Character Transformation through the Psychotherapeutic Relationship (Book Review)

Author:  Hooberman, Robert E.
Publisher:  Jason Aronson, 2002
Reviewed By:  Linda B. Sherby, Spring 2003, pp. 36-38

In his introduction, Robert Hooberman states two hopes he has for his book. First, that the approach to treatment he elucidates, “… will lead others to see symptoms and disorders as attempts at adaptation as opposed to pejorative psychopathological entities…” and second, that his readers will come to appreciate that a treatment approach that deals with character structure affords “… a deeper and more satisfying treatment than that accorded by approaches more circumscribed.” These two hopes, which are more than realized, capture the tone of humanity, tolerance, thoroughness, and inclusiveness that pervades the entire book.

In a writing style that is clear, concise, and sprinkled with beautifully turned phrases, Hooberman offers many clinical examples and translates complex psychoanalytic concepts into easily understood and readable language. He is interested in how patients change, as well as how and why they resist change. He focuses on a multi-layered approach that deals with symptoms, defense, character structure, and unconscious conflict. His contention is that only the affectively charged relationship between therapist and patient can bring about structural change, and that this work can be done most effectively in what he calls the preconscious or implicit mode. Character, the constellation of individual beliefs, habits, and psychic structures, develops as a person attempts to adapt to internal and external pressures, and this adaptation affords the greatest safety and security that an individual can muster. It is precisely because character structure provides such a sense of safety that it is so intransigent to change. “The development of personality structure represents both failure and success. It is a failure in the sense that the individual feels forced to develop neurotic (in the best case) choices in order to solve intrapsychic and interpersonal problems. It is a success in that these choices are often creative underpinnings for future problem solving” (p. 128).

The roots of character structure are organized unconsciously and grounded in childhood beliefs, misconceptions, and fantasies. On a day-to-day basis, they are reflected in what Hooberman calls a worldview, a characteristic way of behaving and relating, that is not articulated and that exists on a preconscious level. In an example of Hooberman’s respect for patients and, indeed, all individuals, he seeks to understand and normalize the difficulty inherent in giving up this worldview, regardless of how much pain or difficulty it might bring. One’s character structure and worldview have developed over a long period of time for the purpose of protection from internal or external impingements, as well as for bolstering the sense of self and, therefore, cannot easily be surrendered. It is also not in conscious awareness, and, so, it must await the gentle yet persistent interpretations of an analyst to be brought into the light of day.

This is not to say that Hooberman would suggest that interpretations alone bring about structural change, for that is certainly not the case. “Explicitly or implicitly, all contemporary psychoanalytic models suggest a creative engagement between patient and therapist. This goes beyond the awareness and use of countertransference, beyond even the use of enactments, and embraces the larger supposition that patients—nay, people—need interpersonal engagement in order to prosper” (p. 12). In detailing his style of working with patients, Hooberman can be seen as an astute listener who is calm, respectful, and inquiring. He believes every patient has a right to intensive treatment: “… I do not want to deprive any patients, of whatever stripe, of what might be their only chance to alter their lives significantly” (p. 23). For Hooberman, much of the treatment is focused on characterological issues, the identifications and internalizations of beliefs, values, and habits which the patient has taken in from the family, and which patient and analyst now attempt to elucidate and clarify, particularly as they recur in the therapeutic relationship. To be most effective and to provide treatment that is most understandable to the patient, the analyst must stay focused on the patient’s affect in the present.

Hooberman advises against focusing on symptoms, the explicit, because they miss the complexity of the individual. Depression, for example, may serve different purposes and have different meanings depending on the patient. He also suggests that the most fruitful analytic work often does not take place in the hidden or unconscious arena either. “Heavy emphasis by the clinician on the past or on unconscious processes seems to me to point to an uncomfortable transference/countertransference issue that seeks relief in distance from the immediacy of the moment” (p. 108). This is not to say that Hooberman rejects the importance of the unconscious. To the contrary, he believes that by focusing on character issues and how they manifest themselves in the present, one can most readily arrive at the link between the present and the past, between the conscious, the preconscious, and the unconscious. He believes that focusing on the implicit provides “signposts” to the unconscious, whereas “… the elucidation of unconscious material suffers when attention is given only to the interactive domain or to the domain of conflict” (p. 60-61).

Again and again, Hooberman returns to the importance of the affectively laden treatment relationship and of an interactive therapeutic approach, which models for the patient involvement and assertion. He emphasizes the importance of patient and therapist working together in a joint venture and cautions that, “Ultimately… the patient is the ultimate authority on how he or she will configure reality, internal and external” (p. 51). In addressing many of the oft-debated questions in psychoanalysis these days—frequency, authority within the analytic setting, psychic reality, free association—Hooberman’s is the calm voice of moderation, inclusion, and an appreciation that analysts also have a worldview which greatly influences their theoretical and clinical predilections. For example, while agreeing in principle with Renik’s idea that a therapist’s viewpoint should not be given more weight than a patient’s, he adds that it is a very difficult perspective to maintain. “The fact that an analyst or therapist subscribes to one particular theoretical orientation or another suggests in itself a preferred (implicit) way of looking at the patient and at life. These are conveyed to the patient by the nature of the analyst’s attention to associative material… [which sets the] type of stage on which the patient’s life drama will be acted out and elucidated” (p. 53).

Hooberman also brings his characterological approach to bear on many familiar psychoanalytic concepts such as defense, the repetition compulsion, and sadomasochism. For example, in discussing defenses, he stresses not their pathological aspects, but rather the safety that they provide in helping the person to cope with what would otherwise be unbearable experiences. Themes about trauma are interwoven throughout his book and he makes it clear that he is talking not only about cataclysmic trauma, such as the Holocaust or incest, but cumulative trauma as well, the trauma born from repeated emotional assaults on an infant or young child’s psyche. It is from these assaults, as well as internal stresses and conflicts, that defenses materialize. “[T]he patient develops these psychic structures to fend off disappointment, to establish a sense of safety, and, above all, to ensure psychic survival” (p. 82). In his discussion of the repetition compulsion, Hooberman’s basic humanity, respect, and understanding shines through. He writes, “… that repetition compulsions represent, especially in traumatized patients, a sense of the inevitable. As aspects of character structure, they transcend simple motivational etiologies and exist, in part, to maintain a sense of self and to provide a sense of stability” (p. 119).

For myself, I found Hooberman’s chapter on “Anarchy, Perversity, and Sadomasochism” to be one of the most enlightening of the book, filled with thoughtful ideas and new ways of looking at old concepts. For example, one little, almost tangential, tidbit that caught my attention had to do with the result of treating a child as a narcissistic extension of a parental caretaker. The child may learn from this experience to externalize their own internal conflicts onto others, just as was done to them by their caretaker. In retrospect, this seems like an obvious thought, but one that helped clarify my work with a patient who continually sees his problems as being caused by forces outside himself.

The main contribution of this chapter was a broadening of the concepts of perversion and sadomasochism beyond the concrete sexual realm. Drawing on the work of Winnicott, Khan, and, later, Novick and Novick, Hooberman sees perverse patients as having existed only to fulfill their parents’ needs and are therefore terrified by annihilation anxiety when they are not satisfying the needs of another. “This is the shape of the internalized relationships they reenact. Inner deadness is what perverse patients defend against, even to the extent of risking their physical well-being” (p. 140). Sadomasochism is a similarly pathological solution to feelings of terror arising from either a fear of loss of self or a dread of emptiness. These patients cannot tolerate to not suffer because it gives them an illusionary sense of control via omnipotence. Therefore, they attempt to establish the analytic relationship as they have all other relationships: looking to be beaten. The analyst, in turn, must stay exquisitely attuned to the smallest of injuries that occur within the therapeutic relationship. These injuries violate the patient’s sense of omnipotence, and, therefore, safety, and they re-stimulate the desire to hurt, and to be hurt, in order to regain the lost omnipotence. This connection must be pointed out to the patient again and again as it is re-enacted in the transference/countertransference relationship.

Although I do not disagree with Hooberman’s formulation, my theoretical bent would lead me to add one element that I see as missing. It would be my contention that part of the intransigence of these patients, and, in fact, many traumatized patients, has to do with their having internalized a very negative parent-self image constellation to which they remain tied, and from which they cannot separate, without great pain and mourning. Thus, I would maintain that in addition to drawing repeated attention to the connection between these patients’ hurts in the therapeutic relationship and their need for omnipotent control, one could benefit from also looking at the patients’ attachments to their bad objects and the need to reenact that connection within the transference/countertransference relationship.

So far, I have said little about the extensive clinical material presented in this book, and there is indeed much to be said. Hooberman is very generous in the amount of clinical material he offers through the window into his consulting room. He begins presenting his clinical material early in the book and continues to the very end. Some patients he presents only once to illustrate a particular point; others he presents repeatedly so that the reader can have some sense of their growth and change. Hooberman is also generous in sharing himself. He talks about his anger at patients, his boredom, his arousal. He talks about feeling frustrated or perplexed or stymied by a particular patient. We see him as a human being with both his own worldview and his own imperfections, and that is rare within the psychoanalytic literature.

Given my comments about Hooberman’s generosity in sharing both his patients and himself, it may seem contradictory for me to say that I wished for more. Not more cases, but more experience-near examples. I wanted to know the actual words that were spoken in the room. I wanted to know, for example, what he explicitly said to his sexually unresponsive patient that enabled her to eventually “… understand the origins of her frantic need for male approval and her concern about sexual feelings and behavior” (p. 13). Similarly, I wanted to know how he went about telling his anesthesiologist patient that her need for distance made him sleepy and interfered with his attentiveness, and how she reacted to his telling her this. I wanted to know how many times he told her and how she may or may not have reacted differently as the treatment progressed. Since Hooberman obviously could not tell us about each of these patients in depth, I would have preferred for him to select a few patients and trace their treatment through the course of the book, using actual dialogue whenever possible. I also found that identifying the patients by title and initial (e.g., Dr. R. or Mr. T.), detracted from their humanity and aliveness, as well as being more difficult to follow from one chapter to another. In a book that was less well crafted and focused less on the importance and intensity of the therapeutic relationship, I would have been more than happy with the extensive and varied clinical material presented. It is precisely because Hooberman’s patients are clearly so vital and alive for him that I wanted to more fully share and resonate with his experience. I wanted to see his patients come alive on the written page so that I could care about them as much as he did, and for this to happen I believe that explicit dialogue would have been greatly beneficial. Having expressed my desire for more, I hear Hooberman’s cautionary words in his beautifully written and thoughtful chapter on “Hating, Forgiving, and Healing.” I am then reminded that we must all relinquish the fantasy of perfection and come to terms with the limitations of both our idealized others and ourselves.

In closing, I will say that I found this book to be an invaluable addition to our field, a book that can be appreciated by both the novice therapist and the experienced analyst. This is a book that could, and should, be incorporated into the curriculum of both graduate training programs and psychoanalytic institutes. Hooberman does a masterful job of integrating concepts, of bringing in the new, more relational aspects of psychoanalysis, without discarding the contributions of Freud and more traditional theorists. The book is, as he hoped it to be, a humane testament to an integrative approach to both theory and practice.

Reviewer Note

Linda B. Sherby is a founding member and a personal and supervising analyst at the Southeast Florida Institute of Psychoanalysis and Psychotherapy. She is in private practice in Boca Raton, Florida and she is a past-President and present Secretary of the Southeast Florida Association for Psychoanalytic Psychotherapy.

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