psychoanalytic writings,” Journal of the American Psychoanalytic Association, 25: 835–871. Rizzolatti, G. and M. Gentilucci. (1998) “Motor and visual-motor functions of the premotor cortex.” In P. Rakic and W. Singer, eds, Neurobiology of Neocortex. New York: Wiley: 269–284. Ronalds, C., and F. Creed, K. Stone, S. Webb, and B. Tomenson. (1997). “Outcome of anxiety and depressive disorders in primary care.” British Journal of Psychiatry, 171 (November): 427–433. Rose, N. (2003). “Neurochemical selves,” Society, November/December: 46–59. See also http://ayp.unia.es/dmdocuments/umbrales17.pdf (checked 2012–05–28). Ross, J. M. (2007). “Trauma and abuse in the case of Little Hans: A contemporary perspective,” Journal of the American Psychoanalytic Association, 55: 779–797. Rudnytsky, P. L. (1987). Freud and Oedipus. New York: Columbia University Press. Sacks, O. (1973 [1990]). Awakenings. New York: Vintage Books. Saks, E. R. (1999). Interpreting Interpretation: The Limits of Hermeneutic Psychoanalysis. New Haven, NJ: Yale University Press. Sandler, J. (1960). “The background of safety,” International Journal of PsychoAnalysis: 41: 352–356. Satel, S. and S. O. Lilienfeld. (2013). Brainwashed: The Seductive Appeal of Mindless Neuroscience. New York: Basic Books (Perseus). Schafer, R. (1959). “Generative empathy in the treatment situation,” Psychoanalytic Quarterly, 28: 342–373. ––––. (1981). “Narration in the psychoanalytic dialogue.” In On Narrative, ed. W. J. T. Mitchell. Chicago, IL: The University of Chicago Press: 25–49. Schlessinger, N. and F. Robbins. (1983). A Developmental View of the Psychoanalytic Process: Follow-up Studies and Their Consequences. New York: International Universities Press. Schwaber, E. (1981). “Empathy: A mode of analytic listening,” Psychoanalytic Inquiry, 1: 357–392. Shapiro, T. (1974). “The development and distortions of empathy,” Psychoanalytic Quarterly, 43: 4–25. Shaughnessy, P. (1995). “Empathy and the working alliance: The mistranslation of Freud’s Einfühlung,” Psychoanalytic Psychology, 12: 221–231. Shedler, J. (2006). “An introduction to contemporary psychodynamic therapy. That was then. This is now.” Available at: www.psychsystems.net/Publications/Shedler/ Shedler%20(2006)%20That%20was%20then,%20this%20is%20now%20R7.pdf (checked 2013–11–25). ––––. (2010). “The efficacy of psychodynamic psychotherapy,” American Psychologist, February–March, 65(2), 98–109. Simmons, R. (2002). Odd Girl Out: The Hidden Culture of Aggression in Girls. New York: Harcourt. Solomon, A. (2012). Far From the Tree. New York: Scribner. Spence, D. P. (1982). Narrative Truth and Historical Truth. New York: W. W. Norton.

References

207

Spinelli, E. (2005). The Interpreted World: An Introduction to Phenomenological Psychology, 2nd edn. London: Sage. Stahl, S. (2008). Stahl’s Essential Psychopharmacology: Neuroscientific Basis and Practical Applications. 3rd edn. Cambridge: Cambridge University Press. Steele, R. S. (1979). “Psychoanalysis and hermeneutics,” International Review of Psycho-Analysis, 6: 389–411. Stern, D. B. (2003). Unformulated Experience: From Disassociation to Imagination in Psychoanalysis. Hillsdale, NJ: The Analytic Press. Stolorow, R. D. (2007). Trauma and Human Existence: Autobiographical, Psychoanalytic, and Philosophical Reflections. New York: Taylor & Francis. Stolorow, R. D. (2011). World, Affectivity, Trauma: Heidegger and Post-Cartesian Psychoanalysis. New York: Routledge. Stolorow, R. D. and G. E. Atwood. (1992). Contexts of Being: The Intersubjective Foundations of Psychological Life. New York: The Analytic Press (Taylor & Francis). Strachey, J. (1934). “The nature of the therapeutic action of psycho-analysis,” International Journal Psycho-Analysis, 15: 127–159. Strachey, J. and A. Strachey. (1986). Bloomsbury/Freud: The Letters of James and Alix Strachey 1924–1925, eds P. Meisel and W. Kendrick. New York: Basic Books. Strozier, C. (2001). Heinz Kohut: The Making of a Psychoanalyst. New York: Farrar, Straus & Giroux. Summers, F. (1994). Object Relations Theories and Psychopathology. Hillsdale, NJ: The Analytic Press. Terman, D. M. (1984). “The self and the Oedipus complex.” Annual of Psychoanalysis, 12: 87–104. ––––. (1988). “Chapter 8: Optimum frustration,” Progress in Self Psychology, 4: 113–125. Titchener, E. B. (1909). Lectures on the Experimental Psychology of the ThoughtProcesses. New York: Macmillan. Tolpin, M. (2002). “Chapter 11: Doing psychoanalysis of normal development: Forward edge transferences,” Progress in Self Psychology, 18: 167–190. Tomasello, M. (1999). The Cultural Origins of Human Cognition. Cambridge, MA: Harvard Press. Tomkins, S. S. (1962 [1963]). Affect, Imagery, Consciousness, Vols. 1 and 2. New York: Springer Verlag. Trimble, M. R. (1981). Post-Traumatic Neurosis: From Railway Spine to the Whiplash. New York: Wiley. Trosman, H. and Simmons, R. D. (1973). The Freud Library. Journal of the American Psychoanalytic Association, 21: 646–687. Tuch, R. H. (1997). “Beyond empathy: Confronting certain complexities in self psychology theory,” Psychoanalytic Quarterly, 66: 259–282. Turnbull, O. and M. Solms. (2003). “Memory, amnesia and intuition: A neuropsychoanalytic perspective.” In Emotional Development in Psychoanalysis, Attachment Theory and Neuroscience, ed. Vivian Green. New York: BrunnerRoutledge (Taylor & Francis): 55–85. Tutu, D. (1999). No Future Without Forgiveness. New York: Doubleday. Tyson, R. L. (1986). “Countertransference evolution in theory and practice,” Journal of the American Psychoanalytic Association, 34: 251–274.

208

References

van Weel-Baumgarten, E. M., W. J. van den Bosch, Y. A. Heckster, H. J. van den Hoogen, and F. G. Zitman. (2000). “Treatment of depression related to recurrence: 10-year follow-up in general practice,” Journal of Clinical Pharmacology Therapy, 25 (1): 61–66. Viderman, S. (1979). “The analytic space: Meaning and problems,” Psychoanalytic Quarterly, 48: 257–291. Viederman, M. (1995). “The reconstruction of a repressed sexual molestation fifty years later,” The Journal of the American Psychoanalytic Association, 43: 1169–1195. Vul, E., C. Harris, P. Winkielman, and H. Pashler. (2009). “Puzzlingly high correlations in fMRI studies of emotions, personality, and social cognition,” Perspective on Psychological Science, 4 (3): 274–290. Wallerstein, R. (1986). Forty-two Lives in Treatment: A Study of Psychoanalysis and Psychotherapy. New York: The Guilford Press. Whitaker, R. (2010). Anatomy of an Epidemic: Magic Bullets, Psychiatric Drugs, and the Astonishing Rise of Mental Illness in America. New York: Broadway Paperbacks. Wikipedia. (2014). “Penn State child sex abuse scandal.” Available at: http://en. wikipedia.org/wiki/Penn_State_child_sex_abuse_scandal (checked 2014–07–06). Wilson, K. J. (1996 [2006]). When Violence Begins at Home: A Comprehensive Guide to Understanding and Ending Domestic Abuse, 2nd edn. Alameda, CA: Hunter House (Publishers Group West). Wimsatt, W. C. (2007). Re-Engineering Philosophy for Limited Beings. Cambridge, MA: Harvard University Press. Winnicott, D. W. (1965). The Maturational Processes and the Facilitating Environment: Studies in the Theory of Emotional Development. London: The Hogarth Press and the Institute of Psycho-Analysis. Wolf, E. S. (1988). Treating the Self. New York: The Guilford Press. Yalom, I. (1989 [2000]). Love’s Executioner. New York: HarperCollins Perennial Classics. Young, A. (2007). “Bruno and the Holy Fool: Myth, mimesis, and the transmission of traumatic memories.” In Understanding Trauma: Cultural, Psychological and Biological Perspectives, L. J. Kirmayer, R. Lemelson, and M. Barad, eds. Cambridge: Cambridge University Press: 339–362. Zaffron, S. and D. Logan. (2009). The Three Laws of Performance: Rewriting the Future of Your Organization and your Life. San Francisco, CA: Jossey-Bass.

Index

abstinence 15, 61, 62, 93, 106, 107, 114, 150, 159 abuse 4, 41, 55, 71–75, 81, 117, 119, 133, 141, 179–182, 188, 190, 191, 193, 203; and affective disorder 135; as boundary violation 103, 174; as resource 179, 181–185; do not diminish 134; emotional equilibrium and balance 181–182; Freud’s position (child) abuse 4, 92, 142, 156; honor killing 172–174; lives on 143; readiness to listen 139; return to get revenge 177, 191; shrouded in mists of the past 177; top reasons for not leaving 190–191; why men abuse 146–185; see also boundary violation; domestic violence affective action at a distance: emotional contagion 21 Agosta, Lou 65, 95; on Dora 87; speech act of story telling 26; empathy versus compassion 63 Aichhorn, August 53, 145 Aldous, Huxley xxii, 110 Alexander, Franz 30, 60–62, 197 altruism and empathy 26 Anscombe, G. Elizabeth M. 70 Anthony, E. James 24 Appignanesi, L. 76, 132 Arendt, Hannah 146, 156 Aristotle 8 Arlow, Jacob 27; anticipates micronarrative 75; identification, fantasy and empathy 19

Bacal, H. A. 27, 107, 108, 188, 198; optimal responsiveness 26 Baron-Cohen, Simon 27 Basch, Michael Franz 8, 22, 25, 198 Batson, C. D. 27, 198 Beres, David see Arlow Berliner, Bernard 53–54 betrayal oozes at every pore 61; applies not only to patients 150 Bonaparte, Princess Marie 102–103 boundary and empathy 169; between fact and psychic reality 3, 5, 27, 73; between narrative and historical truth 94, 99; in therapy 3; in relationship 166; issues 133, 166; psychotherapy 155; pushing 45; seduction euphemism 4; setting 46, 47, 167, 169, 185; violation of in Freud’s Dora 87–92 boundary violation 35, 87–92, 99, 100, 104, 108, 139, 141, 142, 144, 155–157, 170, 174; defined 171; in relationships 166; numbness 172; original trauma redescribed as 103; silence redescribed as aiding the 149 Breggin, Peter 122, 198 Buie, Dan: empathy as ESP 20; empathy as multistep 21 case histories (Freud’s): Dora 5, 15; Elizabeth von R. 76, 186; Frau Emmy von N. 76; Little Hans 76–77; Lucy R 76, 85; Rat Man 107, 156; Wolf Man 73, 94, 97 chemical vacations from intolerable selfhood xxii

210

Index

child abuse 71; defined by Kempe in 1962 73; versus cruelty to children 72 child scientist: Little Hans 77 Chused, Judith 60 Clark, Andy 21 clinical vignettes: Mr. D, bother instead of belonging 56; crashing the bike 38; de-idealization 47–51; example of corrective emotional experience 61–62; Freud (fraud) of psychiatric diagnosis, the 32; honor killing 164; Mr. C’s chemical imbalance 115–121, 135; Ms. G 130; Ms. L 133; Ms. S 165–169; rumor of Mr. A 41; shoemaker’s daughter, the 78; skeleton in the closet 81–82; speaking truth to power 34; story of the stork (Little Hans) 76–77; see also micronarrative compassion fatigue 24; empathy as defense against 63, 169 complimentary identification 28, 51 conform(ity) 6, 30, 34, 57, 81, 82, 94, 110, 142, 152, 185 concordant identification 28, 51 construction 3, 69, 82, 87, 91, 94, 102, 158, 196; and truth 4–5 corrective emotional experience 34, 55; and empathy 61–63 countertransference xix, xx, xxiii, 5, 15–16, 27–28, 35, 37, 43, 47, 49–51, 56, 60, 80, 88, 117, 175, 194; and empathy 29, 87; as blessing in disguise 15 Darwin, Charles 21 deal with the devil 123; be sure fine print 124; survivor feels 163 Decety, Jean 19, 21 Deutsch, Helena: occult process 19 de Waal, Frans 26; nested model of empathy 27 Diagnostic and Statistical Manual (DSM) xxi Dilthey, Wilhelm 9

domestic violence (DV): acknowledgement of courage 161; acknowledgement of what happened 157; bystander in 160; fighting back 161; focus on women survivors, men perpetrators 145; invalidating the survivor’s experience 160; inversely correlated with violence 146; men’s lack of leadership on 147; own the darkness to overcome it 164; redescription 171; safety plan 151–152; sensitivity versus leadership 149; silence as consent 150; subset of trauma 141; survivor theory of causation 143; survivor, tendency to blame self 144, 163, 164; threat of an honor killing 164; what one made it mean 163; see also framework for treating domestic violence in psychotherapy don’t think too deeply 115, 135; can’t stop people from doing so 130; on inpatient unit 129, 132 Dora (Freud’s case): and a rumor of empathy 5; as failed case 15; boundary violation in 88, 89; case history as Freud’s confession, the 97; description, redescription and empathy 87–92; Freud as bystander in 91; intolerant of lack of empathy 92; redescriptions of intentions 71; suffers 89; the rumor of empathy remains a rumor 93 Einfühlung [empathy] 83–84, 205 Ekman, Paul 21, 122 empathic distress 27 empathic interpretation xx, 9, 21, 22, 27, 36, 65, 164, 178, 196–7; acknowledgement of courage 157; as if 25; in the hermeneutic circle 23, 105; micro-narrative 75–76, 176; return to the abuser 176; Socrates 113; with dear little suffering 56; what happened, what meaning 193 empathic listening xx, 21, 22; as empathic speech 25, 27; language knits together 65; reduces force of

Index

trauma, upset 157; sinking into a warm bath 186; survivor slips 173 empathic narrative xx; as optimal response 105, building community 195; see also narrative empathic receptivity xx, 9, 21, 22, 27, 34, 35, 52, 118, 157, 164, 189; and language 65; as filter 24; as vicarious experience 23; context lacking 135; detailed examples 78–82; Freud’s evenly-suspended attention 26; gleam in the eye 108; in the hermeneutic circle 23, 105; micro-narrative 75–76; return to the abuser 177; righteous indignation 193; Socrates 112, 113; with suffering 56, 179 empathic relatedness 14, 43, 51, 182, 187; see also relatedness empathic responsiveness 9, 21, 22, 27, 56, 178; and language 67; and micronarrative 75–76; context lacking 135; detailed examples 78–82; gleam in the eye 108; in the hermeneutic circle 23, 105; patterns 160; return to the abuser 177; Socrates 113 empathic speech 27; listening as primary form and optimal responsiveness 25; see also narrative empathic understanding xx, 9, 21, 22, 36, 52, 164, 178, 197; and language 65; and micro-narrative 75; as recognition of possibility, relatedness 24; detailed examples 78–82; in the hermeneutic circle 23, 105; mutual respect 193; recovering power of agency 189–190; reengage with development possibilities 184; return to the abuser 177; Socrates 113; top down 25; with dear little suffering 56 empathy: about boundaries 30, 169; ambivalence 14; and countertransference 15; and its discontents 60; and MCAT score 186; as cognition 20; as corrective emotional experience 61–63; a single candle against the darkness 197; asked for by name 128; as recognition of humanity 105; as sample (trace affect)

211

24, 45, 169, 192; a vile word (Alix Strachey) 84; being in the presence xxiii; belong to the community 29, 67; body close form of 108; comes into language as an optimal response 105; countertransference 29; creation of possibility 185; defined as multidimensional process 22; distress 27; does not mean agree 148; emerges spontaneously unless interrupted 63; engaging with survivors 144, 157; expresses a micro-narrative 76; fails of 169; Good Samaritan 26; hermeneutic circle 9; inauthenticity 14; integration and regulation 187; introspection 17, 41, 135, 138, 139; learning to live with ambiguity 145; like oxygen xx, 44, 195; masochism 53–54; multidimensional process (method) xiii, 2, 10, 21, 22, 26, 27, 32, 34, 105, 169; multistep process xx; narcissistic rage 30; not a priority 34; not to judge return to the abuser 177; non-traumatic failures of 187; on inpatient unity 128–130; optimal frustration 26, 187; oxygen for the soul 44, 195; patient’s empathy to the therapist 52; recognition 22; redescribed as selfsoothing 188; reduces force of trauma 157; resistance to 8 163; scandal of mistranslation of 84; self-soothing 182; shotgun approach, unworkable 130; speaks truth to power 30; story telling 67; symptom relief 186–187; tension increase 3–4; unempathic system 33; unfolding sui generis 63; versus compassion 63; vicarious experience 22; what happened versus what it means 135; world without 95; wounds narcissism 196 empathy, rumor of see rumor of empathy emotional infection 21 enactment 8, 11, 14, 18, 40, 43, 48, 54, 63, 101, 104, 109, 119, 176, 177; defined 60 Erikson, Erik 32, 36, 37; and psychobiography 69

212

Index

evidence-based interventions and outcomes 125–127 facts xxii, 2–5, 72, 74, 77, 89, 90, 91–94, 100, 103, 128, 155, 156, 158, 162, 172, 178; as fragile 93, 155, 162; as stable background 96; boundary of historical 98; defined in psychoanalysis 1; thoroughly documented crime 96 Fain, Leonard; resistance to empathy 18 Forrester, John 76, 132 forward edge; and education 185; see also Tolpin, Marion framework for treating domestic violence 179; access to emotional resources 182–184; acknowledgement of what happened 157–161; boundaries, confrontation of 169–172; escape 151, 185; example of threat of an honor killing 164, 172–174; expectation of compensation 172–176; failures of empathy 169; getting an education 185; own the darkness to overcome it 164; recover emotional balance 182; reengage with the development process 184; risks: retraumatization, stuckness 189–195; safety (Sandler) 153; what the survivor made it mean 162–165 Frank, Jerome 114 Freud, Anna 45, 60, 74, 114 Freud, Sigmund: as psychotherapist 84; as story teller 83; confrontational methods with Dora 88; defines love 191; empathy for Dora 87–92; empathy in 82–93; evenly-suspended attention 26; evil spirit in fairy tale disappears 157; explicitly recommends empathy 83; first engagement with trauma (seductions) 141; hermeneutics and energetics 8; kinds of suffering 10; methods highly empathic 83; Odysseus 193; Oedipus 104; on transference 25, 193; original trauma = x redescribed 103; perversion 192; position of studied ambiguity on abuse 4, 92, 142, 156; psychoanalytic training xxii; repetition compulsion 142, 193; sadomasochism 191; second

engagement with trauma (shell shock) 142; seduction theory 4, 141–142, 156; somatic compliance 115, 122; trauma 73, 141–143; transmitting unconscious 19; writer of short stories 1; Wolf Man as Victorian porn 97; see also case histories Friedman, Lawrence 108 Gadamer, Hans Georg 9 Gallese, Vittorio 21 Garbarino, James 68 Gedo, John 136 Gehrie, Mark 56 glimmer in the eye 37 Goldberg, Arnold 11, 22, 25, 86, 121, 126, 201 Greenson, Ralph: inhibition and overidentifying of empathy 17; working model 25 Grosz, Stephen 68 Hacking, Ian 4, 70, 73, 142, 158; recovered memory 161 Halpern, Jodi 34 Hartmann, Heinz 95 Healy, D. 122, 127, 201 Herder, Johann Gottfried von 9 hermeneutic circle 9; and language 65; empathy forms a 27; narrative and historical truth in it 97, 99; redescription 71 Hermeneutics 2, 10, 204; defined 7–9 Hickok, Greg: debunking mirror neurons 19 historical truth 94–103; examples of narrative truth 98; in hermeneutic circle with narrative truth 96; Janet convinces Marie 101; no way history 102; see also facts hysterics suffer from reminiscences 1 infanticide 72, 104 interpretation 3, 4, 7–10, 15, 16, 18, 21–23, 25–27, 32, 34, 36, 43–44, 47, 60, 63, 68, 72, 74–77, 81, 107, 139, 172, 196; acknowledgement 158; canonical 145; clumsy 108; deep 137;

Index

defined 69–70; description 96; emerging 77; micro-narrative 79; narrative 104; redescribed 150; single word 106; useful 173; see also empathic interpretation intersubjectivity 53, 76, 197; defined 65 introspection 8, 16, 29, 30, 31, 120, 129, 157, 195, 226; and empathy 17, 41, 135, 138, 139; fallibility of 94; founding experience of psychoanalysis 43–44; gets a bad name 84; resistance to 43–45, 115, 128, 132; stress increasing 113; vicarious 2, 18, 19, 20, 23, 27, 45, 113, 63, 169, 188; vicarious empathy 188 Jamison, Kay Redfield 127, 201 Janet, Pierre 100, 103; narrative truth and historical truth in 101; anticipates cognitive behavioral therapy 102 Kafka, Franz 38, 202; “Letter to the Father” 11; world without empathy 95 Katz, Jackson 148–149 Kempe, C. H. 71 Klein, George 8, 202 Kleinman, Arthur 68 Kohut, Heinz: and positive science 2; angry 30–31; average expectable humane response 150; body close form of empathy 108; corrective emotional experience 61–63; defining document of resistance to empathy 30; economic vocabulary of narcissism 8; empty suffering 11; explicitly rejects corrective 60; gleam in the eye 108, 187–188; goals of psychoanalysis 12; innovation of data gathering 63, 169; Kafka 11, 38; listening like sinking into a warm bath 186; non-traumatic failures of 187; Odysseus 34; Oedipus redescribed 31, 104; optimal frustration 26, 187; out of touch 20; oxygen for the soul 44, 195; resistance to empathy 30–31, 195–196; resistance to introspection 16; toothless gums on empty nipple 106; traumatic emotional

213

deprivation 143, 188; vicarious introspection 2; world without empathy 95 Kramer, Peter 110; knocked the knees out from under talk therapy 122 Kris, Ernst: personal myth 69, 99–100, 202 Kulka, Raanan: on resistance to empathy 17–18 Lane, Chris xxii, 110, 123 language 54, 69, 75, 78, 81, 90, 94, 105–106, 140, 144, 176; access 157; and traumatic experience 7; Aristotle treatise 9; background 3; barrier 190; coded 89; devaluing 150; integrity 26; of energy 11; of mechanism 12; optimal 22; paradoxical xx; responsive 197; self-deception 7; speech act of narrative and empathy 65; speech acts 65–67; story telling 76; translate 9; untranslatable 95; see also empathic responsiveness; empathic language narrative Laub, Dori 96, 162 Lichtenberg, Joseph: empathic vantage point 17 Lipps, Theodor: and Freud 83 Lipton, Samuel 107 listening: as empathic receptivity 26; see also empathic listening; empathic receptivity Loewald, Hans: empathic moment 25; language and empathic responsiveness 67 Maechler, Stefan 4, 95, 203; literary hoax of Benjamin Wilkomirski 161 Margulies, Alfred 68 Marinoff, Lou xxii, 110, 223; author, Plato Not Prozac! 109 McWilliams, Nancy 69, 151 Metzinger, Thomas 157 micro-narrative 23, 67, 75, 117; altruistic surrender 45; chemical imbalance 114, 135; crashing the bike 38, 180–181; cultivating the tree of her sorrows 135–137; defined 74–75; don’t hurt

214

Index

yourself 189; emotional equilibrium and balance 181–182; emperor’s new clothes, the 80; knowing and not knowing (Miss Lucy R) 86; lack of impulse control 147; mom liked you best 76; Ms. G’s encounter 130; return to the abuser 177; rumor of Mr A 41; shape up and fly right 117; she loves him 191; shoemaker’s daughter, the 78; “Six roses or cirrhosis?” (Viderman) 75; skeleton in the closet 81–82; speaking truth to power 30, 35; “Stillborn?” (Waelder) 77; story of the stork 76–77; take your medicine 127; toothless gums on empty nipple 106; we’re not in Kansas anymore 154; see also case histories; empathic speech; narrative Modell, A. 53, 54, 55 mourning 131; exemplary case 1 murder of the original Egyptian Moses 97 murder of the six million 96 Nachträglichkeit [retrospective action] 71; indeterminacy of the past 73–74; description, redescription and empathy 87–92 narcissistic rage xix, xxii, 17, 19, 33, 36, 38, 44, 57, 90, 92, 118, 144, 148, 152, 165, 166, 167, 169, 170, 171, 172, 173, 175, 180, 182, 189, 190, 202; transformed into aim-inhibited assertiveness 31; vulnerabilities of the self 32 narrative 1, 27, 44, 57, 73, 132, 134, 169, 186; based on a true story xxiii; chemical 115; delusional 168; Dora 93–95; dream 70; empathy 65–66; empathic as optimal response 105; facts 155; gives access to transference 68, 193; grooming 173; history 96–106; injustice 166; latent 85; let tell 47; meta 156; mother of interpretations, the 69; new 80; Oedipus 31; of abuse rewritten as possible future 188; of suffering 10; parable of the Good Samaritan 26;

paradigm of empathy 22; patient comes in with one 62, 68; poetry 67; relatedness, access to 2, 36, 68–69; speech act that corresponds to empathy 22, 65; story telling 67, 157; survivor 161; temper 118; threat 174; symptom 76; transference 68, 159; Wilkomirski 161–162; world of meaning 75; see also empathic narrative narrative truth 94–103; at the bottom of a slippery slope 96; examples of reciprocal relation with historical truth 98; Janet co-constructs with Marie 101–103; points way to historical truth 97; see also narrative neutrality (analytic) 15, 60, 61, 62, 90, 93, 107, 114, 159, 170, 204; distinct from lack of commitment, engagement 150 Newman, Kenneth 46 Odysseus, the 34 Oedipus 69, 103; redescribed 72; defining narrative for Freud 104 Ogden, Thomas 14, 113; post-traumatic stress disorder (PTSD) 133, 142, 143, 165, 173 optimal response: as empathic 105; gleam in the eye 108; to Ms. G 131; see also Bacal, H. A. Orlinsky, D. E. 121, 126, 204 pain 8, 10–11 , 31, 34, 43, 44, 72, 113, 116, 126, 127, 143, 155, 188; abuse 160, 170, 171; and suffering 12, 117; in legs 76; masochism 54, 191, 192; mental illness as expression of 127; relieve 101 wearing mask of smile 54 Parable of the Good Samaritan 26 personal myth see Kris, Ernst Pigman, George 83; on translating Einfühlung [empathy] in Freud 84 power 30; loss of 193; inversely correlated to violence 146; of the forward edge; words as 121 procrastination 11

Index

psychic reality 2, 73, 75, 77, 78, 90, 91, 92, 94, 97, 99, 102, 136, 156, 161, 162 psychoanalysis xxi, xxiii, 8, 14, 22, 25, 30, 68, 94, 107, 125, 156, 191, 197; archaeology 95; break out 142; difficulties in path 196; driven by tension between narrative truth and historical truth 97; embattled discipline xx; epistemological status 94; fact in defined 1; founding in introspection 44; hermeneutics 7; narrative 88; observation 26; origins of 103; training 15; two fingers 106; versus psychotherapy 12; war games 31 psychopharmacology 109, 128; cardiometabolic risks 124; knocked the knees out of talk therapy 122; neurochemical reshaping of personhood 123; rapid cycling in 124; see also deal with the devil psychotherapy: absent empathy, suffering; 126; acknowledgement and recognition 161; and a rumor of empathy xx; and self-knowledge 5; balance 52; career 133; college of hard knocks 132; diagram 152; domestic violence 151–195; education 8; efficacy of 125; empathy 127; engaging with survivors 144; fragility of facts in 155, 178; goals 12; history of the future 188; living with ambiguity 161; market for xx; no place on unit 128; not consistent with ongoing domestic violence 151; own the darkness to overcome it 164; phases in the treatment of domestic violence 141; self-deception 95–96; short-term 129; suffering 10; therapist dare not 161; therapist bull in china shop 144; therapist tested 158; study of efficacy of 125; versus psychoanalysis 12; with survivors 155–157, 163, 170, 175, 182, 183, 188, 196; working as designed 52; see also framework for treating domestic violence in psychotherapy

215

Rabinowitz, D. 161 Racker, Heinrich 52; countertransference 15; defines empathy 27; introspection 28 railway spine 11 rapid cycling: defined 124 recognition of the other: paradigm of empathy 22 redescription 70, 73–74, 171; and indeterminacy 72; description and empathy in Dora 87–92; Janet redescribes Marie’s trauma 101; Ms. L 132, 135; original trauma = x, 103; positive expressions by conformists 185; take a vote and blame the victim 90 relatedness xx, 1–3, 8, 20, 22, 24, 27, 29, 33, 41, 42, 45, 47, 54, 184, 188, 191, 195, 197; access through narrative 60, 68; hunger 35; see also empathic relatedness Renik, Owen 60, 114 retraumatize 34, 55, 56, 141, 163, 178; blaming the victim 189; by an indifferent, unempathic system 176; ; return to get revenge 177, 191; return to the abuser 189–190 retrospective action [Nachträglichkeit] 71; indeterminacy of the past 73–74; redescribe to blame the victim 90 resistance to empathy 8, 38, 139, 163; account of why 195–196; and inauthenticity 14; and prescribing (psychopharmacology) 109, 122; as extension or archaic grandiosity 47; countertransference 15–16; economic account of 44; fear of being perfectly understood 60; institutional 40; introspection 16, 43; Kohut’s ultimate statement of 30–31; masochism as 53–54; Mr. C as witness to 115; on inpatient unit 115, 129, 128; organization’s 29–30, 115, 129; overcoming in Socrates example 111; patient’s, the 51; perfection, enemy of the good, 129; suspiciousness towards health as 185; therapist’s, the 42, 45; types of 16; vulnerability 52, 56, 87,

216

Index

185; Winnicottian 54; wounds narcissism 195; see also empathy, resistance to Ricoeur, Paul 95; defines psychoanalytic fact 1; psychoanalysis as hermeneutics 7 Ross, John Munder 76, 108 rumor of empathy: and psychotherapy xx, 197; and vicarious introspection 2; as speech act 66; association emerges as 80, 81; at the boundary 196; at the Chicago Institute 68; confirmed in Freud 86; how title determined xx; in Freud 82; in Freud’s Dora 5; in Socrates 111; on inpatient unit 128–130; position of this book xxiii; remains a rumor in psychopharmacology 128; restores power to 195, 196; scandal of mistranslation 84; scandal of psychopharmacology 122; starts with a single statement in Freud xxii; ultimately an inquiry into the human 197 Sacks, Oliver: every psychopharmacologist’s dream 122–123 Sandler, J. 153, 205 Satel, Sally: debunking neuroscience 19 scandal of empathy xxii, 195, 203; free spirits 123; in mistranslation 84; lack of leadership 149; mistranslation 84; psychopharmacology 122; Strachey 83 Schleiermacher, Friedrich 9 Schlessinger, Nat 121 seduction theory 88; see also boundary violations self-deception 65, 66, 95–96, 139; conflict of interest 155; Dora 89; Kris 99; language required for 7 self-knowledge 1, 6, 7, 42, 88, 197; and abyss 103; and natural science 5; cognitive impenetrability 5; hard 195; raid on the inarticulate 5; selfdeception 6–7; under-estimate the challenges of 119; unexamined life 111, 113

selfobject 47, 49; defined 18, 31; unempathic 54, 58, 95 self psychology 18, 30, 31, 32, 46, 52, 63 Shafer, Roy 69 Shapiro T: empathy as a form of defense 19–20 Shedler, Jonathan 125, 126, 206 Smaller, Mark xxi Sophocles’ Oedipus drama as evidence 104 speech act: defined 65–66; to construct a fact 155 Spence, Donald 94–98, 156; relate to Ernst Kris 99–100 Spinelli, Ernesto 145, 205 Stahl, Stephen xxii Stern, Donnel 5, 102, 230 Stolorow, Robert xvii, 8, 33, 137, 197, 206; and relational home 7 story telling: saying what is not the case 76; see also narrative Strachey, James: scandal of empathy, mistranslating Einfuehlung 83 Strozier, Charles 30 suffering: absent empathy 126; dear little suffering 56; dehumanization 11; empathy in the face of 63; forms of 10; guilt 11; mental illness as expression of 127; paradox of 136; relation to pain 12; single candle against the darkness 196; sticky 53, 55, 103, 117, 149, 177, 190; top reasons for not leaving abuser 190–191 Summers, Frank 57, 206 Terman, David 26, 27, 31, 108, 206; gendered self 12 therapy and narrative 67–68; and Socrates 111; removes resistances development resumes 61 Titchener, Edward Bradford 83–84 Tolpin, Marian 40 179, 182, 206; forward edge 50, 164, 179, 182, 188; healthy tendrils 185 Tomasello, Michael 21 trace affect: empathy as signal 44

Index

training program xxi, 2; countertransference to the organization 16; expanded empathy in 44; Freud’s Lehrmeisterin 47, 132; Mr. C’s contribution 115, 118; Ms. G’s contribution 130; rumor of empathy in 196; sensitivity versus leadership 141, 149; shortness of breath (oxygen) in 44, 195; training analysis 15 transference 15, 18, 22, 25, 29, 32, 35, 52, 56, 68, 94, 107, 117, 136, 159, 162, 167; access through narrative 2, 66–68; forward edge 183, 185, 186; in Janet as rapport 101; issue migrates into the room 160; original meaning of 193; transference mutualization 17 trauma and hyper-vigilance 154; bystander to 160; documented in Janet 102; domestic violence; 141; fact versus fantasy 73; fall from grace in Genesis 10; fragility of facts 155; interrupts natural development 188; invalidating the survivor’s experience 160; keep the lid on 135; noticeable absence of 136; numbness 145, 172; original buried in the past 103; persisting lack of safety 154; power of 193; psychic versus physic 88; railway spine 11; spontaneously morphs 160, 171, 172; threat of abandonment 118; threat of an honor killing 164; thrown out naked 38–41 Trotsky, Leon: example of an individual fact that might never have existed 155 truth and interpretation 3; asceticism of 3; correspondence theory of 4; literary hoax 185; self-knowledge 5; speaking truth to power 30; under a description 96 Tuch, Richard: resistance to empathy 18; anticipates empathy as multistep process 18 Tyson, Robert L. 27, 206

217

unconscious xxii, 17; abstinence 106; always listening 40; and fantasy 165, 177, 185, 191; cognitive impenetrability, 6, 189; communication, 19, 24; death 10; Dora 91; evil spirit 157; elves 79; fantasy of causation 143, 144; Freud on 86; intentions 85; interpretation 25; jokes 83; master 196; past in transference 62; rumor of empathy from 78, 80, 81; self-knowledge 111; split off 52; wishes 70 unexamined life, the xxii, 110, 124, 138, 196 vicarious experience 24, 29, 45, 46, 64, 182, 192, 193, 197; as empathic receptivity 23, 179; discussed in depth 44; paradigm of empathy 22; see also introspection vicarious introspection see introspection Viederman, M.: and recovered memory 158 Vul, Edward: voodoo correlations in MRI research 19 Waelder, Robert 77, 156 Whitaker, Robert 121, 124, 207; see also rapid cycling Wilkomirski, Benjamin: literary hoax 161, 162, 203 Wilson, K. J. 146, 152, 193 Wimsatt, William, 21 Winnicott, D. W. 54, 127; impingement 118 Wolf, Ernest S. 24, 25, 46 Yalom, Irv 68 Young, Alan 96 Zaffron, Steve 140