Psychoanalytic Treatment: An Intersubjective Approach (Book Review)

Author:  Stolorow, Robert D., Bernard Brandchaft and George E. Atwood
Publisher: Hillsdale, NJ Analytic Press, 2000
Reviewed By: Paul Wachtel, Winter 2002, pp. 47-49

Intersubjectivity, Vicious Circles, and Developmental Arrests

This is a reissue of an influential 1987 volume that explored the theoretical and therapeutic implications of the authors’ intersubjective approach to psychoanalytic theory and practice. The perspective provided by the years between the book’s original publication and its reissue offers an opportunity to reflect on the place of these authors’ intersubjective approach in the larger context of psychoanalysis today and on the ways in which their approach parallels certain other trends in psychoanalytic thought and the ways in which it is distinctive.

In the time since this book was originally published, psychoanalysis has moved very substantially in two (largely overlapping but somewhat distinguishable) directions – toward a two-person model and toward a relational model. Both of these conceptual tendencies – by now very much in the mainstream, and perhaps even the majority viewpoint among American psychologist-psychoanalysts – were still emerging as influential viewpoints at the time this book was first published. Moreover, since the book from the first was essentially a reprinting (with some reworking) of papers that were written even earlier, these two tendencies were even further from full development and acceptance when the ideas of this book’s authors were first being introduced. It is thus easy to underestimate how much in the vanguard many of the book’s ideas were at the time they were written because in certain ways the field has now caught up to them. The intersubjective approach is very clearly both a two-person approach and a relational approach, though its way of embodying each has distinctive features that set it apart from its theoretical cousins.

The clearest and most explicit starting point for the authors’ psychoanalytic approach – the source from which they derived inspiration and, by way of contrast, against which they sharpened and refined their ideas – was the work of Kohut. Their debt to him is made very explicit throughout the volume. In contrast, Sullivan is referred to only once in the book, and then primarily to distinguish their approach from his – contrasting their emphasis on the need for the therapist to be cautious about assuming she knows what is “really” true and what is a “distortion” with the quite different epistemology that characterized Sullivan’s conceptualization of parataxic distortion. To be sure, Sullivan’s much more “objectivist” epistemology, his emphasis on the psychiatrist as “expert,” his endorsement of operationism, all do contrast sharply with Stolorow et. al.’s, epistemological stance, and, from this reviewer’s perspective, their critique of Sullivan’s views in this regard is a useful contribution. But it is difficult to imagine the authors having achieved their impressively thoroughgoing two-person stance without having had Sullivan’s prior work to build on. Sullivan’s insights into the problems associated with assuming we can see “the patient” without taking into account the continuous role of our own participation in what we are seeing were an almost inescapable influence on all analysts open to exploration of these issues, especially in America.

The greatest strength of the intersubjective approach lies in its attention to the subtleties of ongoing interpersonal influence – its acute appreciation of the impossibility of “neutrality” – combined with a deep respect for the patient and the patient’s experience. This respect is manifested in the many ways that the authors alert the analyst reader to the danger of dismissiveness that is so troublingly woven into the fabric of analytic discourse. This dismissiveness, Stolorow et. al., point out, is evident not only when the patient is viewed as “distorting,” but even when the analyst acknowledges the role of her “actual” behavior but does so in a way that reserves to her the warrant for deciding what her actual behavior was and its relevance to shaping the patient’s transferential response.

A similarly respectful spirit is manifested in their discussion of analysts’ failures of understanding that can lead to viewing the patient as “an intrinsically difficult, recalcitrant person.” (p. 3). In contrast, they offer a perspective in which emphasis is on empathically grasping why the world does look to the patient as it does, why the patient’s perspective, however problematic for the patient in leading his or her life, makes sense if one genuinely understands the person’s experience. This is a viewpoint on patients’ experiences that, as they note, can be at odds with certain longstanding traditions in psychoanalytic discourse. But it is at the same time one that has emerged, more or less independently, from a number of different lines of psychoanalytic theory development. The tie the authors understandably emphasize is to Kohut’s (1959) efforts to establish psychoanalysis on an epistemological ground of empathy. But parallels and consonances are also evident between their work and Gill’s (1984) emphasis on understanding what is valid in the patient’s transference response and on transcending the idea of the transference as a “distortion,” and interesting parallels may be seen as well to the work of other writers who have addressed the potential for pathologizing in psychoanalytic formulations and have emphasized the clinical value of a more respectful and validating perspective on the patient’s experience (e.g., Wachtel, 1993; Weiss & Sampson, 1986; Wile, 1984).

A central contribution of the authors’ approach is their insightful dissection of the false dichotomies that characterize not only psychoanalytic formulations but Western psychological thinking more generally. In addressing, for example, the frequent debates in psychoanalysis about the role of insight versus that of new relational experience in the psychoanalytic process and in the process of cure, they suggest that this debate reflects the chronic tendency in Western culture to fragment the psyche into separate affective and cognitive domains, and they argue that “insight through interpretation, affective bonding through empathic attunement, and the facilitation of psychological integration are indissoluble facets of a unitary developmental process that we call psychoanalysis” (p. 101). To this they add, insightfully and usefully, that, “[T]he therapeutic impact of the analyst’s accurate interpretations lies not only in the insights they convey, but also in the extent to which they demonstrate the analyst’s attunement to the patient’s emotional states and developmental needs. The analyst’s interpretations are not disembodied transmissions of insight about the analytic relationship. They are an inherent, inseparable component of that very bond, and their therapeutic action derives from the intersubjective matrix in which they crystallize” (p. 101, italics in original).

Yet ironically, and perhaps inevitably, the authors at times themselves manifest the very dichotomizing they elsewhere are so perceptive in challenging. Perhaps most significant for the psychoanalytic reader is their insistence that the very definition of psychoanalysis should include a restrictive limitation that dichotomously separates psychoanalysis from all the rest of the social and behavioral science disciplines. As someone who shares Stolorow et al’s emphasis on the importance of respectful appreciation of the patient’s viewpoint and experience, and who, shares as well their concern about the ways a psychoanalytic perspective can be used to “see through” the patient in a manner that diminishes him or her, I can understand why they place such great importance on the “empathic-introspective” mode of investigation. But I find unfortunate their insistence, following Kohut, that psychoanalysis should be “defined and delimited” by this perspective (p. 27). This view, like other visions of the field that are grounded in restrictive definitions, such as the contention that psychoanalysis should be an exclusively hermeneutic discipline, impedes our ability to integrate psychoanalytic knowledge with advances in our understanding of brain function, infant development, or social and cultural influences on behavior and experience. One need not be a straw-man positivist to believe it is important to address and to integrate into our psychoanalytic understanding regularities that may be observable from a frame of reference other than the person’s own subjective frame of reference (e.g., observations of how certain experiences, desires or attitudes – however “subjective” or “internal” they may feel – may vary with the levels of certain hormones in the blood; or observations such as those deriving from the famous Asch (1956) experiments in social psychology, in which people’s subjective experience of something as straightforward as the perceived length of a line were influenced by the expressed judgments of other people about how long the line was). Such phenomena may ultimately be mediated and registered through the subjectivity of the individual behaving or experiencing, but adequate and comprehensive understanding of them seems to require a more “external” frame of reference as part of one’s conceptual repertoire.

Stolorow et al., discuss perceptively the problems and distortions introduced into psychoanalytic discourse by efforts to align discussions of psychological conflict with mechanistic metapsychological formulations, and I believe it is a useful project to see just how far we can get by consistently applying a subjective, phenomenological point of view. But to definitionally restrict psychoanalysis to a “pure psychology” (p. 88) in the fashion they propose is to beg important questions, to say “it’s not my problem,” with regard to questions that are problems with which psychology and psychoanalysis should be concerned. It is essential to be able to ask, for example – and to have a framework that acknowledges the legitimacy of asking -- how biological variables influence our subjectivity. If puberty and Prozac are declared to be outside the realm of psychoanalysis, then psychoanalysis itself becomes diminished. It is as if physicists were to declare either a wave view of light and matter or a particle view to be “pure physics” and to declare an interest in the other perspective as perhaps interesting but just not physics. It is in the very effort to hold and address the tension between these seemingly incompatible or disparate frames of reference that the stimulus for new knowledge largely lies. The same, I believe, holds for psychology and psychoanalysis.

Problematic in a different way—and, interestingly, inconsistent with the valuable and progressive contribution that is their overall point of view—is the incorporation into their analytic framework of the concepts of developmental deficit and developmental arrest. Oddly, this conceptual tack seems to be one place where they do go outside the introspective-empathic mode. Rather than highlighting why a particular desire or perception might make sense from the point of view of the patient’s experience, the concept of developmental arrest implicitly makes judgments that essentially dismiss the patient’s inclinations as infantile. In contrast to their overall perspective, which seeks to understand the frame of reference through which the person is making sense and meaning out of what is happening in his life right now (even if that frame of reference may be highly idiosyncratic and reflect conflicts and anxieties important to examine more closely), the developmental arrest perspective attributes the patient’s perception to a limitation, a deficit from childhood. This conceptualization is closer to the invalidating “distortion” view of transference that, like Gill and like the present author, Stolorow et al are generally at pains to critique.

The idea of developmental arrest also rests uneasily with intersubjectivity theory’s overall emphasis on contextualism. As Stolorow, Orange, and Attwood (1998) have put it, intersubjectivity theory “pictures personal experience as fluid, multidimensional, and exquisitely context-sensitive (p. 720).” None of these qualities seems applicable to a depiction of developmental arrest. If personal experience is fluid, it is not “stuck” at a particular arrested developmental level; if it is exquisitely context-sensitive, it is not just mired in the past or repetitively manifesting a fixed “early” structure from the past.

It is important to notice in this regard that the concept of developmental arrest is by no means essential to their point of view. Their other insights and formulations stand quite well without this concept. In part, I suspect, the retention of the developmental arrest concept is an unexamined holdover from the influence of Kohut on the origins of intersubjectivity theory. In part, however, it is likely also maintained by observations that may seem to be consistent with it. When the observer has the opportunity for intense immersion in the other’s experience that is afforded not only by the intersubjective approach but by almost all psychoanalytic practice, people often do seem to perceive and react to the events of their lives in ways that can look more suited to an earlier developmental period than to the “realities” of adulthood. But a still closer look reveals a larger structure to experience; a structure related to the systemic dimension that is another central feature of intersubjectivity theory. From that vantage point, one can see that these seemingly anomalous features, these seemingly “arrested” psychological structures, are indeed, just as intersubjectivity theory posits, “exquisitely context-sensitive.” What one sees is that the actions in the world that are generated by the person’s subjectivity create an intersubjective experience that is unique and idiosyncratic. Far from living in an “average expectable environment,” every person lives in a particular environment, especially with regard to the realm of affect and relations with others. If one follows the subtleties of how people elicit responses from others and how those responses in turn feed back to maintain or modify the subjective structures that initially elicited those responses – and especially if one does that from a vantage point that utilizes the insights both of psychoanalytic and systemic theorists and investigators – one sees over and over a proces of repetitive, self-perpetuating, and self-justifying interaction cycles, often in the form of vicious circles but also of a sort that maintains positive or benign experiences as well (Wachtel, 1987, 1993, 1997, 1999). Such a process – deeply contextual, mutual, and intersubjective – seems a far better foundation for an intersubective understanding of how old patterns persist than does the concept of developmental arrest.

These quibbles notwithstanding, however, what I most wish to convey is my appreciation for the contribution of these authors to a more humane and more sophisticated version of psychoanalytic thought. In the intersubjective experience of reading their words I have engaged in many implicit conversations from which my understanding has grown substantially. I hope that in their reading of this review, a similar process ensues.

References

Asch, S. (1956). Studies of independence and conformity. Psychological Monographs, 70, No 9, Whole No. 416.
Gill, M. M. (1984). Psychoanalysis and psychotherapy: A revision. International Review of Psycho-Analysis, 11, 161-179.
Kohut, H. (1959). Introspection, empathy, and psychoanalysis. Journal of the American Psychoanalytic Association, 7, 459-483.
Stolorow, R. D., Orange, D. M., & Atwood, G. E. (1998). Projective identification begone!: Commentary on paper by Susan H. Sands. Psychoanalytic Dialogues, 8, 719-725.
Wachtel, P. L. (1987). Action and insight. New York: Guilford.
Wachtel, P. L. (1993). Therapeutic communication: Knowing what to say when. New York:Guilford, 1993.
Wachtel, P. L. (1997). Psychoanalysis, behavior therapy, and the relational world. Washington, DC: American Psychological Association.
Wachtel, P. L. (1999). Race in the mind of American: Breaking the vicious circle between blacks and whites. New York: Routledge.
Weiss, J. & Sampson, H. (1986). The psychoanalytic process. New York: Guilford.
Wile, D. (1984). Kohut, Kernberg, and accusatory interpretations. Psychotherapy: Theory, Research and Practice, 21, 315-329.

Reviewer Note

Paul L. Wachtel. is CUNY Distinguished Professor in the doctoral programs in clinical psychology and social-personality psychology at City College and the CUNY Graduate Center. He is the author, among other books, of Therapeutic Communication: Knowing What to Say When (Guilford, 1993). Psychoanalysis, Behavior Therapy, and the Relational World (APA Books,1997); and Race in the Mind of America: Breaking the Vicious Circle between Blacks and Whites (Routledge, 1999).

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