Psychoanalytic Empathy (Book Review)
Author: Bolognini, Stefano
Publisher: Free Association
Reviewed By: Juan Tubert-Oklander, Vol. XXVII, 1 (Winter 2007), pp. 54-59
Stefano Bolognini is one of the leading contemporary European psychoanalysts. Having met him and witnessed his superb clinical presentations, I tend to think about him as a latter-day Winnicott. Just like the old English artificer, Bolognini is a non-partisan psychoanalyst, who is at home both with the treatment of severe personality disturbances and with the turmoil of adolescence, and also a master of the middle ground. In his fascinating book, Psychoanalytic Empathy—an English translation of his 2002 original Italian edition, L’empatia psicoanalitica—the author rejects the facile criticism which claims that “empathy is not a psychoanalytic concept,” while traversing the narrow strait that lies between the Scylla of a monolithic and univocal system of thought, and the Charybdis of an eclectic plurality of theories in which anything goes.
In order to attain this juggling act, it is necessary to develop an adequate frame of mind:
“In certain cases, knowing how to maintain a temporary suspension, when faced with the apparent irreconcilability of different models, may lead in time to a better understanding of when, how, where, and why a particular model is pertinent and suitable, what its sphere of application and heuristic limitations are, how different models with intriguing similarities may overlap or be brought together . . . and so forth. A conscious suspension of the sense of incompatibility when assessing different models is quite another thing to the split use of various models by the analyst himself” (p. 16).
This is strikingly similar to Bolognini’s treatment of empathy. For instance, when reviewing Greenson’s conception of empathy, he points out, “the capacity to suspend judgment, to the very limit of credulity, is what makes empathy with the patient possible, and will eventually lead to an understanding of the underlying movements” (p. 47). True psychoanalytic empathy, however, requires both a sympathetic openness and an acceptance of the patient’s subjectivity and its impact on the analyst, and a relentless intellectual scrutiny that both differentiates the analyst’s mental processes, experiences, and views from those of the patient, and paves the way for another, and hopefully deeper, understanding. Consequently, the analyst must keep a dialectic tension—my term, not the author’s—between an uncritical empathic resonance and an analytical inquiry of the experience that is thus harvested.
Clearly, Bolognini is making a plea for a reading, both of psychoanalytic texts and of the patients’ manifestations, which keeps the balance between empathic acceptance and critical scrutiny. This is akin to the proposal of analogical hermeneutics. Since this has been for some time a focus of my theoretical interests, I will allow myself a little roaming into a sidetrack.
Analogical hermeneutics is the name given to the theoretical proposal put forward by Mexican philosopher Mauricio Beuchot (1997, 2003, 2004), which deals with a problematic that is widely coincident with ours. Hermeneutics is traditionally conceived as the interpretation of texts. A text is an organized set of signs that conveys a meaning, which has to be revealed by means of the work of interpretation. The contemporary conception of a text includes not only the spoken and written discourses, but also dialogue, relation, action, and cultural products such as images, ritual, mores, music, dance, fashion, or architecture.
There are three possible types of signification, which represent three forms of predicate distribution: univocality, equivocality, and analogy. Univocality maintains that, for every given text, there is only one valid interpretation, which is true, while every other possible one has to be false. Equivocality recognizes that there are many possible interpretations for every text—some say that they are unlimited and that there is no criterion for choosing between them; others say that it is personal taste or practical convenience. Analogy, a word that originally meant “proportion,” is multivocal, in as much as it accepts the existence of a plurality of interpretations for the same text, but it does not relinquish the effort to appraise them. There are many possible interpretations, yes, but they are not necessarily equivalent: some are better, others not so good; some are poor, and yet others are outright bad. The criterion for such a winnowing is to be found in ontology, that is, the intuition of the existence that lies behind the text and all its interpretations. In the case of psychoanalysis, this would be the direct experience of the personal encounter between patient and analyst, which is reflected over and over again in their interaction, their dialogue, and their many attempts, both conscious and unconscious, to represent and account for what is going on within and between them (Tubert-Oklander, 2006a, b, c).
Analogical hermeneutics consequently thrives in the middle ground between identity and difference, even though it leans more toward the latter. It implies looking for similarity in difference, and for difference in similarity, while giving each one its due. From univocality, it receives the belief that there is a truth to be found out, even though we may never be fully able to grasp it, which prevents us from falling prey to the authoritarian and dogmatic delusion that our present interpretations are Truth itself. From equivocality, it derives a clear awareness of the multiplicity of interpretations and frames of reference, but still striving to preserve a search for truth, albeit a partial and temporary one, to be compared with other versions of it, and yet sufficient to keep on thinking and acting on it, that is, an analogical truth.
Such willfulness to stay in between two apparently opposite and incompatible positions is what led Donald Winnicott (1971) to develop his concept of a “third area” between the internal and the external as well as to nurture his love of paradox. It is also Bolognini’s preferred approach to the dilemmas of psychoanalytic theory and practice. As we shall later see, this is not the only ground on which he adopts an analogical stance.
Now, going back to the book itself, it is worth noting that, after an introduction called “The Psychoanalyst’s Theoretical Models, Harmony and Consistency,” which states the author’s view of psychoanalysis and its plurality of theories and techniques, the rest is divided in two parts. The first one deals with a “Historical Review” of empathy in psychoanalytic literature, while the second is “A Contemporary Prospective,” in which he develops his own understanding of the concept, from the vantage point of his clinical practice. I shall now summarize and comment on their contents.
Part I comprises the first six chapters. Chapter 1 on “Romantic Empathy” presents a delicious glimpse of the Romantic’s conception of “sympathy,” understood as a deep and almost organic continuity between the individual and everything that is, one that covers both body and spirit. This way of looking at things was to be found not only in aesthetics and the arts (for instance in the work of Theodor Lipps), but also in science and philosophy (with Wilhem Dilthey), as well as in medicine, where it fostered the belief in a contagion of both disease and health.
Chapter 2, on “Freud and Empathy,” shows that Freud knew well and admired the writings of Lipps, while fearing that the philosopher might have preceded him in the development of metapsychology. However, he hardly used the term Einfühlung (empathy), a situation compounded by the fact that James Strachey’s translation almost drops the term completely. Although Freud (1913) stressed—in “On Beginning the Treatment”—the importance of keeping an attitude of “sympathetic understanding” (einfühlung), and privately endorsed in a letter, Ferenczi’s (1928) considerations on “tact,” he was suspicious of anything that might connect psychoanalysis with intuition, irrationality, or what he called “occultism.” This was certainly part of his obsessive traits, his positivistic education, and his ambivalence toward emotions. Such a stance may, of course, also be understood in terms of his need to defend psychoanalysis against dire criticism, by underscoring its scientific status. Chapter 3, “The Pioneers,” briefly reviews the contributions of Helene Deutsch, Sándor Ferenczi, and Robert Fliess. Perhaps Ferenczi’s major contributions would have deserved a more extensive treatment, but this opinion may be only a reflection of my own theoretical sympathies.
Chapter 4, “The Fifties: The Rediscovery of Empathy,” focuses on the contributions of American psychoanalysts, commenting on the work of Christine Olden, Roy Schafer, Ralph Greenson, Heinz Kohut, and Ping-Nie Pao. From these, Bolognini highlights the idea that empathy requires a dynamic balance between fusion and separateness, that it offers the pabulum for the development of the patient’s self and selfobjects, and that it takes a long effort to develop the network of communications that makes it possible.
Chapter 5, “The Kleinian and Post-Kleinian Conception of Empathy,” shows that, even though these authors do not use the term, the concept underlies the writings of writers such as Herbert Rosenfeld, Roger Money-Kyrle, Wilfred R. Bion, and James Grotstein. Bion, in particular, developed a concept of the mind that is both extended and relational, because it shows how the baby’s (or the patient’s) mind develops from the inner and outer responses of the mother (or the analyst) to their unconscious communications.
Chapter 6, “An Italian Contribution: Savo Spacal and ‘Comparative Analysis,’” draws heavily on the posthumous work of Spacal, an Italian psychoanalyst of Slovenian origin, who studied two different approaches to the understanding of other human beings—including, of course, patients—which are: a concordant identification with the other’s conscious experiences (“empathy”) and a complementary response toward his or her projections of rejected aspects of the self (“countertransference”). Even though individual analysts may lean toward one or the other pole, on the basis of their own personal cognitive–affective organization and the bias of the analytic school in which they trained, a deeper understanding must necessarily be based on a dynamic balance between the two. Bolognini clearly admires Spacal’s contribution, but takes exception at his identification of empathy with concordance, because he strongly believes that true psychoanalytic empathy should encompass all aspects of the patient’s personality, including those that have been repudiated, split-off, projected, or otherwise alienated, and that it takes a long time and a protracted effort to develop.
Part II, “A Contemporary Prospective,” includes Chapters 7 through 14. In Chapter 7, “The Analyst’s Internal Attitude: Analysis With the Ego and Analysis With the Self,” the author stresses the importance of affect and of making contact, both with the patient’s and with the analyst’s own emotional experiences. He defines the ego, for the purpose of his present analysis, as “a nucleus of consciousness and a set of active mental functions” (p. 70), and the self as “the internal reality (including object representations) which turns out to be a lasting, characterizing and constituent part of a person’s mental world, and which may be the object of his subjective experience” (pp. 70-71). The analyst may be working either with his ego or with his self, and he may enter contact with either the patient’s ego or self, thus defining four possible combinations that define the analytic dialogue. Even though any one of them may be germane at some given point of a treatment, the analyst’s deeper understanding of his patient happens when he is able to work with his own self, thus combining emotional and cognitive comprehension; true analytic developments come about when there is a dialogue between the patient’s and the analyst’s ego-selves. This kind of work is obviously more risky than that which ensues when the analyst keeps an intellectual detachment, because it implies that he cannot come out of a treatment unaffected, but it seems to me that it is the only kind of work that really makes a difference for patient and analyst alike, thus deserving the name of “psychoanalysis.”
Chapter 8, “Empathy and Countertransference: The Analyst’s Affects as a Problem and a Resource,” emphasizes the importance and value of the analyst’s emotional responses, which are both unavoidable and enriching for the analysis. Although in the first stages of the psychoanalytic movement a natural suspicion existed toward emotional responses, and a fear of the dire consequences that might result from the analyst losing his scientific cool, we have long since found that the perception of the analyst’s affects not only gives a natural sense of reality and truth to his work experience and interpretations, but it also significantly reduces the danger of acting out denied emotions in the session.
This chapter also begins the clinical part of the book, which is rich with Bolognini’s compelling case presentations—one per chapter. In these, not only does he include a thorough discussion of his subjective participation in the analysis, but he also makes an extensive use of metaphor in order to describe complex relational events. In this he follows Freud’s penchant for analogy, but sticking to the use of human and relational models, as the master did in Chapters 2 through 6 of The Interpretation of Dreams, and not that of physical and mechanistic models, as in Chapter 7.
The main part of the chapter is the case of Aldo “the Heartless Executive,” in which the author shows the evolution of a most conflictive and apparently sterile transference-countertransference relationship, toward a final recovery of the patient’s humanity. This was attained as a result of his being able to keep his neutrality, understood not as “non-affectivity, but [as] a temporary suspension of judgment and. . . keeping oneself open to complex perceptions and unpredictable developments in the field and process of analysis” (p. 90). Affects can never be decided or planned; they always come about as unexpected natural developments. They are also both an asset and a problem, and have to be dealt with by means of understanding.
Chapter 9 on “Empathy and Sharing: A Necessary Distinction,” elaborates the author’s contention, to be found throughout the book, that there is a clear distinction between empathy, which is a necessary prerequisite for psychoanalytic understanding, but which cannot be planned, and psychoanalytic empathy, which is always the end result of hard analytic work. But sharing and the corresponding actions of the analyst are usually hard to communicate to colleagues. There seems to be a growing gap between the novelty of our analytic experiences and the conventional technical language that we use in order to communicate with other analysts and ourselves, that is, to think. This is clearly illustrated in the case of Sara, a reluctant patient that seemed to be impervious to psychoanalysis, who was finally reached by the analyst, after the latter painfully felt an utter lack of hope about the treatment, and innerly accepted that it should come to an end. This is presented by Bolognini as a case of sharing without empathy. But sharing is a much needed precursor of empathic understanding.
Chapter 10 is called “The ‘Kind-hearted’ Versus the Good Analyst: Empathy and Hate in the Countertransference”—an attempt to translate the original Italian pun, “L’analista buono e il buon analista,” something like “The goody analyst and the good analyst.” Here the author charges against a sentimentalist conception of psychoanalysis that relies on maintaining a blissful experience of love, care, and total understanding, and discusses the issue of what Winnicott (1949) called “hate in the countertransference.” Empathy is not necessarily love, and there are some patients that systematically induce in the analyst hate toward them, as he shows in the case of a narcissistic doctor, who finally proved to be inaccessible to analysis. If the analyst represses or denies this hate, this would represent a lack of empathy on his part. This argument is continued in Chapter 11, “Empathy and ‘Empathism,’” previously published in The International Journal of Psycho-Analysis (Bolognini, 1997), which offers a subtle definition of empathy:
“Empathy to me is properly a condition of conscious and preconscious contact characterized by separateness, complexity and a linked structure, a wide perceptual spectrum including every color of the emotional palette, from the highest to the darkest; above all, it constitutes a progressive, shared and deep contact with the complementarity of the object, with the other’s defensive ego and split off parts no less that with his ego-syntonic subjectivity” (p. 120).
Therefore, he takes exception to the view that identifies empathy with concordant identification, that is, with the patient as subject. From his point of view, complementary identification with the patient’s internal objects—which other writers call “countertransference,” as different from empathy—is also an essential part of psychoanalytic empathy, which is the final harmonious result of a long, difficult, and painful process. This is shown in the case of Alessandra, whose false self presentation of an aloof and artificial “refined young lady,” induced no empathy in the analyst, until an interpretation of the transference—“I feel that today you are asking me for complicity and not for understanding”—revealed the confused and persecuted little girl that hid behind the mask. Now the analyst was able to experience true empathy with her suffering. “Empathizing” should not be set as a task or a claim, since empathy can never be planned; it is a goal, not a method. The case of Ada, who seemed to have stifled all her drives and wishes, drove the analyst to despair, but he managed to come out of it by means of an inner reflection about everything he knew about her, which finally turned into an interpretation, of which he writes: “This intervention was generated not by empathy with the patient but by good inner attunement to what I was feeling and thinking at the time” (p. 131). Consequently, the analyst also needs to be empathic toward him- or herself. This brings the author to a conclusion, which may well summarize the intention of the book:
“I believe that effective and genuine empathy is the fruit of a set of valid concordant and complementary identifications that are thoroughly elaborated and integrated and that sharing is a precursor of empathy, of which it constitutes the necessary crude experiential premise, but not the end-product, still less the guarantee” (p. 133).
Chapter 12, “Empathy and the Unconscious,” tackles the most difficult problem of the metapsychology of empathy. This was rather disappointing to me, because I felt that Bolognini pulled the brakes precisely when he should have upped the throttle. But this is perhaps only an expression of my own theoretical bent. I strongly feel that clinical experiences such as those depicted by the author urgently require a major overhaul of generally accepted theory; Bolognini obviously does not share my point of view, because he sticks by the traditional topographic and structural models. Although I fully endorse Winnicott’s (1971) dictum that “in any cultural field it is not possible to be original except on a basis of tradition” (p. 117), in the innovation–tradition continuum I lean heavily toward the former, while the author is nearer to the latter, at least in questions of theory.
But any disappointment I may have felt turned into outright admiration when he closed the chapter with the case of Anna, who kept a tight-lipped smile and demanded full self-disclosure by the analyst, while she utterly resisted any attempt to build an analytic dialogue. Bolognini’s delicate analytic work on a childhood memory—a mutual exhibition of genitals with her bother, traumatically interrupted by her father, surely analogous to her demands vis-à-vis the analyst—in which he focused on what was missing in her narrative—her feeling toward her father’s burst of anger—rather than following his patient’s defensive emphasis on the sexual aspect of the episode, finally arrived at a deep and empathic understanding. What was needed in a case in which the analyst seemed unable to empathize with his patient, was empathy with her defensive ego, which denounced her as a “collaborationist,” when she consciously decided to cooperate.
Chapter 13, “Empathy and Fusion,” is much nearer to the theoretical revision that I expected, because it expounds the subject of normal fusional experiences, both in everyday life and in analysis. Mental health requires the ability to alternate between moments of fusion and those of separateness. This is akin to the ideas of Hans Loewald (1951)—whom he does not quote—and José Bleger (1967)—quoted in a previous chapter—who suggested that primitive indiscriminate experiences coexist all the time with that of individuation and separation. But Bleger, in particular, turned this into a major change in theory, when he suggested the existence of a third position that complemented Klein’s schizoid-paranoid and depressive positions, one characterized by indiscrimination and ambiguity. Bolognini, on his part, emphasizes the need to focus on normal healthy developments, and not only on pathology, in order to better understand fusional experiences.
The chapter ends with the analysis of Leopoldo, a narcissist with perverse traits, who evolves during a session from his usual enraged and defying position, to a regressive relaxation that allows a mutual immersion in a peaceful and calm atmosphere. The element that brought about the change was an interpretation reached by the analyst, but which he kept to himself, because he felt it was not yet the right time to voice it.
Chapter 14 deals with “Natural Empathy and Psychoanalytical Empathy.” The former is a spontaneous development, which is shown by quite ordinary people, who have had no training for this kind of understanding. Having this sort of natural skill is surely an asset for anyone who intends to become a psychoanalyst, but training surely develops more resources that facilitate the emergence of empathy, and help him or her to recognize when it happens. This is shown in a case supervised by the author, in which the patient’s spontaneous empathy toward a girl who feigned having fallen down, in order to attract her rather insensitive mother’s attention, is acknowledged and validated by her analyst, who then interpreted that she had used this account to make him see her own genuine deep suffering. The patient was moved by this interpretation. The supervisor then showed his young colleague how this incident was also a comment on his own lack of empathy, during the past week, when he had been rather insistently trying to analyze his patient’s efforts to control things. Therefore, the patient had managed to catch her analyst’s attention, just like the girl had done with her mother. The author uses this clinical episode, in order to show the similarities and differences between spontaneous natural empathy and its more cultivated psychoanalytic version.
In the final chapter on “Conclusions,” Bolognini stresses that, for him, “empathy [is] just one of the multiplicity of aspects, planes and sectors on which the theory and practice of psychoanalysis is based” (p. 175). He also emphasizes the “delicacy” of empathy, which is fleeting and spontaneous, and cannot be fixed or reproduced at will. It can, however, be expected, recognized when it happens, and cherished. It is also something that should not be always immediately expressed in words, since many patients are for long periods intolerant of emotional closeness and weary of being seen in their intimacy.
The book ends with a final clinical vignette, left by the author without a comment, so that it may resonate in the reader. It is a session of Mr. P.’s analysis, a very difficult patient who had been overtly hypercritical, sarcastic, and impervious for years. Analyst and patient had finally managed to establish a meaningful communication and like each other, developing what could be described as a good friendship, in analytical terms. Mr. P. had already proposed that they finish the analysis, and this had been experienced by the analyst as an impending loss. In the session that Bolognini presents, the patient appears once again as the juggernaut that he had been at the beginning of the treatment. He tells a story about seeing a young woman in a restaurant, who had taken off her shoe, and he saw her little toes moving. This disgusted him intensely, but then he saw that she raised her foot and used it to lift her glass to her lips, since she had no arms! But then Mr. P. said something to the analyst, which was a mixture of supervision and interpretation:
“I know you were laughing up your sleeve just now. But then you were left thunderstruck. Just like me. I think we understand each other you and me. You see, doctor, how easy it is to misjudge an apparently offensive gesture if you don’t know the situation properly” (p. 178).
Needless to say that the analyst was deeply moved by the subtlety and depth of this comment, which clearly referred to their own relationship. And with this last flourish, Stefano Bolognini bids us farewell, while musing about “our profession, so strange and unpredictable that we can hardly ever decide what is ours to experience next” (p. 179).
I can only recommend the reader to catch the opportunity to experience by him- or herself this fascinating book, which certainly deserves more than one reading (indeed, I could only write this review after reading it for a second time).
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