Listening Perspectives in Psychotherapy (Book Review)

Author:  Lawrence Hedges
Publisher: Jason Aronson, 2003, 20th Anniversary Edition
Reviewed By: Stephen Johnson, Summer 2005, pp. 59-61

Why Listening Perspectives is a Classic

This brief essay is in response to an invitation from the editor to commemorate the 20-year anniversary publication of Listening Perspectives in Psychotherapy, by Lawrence E. Hedges. In my book, this book is a classic in psychotherapy and psychoanalysis. It deserves to be kept alive for a long, long time.

First, and most obviously, Listening Perspectives is a tour de force of scholarship and integration. It is a unifying review of the most important contributions of psychoanalysis, beginning with Freud and extending to our time. Hedges brings together these diverse and often complex ideas with two organizing themes which are intimately related. The first is developmental—a catalogue of the requirements, achievements, and possible arrests in development that help define personality and psychic structure. This developmental focus is presented in a relational frame such that the successes and failures of relational development are brought into bold relief. This developmental-relational perspective then leads directly to the understandings and interventions of the psychotherapy.

Hedges’s third organizing theme is his most innovative. That theme is given in the most unusual title: Listening Perspectives. When truly understood, this view of things produces a profound shift in consciousness. It leads to the use of knowledge, constructs, and theories to understand a reality far more complex than the knowledge, constructs or theories themselves. It halts the search for the “real” truth and opens the way to finding the most useful perspectives. It leads to flexibility in listening and responding. It shifts the focus from the knowledge to the person of the client and the person of the therapist. The knowledge is not lost; it is reformatted as a perspective from which to understand and act. And, the perspective that proves most useful for understanding and action can shift at any time. This orientation to perspective allows us to integrate or juxtapose or incorporate perspectives as they serve the larger purposes of understanding and action. The recognition of the mind’s unfortunate tendency to reify constructs opens greater potential for not making that fatal error—to keep the maps and not confuse them with the territory. This orientation to knowledge and its function is related to a number of interacting trends in science and culture—among these are theories of chaos and complexity, constructionism, and post-modernity.

In what follows, I intend to review the four basic listening perspectives proposed by Hedges and amplify on their developmental, relational, and post-modern aspects. For each developmental perspective, Hedges provides a broad review but relies on a key group of theorists and writers.

The first developmental perspective labeled “organizing” emphasizes the infant’s achievement of organizing sensory experience, contact, connection, and mutuality. In explicating this perspective Hedges relies mainly on Klein, Searles, Giovacchni and Freud’s early ideas on the reflex arc. In addition, he employs Franz Kafka’s fiction to illustrate the phenomenology of the person arrested in this earliest period.

One need only read a little of Kafka’s The Trial or The Castle to experience the frightening and numbing disorganization of one urgently trying to make sense of worlds that make no sense. A great deal of data on secure vs. insecure attachment supports the assertion that the earliest period of human life centers on “making sense” of human experience and requires an attentive, empathic, attuned caretaker capable of sensitive resonance and mutual cueing (e.g. see Siegel, 1999 for a review of this attachment research).

When this mutual organizing process has more or less failed, you see, hear, and feel some of the following: (1) More mechanical-like functioning in affect, language, behavior, posture, images, personal relations, self and other perceptions, etc. (2) Anxiety about and withdrawal from social contact, with an underlying longing for that perfectly soothing resonance and nurturance that was absent when most needed. (3) Guilt for being alive and having needs, which the caregivers could not provide; and guilt, too, for not being able to repair these caregivers so that they might be more human and give what a human infant needs. (4) A lack of organization in the early self-system can produce “striking behavior patterns of self-mutilation, hallucinatory creations, hypochondriacal complaints and exaggerated affect states” (p. 229).

The relational requirements of the “good enough” therapist derive from this developmental perspective:

The therapist, like the parent, must patiently wait until the person is momentarily oriented for contact. Contact is usually fleeting and, in essence non-verbal (though words and sounds may constitute the medium of contact). Then comes the smile, laugh or warm squeeze, which forces attention on (and reinforces?) the organizing and transformational contact…. The wise mother, just as the wise therapist, is alert and attentive but saves her energy for the moment that counts—the moment of orientation when the infant/patient can be met in his/her own extension (p. 229).

An equally important relational aspect of this perspective is the appreciation for and utilization of the therapist’s organizing capacities. This includes the therapist’s abilities to form a “therapeutic symbiosis” as well as his or her empathy (based on similarity) for a disorganized early self-system. Included, too, is an appreciation for a co-created intimacy or merger state that can be beneficial, blissful and nurturing for every human being. Once this state can be reliably achieved, the groundwork is set for an eventual differentiation. Much of Hedges’s subsequent work within this tradition has been devoted to further explicating the organizing perspective (Hedges, 1994a; 1994b; 2000).

The listening perspective approach to all of this demands a shift from “believing in” or “looking for” what is “really out there” (e.g. the schizoid personality disorder or the internalized bad object) to an appreciation for the value of useful constructs that help us to think, understand, listen, empathize, or act. Using the organizing perspective, we are urged to remember the organizing qualities and possible arrests of everyone—whatever other strengths or vulnerabilities they may present. Hedges mentions the likely presence of organizing issues in the deeper analysis of Narcissistic and Borderline disorders. I believe they are common in every serious personality disorder. But, the most important point here is that many perspectives can serve. They are constructs that structure, not realities that constrain. They are tools that usefully simplify a much more complex reality for our relatively simple thinking minds.

The earliest organizing of human connection and sensory experience leads to the establishment of symbiosis. The failure to establish a good enough symbiosis produces arrest in the organizing process. When, however, there is contamination of that symbiosis or when there is a failure in subsequent differentiation from it, one sees arrests in symbiosis. Hedges uses the label Borderline Personality Organization to characterize these difficulties and emphasizes the many ways in which we can experience a troubled merger attachment. He employs the constructs of a number of well-known analysts to exemplify the basic road map for symbiosis (primarily Mahler) and the varieties of potential arrests they can experience (primarily Kernberg, Masterson, Winnicott, and Klein). The concepts of splitting, incorporation, introjection, projective identification, false self, replication transference or “scenarios,” self and other representation and affective linking, dysregulation, and differentiation are used to build this listening perspective.

The resulting model is broad and complex but, as with the Organizing Personality, he offers a guiding unifying principle, which is particularly helpful to the practitioner. This is the emphasis on the patient’s need for the replication of one or more idiosyncratic symbiotic scenarios from which differentiation has not yet been accomplished. The emergence of these scenarios in therapy, and the often-incessant demands for their contemporary replication, is both diagnostic and prescriptive. In this book, as well as in a subsequent one on this structure (Hedges, 1992), there is exquisite attention to the need for the therapist to participate or co-create this replication. Therapists in supervision are often embarrassed to “confess” the extent to which they have accomplished this essential step because what is usually required is totally antithetical to neutrality and abstinence. A newer model of development, relational understanding, and treatment is necessary to comprehend the need for this sometimes unusual therapeutic stance. Hedges is very reassuring about this, yet not neglectful of the corresponding need for boundaries and sanity. Still, one who takes on a patient with this personality organization must be willing to bend—sometimes a lot! Knowing that this is necessary and knowing why it is necessary makes it far easier to do with appropriate limits.

And then incrementally, thankfully, the perspective changes to emphasize the latter phases of symbiosis—separation/individuation. Here, the patient needs to move on and the therapist needs to welcome, support, and sometimes nudge. Premature nudging is still the most common therapeutic error but fostering dependency is not unheard of.

This is the relational map—but the map is still a map. Hedges comments on the utility of behavior modification and social skills training for the Borderline patient. Similarly, he emphasizes the unique symbiotic preferences which we all have and the universal appeal of “Mommy and I are one.” In any therapy, or in any relationship, this listening perspective may be called for, and, at any time. Here is the chaos and the complexity. Hedges’s work makes us ready to shift, to understand, and to act—now in “organizing,” now in “merger” or now

In the third listening perspective, we orient to the next developmental achievement: a cohesive self and a smoothly regulated self-esteem. Hedges relies almost exclusively on Heinz Kohut to explicate this process. Kohut’s view is supremely developmental-relational, relying on the key role of the self-object to empathetically mirror the individual’s emerging real self. Also required is self-object repair of the inevitable disappointments and empathic failures that occur in life. When this basic process fails, one sees narcissistic pathology:

…self pathology is characterized by a flaw in the regulation of self-esteem which results from a poorly developed self. The chief complaints are usually vague and diffuse with the person feeling unable to derive joy from the pursuit of his ambitions or goals as well as a failure to develop talents satisfactorily (p. 57).

One often sees the other common narcissistic qualities: extreme sensitivity to disappointment and criticism, the split in self-esteem—grandiosity/worthlessness, relating to others as self-objects, a history of shaming and/or idealization, excessive self-involvement and entitlement, etc.

Once again, when this perspective is appropriate, the requirements of the therapist are the same as those of the original caretaker. However accomplished the adult patient may be, a person suffering narcissistic pathology is operating with the emotional maturity of a very little boy or girl and needs the very same thing that child needed. This is sometimes hard to remember when we experience the predictable irritation at being treated as an object (i.e. a self-object). This counter-transference reaction is, in itself, a good signal that this third listening perspective should be called upon for understanding and action.

Hedges is, once again, very helpful in suggesting to the therapist a single organizing principle for treatment. This is, first, the creation of an “empathic situation that will recreate the early self-object atmosphere.” Then, “the therapist tunes into the patient and waits for signs of his own empathic failures” (p. 60). It is largely the pain, but also the understanding and repair of this “optimally failing empathy” that leads to the “transmuting internalizations” required for the repair of the self (Kohut’s words in quotation). Kohut described this internalization process as one akin to mourning wherein the narcissistic person experiences the pain of the loss of the external self-object(s) and, in that crucible, the creation of internal abilities to self-soothe and self-regulate (see p. 61).

This listening perspective, like the others, tells you what to orient to, what to wait for, and what to do with that when it emerges. Is this oversimplified? Of course it is! Hedges, Kohut, and others have much more to say to fill out this listening perspective. Still, in the chaos and complexity of therapeutic interaction, it is extremely useful to have a navigational heading to which you can return at any time, and there, locate the ground.

In the fourth listening perspective, Hedges employs the classic psychoanalytic model for therapeutic understanding and action for neurotic functioning. The essence of this perspective involves attunement to internal emotional conflict. The desire for power and the fear of having it would be an example. The desire for revenge vs. the fear of retaliation or guilt for anticipated harm would be another.

These conflicts are often more or less unconscious, and neurotic symptoms are often compromise solutions to these conflicting desires, drives, or instincts. “The conflicts typically are conceived of between such things as impulses vs. defenses or Parent tapes vs. the Adult or the Child” (p.57). These conflicts also emerge in dreams, in resistance to free-association, and in transference both in and out of the consulting room, etc.

For life in general, and particularly in psychotherapy, these conflicts are usually brought from the past (i.e. they are genetic). The transference manifestations are then conceived of differently from those exhibited in the other three perspectives. The patient is not arrested in needing fulfillment of unmet needs—for connection, merger, or self-object resonance. And, the therapeutic task is not to restore the developmental flow to the next point of maturation. Rather, the patient is stuck in unconscious internal emotional conflict and in a dysfunctional, neurotic solution to it. From the classical point of view, the therapist’s job is done when all this is brought to consciousness.

Once again, Hedges is helpful to the practitioner in providing a review of the necessary therapeutic stance for this situation. That stance is essentially Freudian and oriented to (1) understanding the patient and bringing to ever-greater consciousness the conflict and the functions of the neurotic solution and (2) achieving this through the analysis of resistance and transference. In this process, the therapist’s role is to “limit his/her influence as much as possible” (p.41). Since the problem is viewed as internal to the patient, the therapist is not to bring in activity that will only interfere with that essential process.

Hedges is very faithful to Freud in this review, outlining all of this in the context of the Oedipal conflict from which this model was derived. But, both implicitly and explicitly, he suggests the broader therapeutic application of the conflict model.

In the Introduction to this current edition, Hedges writes:

Intersubjectively viewed, the four different relational frames or self and other Listening Perspectives, encourage mutual surrender…to a process in which different modes, styles, or patternings of internalized self and other possibilities are active at different moments in the ongoing therapeutic relationship—or perhaps predominate during different phases of the therapeutic work.

Put another way, even though an individual may be best understood, in general, using the organizing, merger, or self-object listening perspective, she may, at any moment, be better understood using another, including the conflict model. Simply put, the “Narcissist,” the “Borderline” the “Schizoid” can also be “neurotic.” And, maybe, the more differentiated and developmentally mature she gets, the more “neurotic” she will become. As self and other, as affects, as defenses become more differentiated and mature, the more relevant will be internal emotional conflict. Or, someone best understood as “neurotic” most of the time may dip into an earlier arrest, and an alternative listening perspective may then be most useful. Listening Perspectives has many gifts but this is its greatest, and this is the reason, more than any other, why it is a classic.

Hedges, L.E. (1992) Interpreting the countertransference. Northvale, NJ: Jason Aronson.

Hedges, L.E. (1994a) In search of the lost mother of infancy. Northvale, NJ: Jason Aronson.

Hedges, L.E. 1994b) Working the organizing experience: Transforming psychotic, schizoid and autistic states. Northvale, NJ. Jason Aronson.

Hedges, L.E. (2000) Terrifying transferences: Aftershocks of childhood trauma. Northvale, NJ. Jason Aronson.

Siegel, D. J. (1999) The developing mind: Toward a neurobiology of interpersonal experience. New York, NY. Guilford Press.

Stephen Johnson was a Professor of Psychology at the University of Oregon for eighteen years and subsequently, for four years, at Pacific Graduate School of Psychology. He is author of four books on character and psychotherapy: Characterological Transformation, Humanizing the Narcissistic Style, The Symbiotic Character, and Character Styles. Currently, he is in private practice of psychotherapy and therapist education based in San Francisco and Menlo Park, California.

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