Transcending the Self (Book Review)

Author:  Summers, Frank
Publisher:  Hillsdale: NJ: The Analytic Press, 1999
Reviewed By:  Susan Kavaler-Adler, Fall 2001, pp. 37-43

An Interview with Frank Summers

Frank Summers has brought object relations theory into a crystallized clinical focus in his two books: Object Relations Theory and Psychopathology (Analytic Press, 1994) and Transcending the Self (Analytic Press, 1999). In Object Relations Theory and Psychopathology, Dr. Summers defined his integration of object relations thinking by defining, critiquing, and contrasting an impressive array of psychoanalytic theories. Dr. Summers has an appreciation for each theory, but is clear in his view of each theory’s shortcomings when applied to clinical work. In line with his deep conviction that theory is only useful if it helps people receive psychotherapeutic treatment that resolves developmental arrests and promotes psychic change towards authentic self development, Dr. Summers approaches his discussions of strengths and weaknesses of each psychoanalytic theory in its clinical application. In doing so, he highlights contrasts between ego psychology and object relations theory, between relational theory and object relations theory, and between self psychology and object relations theory. These contrasts lead to his own formulation of theory at the end of Object Relations Theory and Psychopathology, which becomes the entry to his second book. Transcending the Self has rich clinical illustrations of an evolving theory. In the following interview, part of a mutual interview between Dr. Summers and myself, I engage Dr. Summers as an author to explicate both his metapsychology and his clinical theory.

Dr. Kavaler-Adler: Dr. Summers, in both your books you discuss an object relations approach to helping patients relinquish pathological self and object constellations with the internal world so as to move developmentally forward into more mutual modes of relating that can encourage self development through new modes of internalization. Is there an underlying philosophy of psychic health that lies behind your clinical theory?

Dr. Summers: The concept is Nietzschean: we must become who we are. I believe that the extent to which we experience meaning and fulfillment comes from how well we realize the potential self. I think Winnicott gave us the germ of a useful psychoanalytic concept of psychic health: the development of inborn potential in all its aspects. The extent to which our authentic feelings and capacities become articulated in our ways of being and relating is the degree of our mental health. When our potential self is arrested, we will find some means of expressing it, and such veiled expression are symptoms.

Dr. Kavaler-Adler: How would you define the “self?”

Dr. Summers: The “self” is our articulation of our potential through authentic ways of being and relating. The authentic self will naturally promote activity, creativity and self agency in its expression. This contrasts with the false and pathological selves in character disorder patients, which inhibit all of these potentials. In the character disorders, or any pathological state, the potential self is buried underneath protective defenses so that self formation is arrested.

Dr. Kavaler-Adler: Would you call this negative early self-other constellations seen in character disorders and/or in neurotic patients, “internal saboteurs” or “internal antilibidinal egos” as Ronald Fairbairn did?

Dr. Summers: A good deal of my thinking is influenced by Fairbairn, particularly in relation to the pathological incorporations that seal patients off from contact with new healthy modes of relating with others, promoting schizoid splitting. Consequently pathological incorporations inhibit the formation of authentic ways of relating to others. I agree with Fairbairn that there is an attack against self-other contact, but terms such as “internal saboteurs” and “anti-libidinal ego” tend to be reifications.

D. W. Winnicott has also greatly influenced me. I have drawn on his theory of potential and transitional space to define an important aspect of clinical treatment, all of which is related to his theory of the true and false self, and to his theory of “The use of the object.” Winnicott, like myself, always saw the developmental use of the psychoanalyst as an “object” to be of primary importance in clinical treatments, where authentic self development was a primary goal.

I believe that psychoanalytic psychotherapists need to employ interpretation to dismantle old defensive modes of enactment that forestall self development. In addition, however, clinical experience has shown that one must go beyond interpretation to allowing a transitional space to form new and more vitally spontaneous self in order to facilitate development. The analyst needs to both engage the new self potential and provide a place for it. Ego psychologists have neglected to account for the whole area of new self development in their view of treatment. I agree with ego psychologists that interpretation is an essential clinical tool to dissolve defenses that perpetuate pathological functioning, but I believe the analyst must help the patient articulate the buried self potential that lies beneath the defenses, and I do not think ego psychology accounts for this aspect of therapeutic action. I sharply differ with those self psychologists who throw out the use of interpretation (but this is not true of all of them) as well as with those relational theorist who are headed in that direction because without interpretation any new relationship is in danger of remaining superficial, out of contact with the patient’s core. I part ways with the ego psychologists when they neglect to facilitate new and future oriented self development. Such self development occurs within the treatment situation, where a Winnicottian “holding environment” can provide an evolution of transitional or “potential space” for the arrested self to articulate itself, as I said in the last chapter of Transcending the Self.

Dr. Kavaler-Adler: Could you elaborate on your disagreement with the ego psychologists related to the necessary but not sufficient use of interpretation?

Dr. Summers: Well first of all, I do not agree with the ego psychologists that all you have to do is interpret and the changes will come. Sometimes interpretations are mutative and sometimes not. Frequently interpretations are followed by a patient saying, “I understand what you’re saying, but I don’t know what to do with it.” Then nothing changes.

Dr. Kavaler-Adler: Don’t you think this kind of intellectualized response to a interpretations can be worked with, for example in terms of trying to understand, as the Kleinians do, what core anxieties lie under such an intellectual response? Would you attempt, as the Kleinians do, to use interpretation to help the patient symbolize the underlying anxiety that the patient cannot put into words? In other words, would you as an analyst process the patient’s split off experience, which may be enacted on you on a preverbal level through projective-identifications?

Dr. Summers: Such a response is not necessarily intellectualized. Even after the patient has a deep, affectively meaningful insight, she may not be able to change because the insight has not helped create new ways of being and relating. I find the Kleinians, particularly the modern Kleinians, like Betty Joseph (who uses Bion’s idea of the analyst being a container to process the patient’s pre-verbal or enacted beta elements), to be very useful. However, I find the Kleinian approach most useful in relation to the borderline patient, where I do believe it is absolutely necessary to process the projective-identifications of the patient. But remember: such processing is not interpretation. Sometimes, one has to be a container who silently processes the split off enactments of the patient, allowing for a transitional space, where the rage of the patient can be expressed repeatedly, as Winnicott talks about in “The Use of the Object or Relating Through Identifications.” The therapeutic action of this processing lies in the patient’s reaching the analyst’s subjectivity, which begins the movement from object relating to object usage. None of this is interpretive. Labeling self-object patterns is important, but the mutative factor is the space this process opens for the articulation of dormant potential. I do believe that aggression is very important, particularly in the case of developmental arrest in the character disorders. However I’m more partial to Winnicott than to Klein in relation to the therapeutic action needed in response to the repeated expression of this aggression, particularly when it is the raw, primitive and inchoate aggression of the protosymbolic form that has no differentiated self to object message, but rather is part of an instinctual move out of psychic isolation and into reality and separation. Such aggression needs to be survived, and its purpose recognized.

Dr. Kavaler-Adler: So you believe in Winnicott’s concept of object survival, as opposed to interpretation that might too soon bring the experience of the aggression to a symbolic level, risking more intellectualized false self development? You believe that the analyst must tolerate the expression of aggression related to Winnicott’s preoedipal “unthinkable anxieties” in those without a separate and individuated self. In this case, tolerance implies survival in the sense of not retaliating through interpretations that will be taken by patients on that level of trauma as annihilating accusations or attacks, since such patients are not operating on a symbolic level when they regress into such enactments of rage. In other words, you believe, as did Winnicott, that an analyst must allow themselves to be “killed off,” particularly by “false self patients,” in order to survive as an external object, beyond the fantasy range of “omnipotent control” of the patient? You believe in the midst of such primitive rage, which James Masterson has referred to as part of an “abandonment depression,” and Winnicott has linked to “unthinkable anxieties,” given that the self is threatened with extinction that the analyst needs to survive by refraining from emotional abandonment and from retaliation? Do you believe in object survival, as opposed to interpretation, when the patient projects retaliation into the analyst as the analyst is interpreting, even if the analyst is not counter transferentially aggressive, since the patient’s developmental limitation, based on early trauma, doesn’t allow the patient to take in the symbolic message of the interpretation?

Dr. Summers: Yes, up until the last clause of your question. The reason the patient cannot use an interpretation to change is not due to the developmental level of the patient, but because words cannot effect changes in the self. Patients do take in the symbolic message, but they do not know what to do with it because the message cannot to help the arrested self unfold. Nonetheless, to get to the point where object survival can happen and transitional space for new self evolution can emerge. The clinician must use all the arts of interpretation that we have been taught. The old false and pathological self can only be dismantled through the patient’s awareness of how his/her pathological self/object constellations operate. No patient can relinquish such constellations without the awareness of how these constellations operate in the therapeutic relationship and in the transference, and such awareness necessitates the use of interpretation. You cannot build a new and healthier true self through defensive structures. The defenses must be dismantled through the awareness that comes with incisive, repetitive and differentiating interpretations. Without awareness of the defenses the patient cannot choose to face the fears of relinquishing the old defensive constellations that are attached to the original parents and to their pathological parts and enactments upon the initial child self, as has been stated so well by Fairbairn. Without relinquishment there is not potential space for authentic self to then evolve. Only understanding how the defenses operate in the present, and particularly in the clinical situation, can bring such awareness.

The relational theorists are dangerously close to swearing off interpretations and this is weakening their position considerably. The relational people speak of offering the patient a new relationship without a clinical and developmental theory behind it.

Dr. Kavaler-Adler: I guess the incompleteness of the relational theorists’ view is inevitable once they dispute our most basic understanding of psychic structure and of the internal world of latent and potential psychic fantasy. It’s hardly an adequate substitute for learning about psychic structure and its relationship to development, and about the internal world and psychic fantasy to speak about a transitional space in an interpersonal world that reflects the unconscious in all its manifestations, especially if they’re simultaneously speaking about transitional space as an open space for the new self to emerge. But besides the movement towards disregarding interpretation and all our traditional concepts of defenses, are there any other difficulties you have with the relational theorists?

Dr. Summers: Well yes. The relational theorists do not seem to make any distinction between a healthy and authentic self and a self that just does new things in response to a novel relationship with an analyst. If they do in practice, they don’t in their theory, a disjunction I often find in their writing. It is not enough to provide a new relationship and hope that something new will develop in the patient’s behavior behavior that will reflect something better in the psyche. Also, relational analysts often talk in terms of a revolution to a “two person” model in which all material must be looked at as “co-created” between patient and therapist. Sometimes this is referred to as a change in the unit of psychoanalysis to the “relational field.” Such a posture not only limits the analyst considerably, it is fundamentally impossible. When relational theorists discuss cases, they immediately abandon this model because they have to in order to be responsive to the patient. Once they try to understand the patient’s self, they have abandoned their revolution.

Dr. Kavaler-Adler: But getting back to my point, something new is not necessarily something better. In other words, there is no room for experience in the moment to create the new if the person is sealed off in a Fairbairnian closed system. In this case, the patient would be residing in an echo chamber of old attachment patterns, operating dynamically as if the original objects were perpetually enacting sadomasochistic submissions and anybody outside this closed system, existing in the external world, doesn’t exist or exits only through the externalization and projection of the internal pathological constellations onto the outside objects.

Dr. Summers: So without dismantling the constellations of old bad object constellations, operating as defensive and warded off operations, there is no new encounter with an analyst or with any other external object. If an analyst wasn’t required for interpretation, as well as containing, which involves an active processing of the patient’s enactments, any new object could effect cure. The relational thinkers really are in danger of falling into this trap. If you follow their belief that all that’s needed is a new and hopefully healthier relationship that offers new modes of relating, you are left with the view that a friend or spouse will do. Who needs an analyst? If this were true, my wife could cure me just by relating to me. This is far from the truth as we all know. Yet, when the relational theorists throw out defense interpretations, along with throwing out any understanding of psychic structure as related to different levels of self formation through separation, resolution of psychic conflict and self authenticity, they are left with the view that mere novelty from an object outside the patient’s pathological system. Now I don’t believe any relational analysts really believe this, but I don’t see how they can avoid this conclusion given their theory of therapeutic action. Although some speak of the symbolic function of the analyst, they don’t speak of this in relation to defense interpretation that is based on an understanding of psychic structure and character disorder structure.

One needs a concept of authenticity, of the true self, whether one calls it a “nuclear program” á la Kohut or a personal idiom á la Bollas, to distinguish between the “merely new” from “new and healthy.”

Dr. Kavaler-Adler: What about self psychologists?

Dr. Summers: Well, I respect many contributions of the self psychologists, as I have stated in my books, and the focus on the relationship between self and object as the main concern of treatment is one I share with them, but there are several problems as well as contributions stemming from their approach.

First of all, even more than the relational theorists, some self psychologists swear off interpretation. As I have stated, such a view of treatment lacks any effective means to true psychic change. Some patients have primitive defenses, like splitting, projective-identification, primitive idealization and omnipotence, etc., but all these defenses eventually require interpretation so the patient knows how they are sabotaging themselves in a repeated basis. Early phases of mirroring, holding, or containing may be required with patients who have severe narcissistic disorders, but the narcissistic issues based on profound psychic clinging to old attachment modes, on which primitive and false self has been based, must be addressed by interpretation.

Secondly, self psychologists tend to view the self as a passive recipient in both development and therapy. They want the therapist to be too attuned to the patient, in my opinion. To be attuned means that there is no transitional, analytic, or potential space between the analyst and patient in which self development can take place. Too much attunement and too little transitional space does not allow for the active creation of self and what Winnicott has described as essential to true self development. To speak of a self rupture, displaced from the past to the present, as if it is the result of an “empathic failure” in the analyst, where all activity is seen in an externalized form as the other’s “fault” related to the patient’s passive reactive injury preserves the patient’s regressive “innocence.” Kohut promoted this view, which most self psychologists follow, although differences among self psychologists is proliferating now. Winnicott and Kohut have contrasting views of the self. Winnicott speaks along the lines of active imagination, creation and the spontaneous gesture while Kohut emphasized “transmuting internalization,” a passive process.

Dr. Kavaler-Adler: Some of what you speak about reminds me of James Masterson’s clinical theory, which grapples with a forestalled self-activation process in character disorders. This view requires the reliving of the original trauma’s pain to free the self to self activate, and involves a developmental mourning process related to a whole abandonment depression. No external response from the analyst, in itself, can accomplish this. The patient has to go through the intense frustration and pain of initiating self activation to begin to remember, and thus mourn the past parental opposition to self activation in the patient as a child.

But what would you cite as a positive contribution of the self psychologists?

Dr. Summers: Well their overall view of the self as the main psychic focus for clinical treatment is one I believe in and share. I see an object relations understanding of development to be one in which the evolution of the self is the goal of object relating, object usage, and object internalization. Also, the concept of the “nuclear program of self” is very useful for understanding health and pathology. Furthermore, self psychologists have some awareness of the role of disintegration anxiety in the recalcitrance of patterns. Third, self psychologists grasp the importance of the parent’s and analyst’s seeing who the patient is. One of the critical parental functions is to make the child visible to himself, and Kohut saw this in development and in analysis between analyst and patient. Finally, the self psychologists have shown the importance of the analyst’s responsiveness to the patient’s mental states.

Dr. Kavaler-Adler: Some say Kohut actually plagiarized Winnicott and Fairbairn because he never gave them or anybody else any credit for their ideas. Kohut actually lifted whole phrases from Michael Balint in the Basic Fault. Perhaps Kohut feared annihilation if he were to acknowledge anyone else.

Dr. Summers: Nevertheless, Kohut did speak of the vulnerability to self fragmentation in many patients and this leads into an awareness of the threat that I speak of as “annihilation anxiety,” which I see as fundamental to the recalcitrance of pathological patterns.

Dr. Kavaler-Adler: Winnicott first spoke of annihilation anxiety as the “unthinkable anxieties.”

Dr. Summers: Yes.

Dr. Kavaler-Adler: Currently, Dr. Marvin Hurvich has written extensively about annihilation anxiety, from his Freudian and Kleinian perspectives.

Dr. Summers: Yes, Winnicott’s theories on the “unthinkable anxieties” have been influencing us all as we struggle with failures in the use of words and interpretations to promote change in character disorder patients and even in neurotics who fear loss of their familiar identities.

When I spoke of the diminishing returns from interpretations as patients exclaim: “I understand what you’re saying but it doesn’t help me,” I was speaking of the manifest patient behavior that I believe cannot be addressed with interpretation alone. What I’ve found clinically, as I describe in Transcending the Self, is that words fail when the patient’s terrors are at the preverbal level where the preverbal trauma occurred, at the point of the sealed off core self object as Fairbairn would describe it, or at the point of the “unthought known” as Winnicott would call it.

Dr. Kavaler-Adler: To relinquish old internal object relationships at this point in treatment, to join the analyst in new relating in the transitional space is at first too terrifying for those with trauma in the early years of primal self development.

Dr. Summers: Right. The risk is too great because relinquishing the old relations, no matter how self sabotaging and no matter how painful in their repetition, threatens loss of self, not just loss of a love object. A total loss of identity threatens. A neurotic also fears loss of self and resists change, but a character disorders patient fears annihilation.

Dr. Kavaler-Adler: I would call it “terror.”

Dr. Summers: Yes, the character disorder patient is terrified of total self loss, beyond even self fragmentation, and certainly beyond the mere loss of the familiar. Fairbairn was the first to speak about relinquishing the bad object, which is the original negative parental object as a trial of losing the self, not just losing love or an entire object and its relationship. Since the self is still merged in with the early object in the split off world of the character disorder patient to let go of relating to the analyst and everybody else as though they were the old object, threatens total loss of a sense of self. The patient is confronted with feeling all kinds of archaic disorganization, emptiness, void, rage and depersonalization and dissociation in reaction to not feeling who he/she is.

Dr. Kavaler-Adler: Emily Dickinson’s poetry captures this state of depersonalization at the point of such threat. Dickinson’s best poetry was written at the time of annihilation anxiety terror and at the point of depersonalization ad dissociation. Unfortunately, since she didn’t have an analyst to see her through it, and she was forced to regress into a rigid schizoid defense organization, eventually her creativity dried up-as I speak of in my book

Dr. Summers: There needs to be an analyst to `catch’ the patient,” when the patient risks relinquishing the old object ties and faces the psychic perils of annihilation anxiety because such a state can be successfully traversed with another. This is Winnicott’s distinction between withdrawal and regression; the analyst’s job is to turn withdrawal into regression. Because Emily Dickinson did not have anyone to do this for her, she was left stuck in a state of schizoid withdrawal. In analysis we have our presence as analysts, a holding environment that helps the patient to shift potential withdrawal into regression, creating the possibility of a new beginning.

Dr. Kavaler-Adler: Do you speak about the analyst catching the patient as Winnicott and Ogden (1986) speak of the infant being caught by the external mother when the internal psychic fantasy mother is surrender?

Dr. Summers: Yes.

Dr. Kavaler-Adler: What other holding functions does the analyst provide that extends the analyst’s role beyond that of interpreter?

Dr. Summers: I see the role of the analyst combining an interpreting function with holding and containing functions. One important aspect of the holding is the analyst’s ability to sense the patient’s true self potentials even before the patient can. When the patient well understands certain patterns, but cannot change them, I believe the analyst opens up a transitional space in which the patient can experiment with new ways of being and relating. The analyst’s task is to hold the situation while the patient creates new modes of becoming what was only potential.

Dr. Kavaler-Adler: Do you mean that she/he would anticipate the patient’s self realization while it is still in potential form and as yet unknown to the patient?

Dr. Summers: Yes. I believe as Bollas does that the patient has a personal idiom, with an innate origin, that determines the potential of any one individual. The patient may have no, or minimal awareness of the potential. So, the analyst must see it before the patient can, but the analyst’s vision must come from what we see in the patient. Loewald saw this dialectic: we are always one step “behind” because the patient’s material leads us, but also one step ahead because we see potential in this material that the patient cannot see.

Dr. Kavaler-Adler: Is the idiom like an innate blueprint that can unfold with facilitation of the environment as in Winnicott’s concept of a facilitating environment, which allows the developmental journey to advance in any one individual?

Dr. Summers: Yes. The idiom suggests a potential direction for the self to develop but that direction needs to find fulfillment through the responsiveness of the caretaker in childhood and through the responsiveness of the analyst in a reparative object relations analysis. If that responsiveness is lacking childhood and if the parent is retaliatory, withholding, attacking or abusive, then the self idiom will remain as a potential that is arrested and inhibited. The intense and traumatic frustration around the arrest of this self potential will necessarily lead to a form of hostile aggression that my look like the impulses of a drive, but which I see as affect states related to developmental trauma. The appearance of aggression as impulse I see as secondary to another issue, such as injury to the self or the inhibition of assertiveness. Whatever the particular issue, the impulsive aggression reflects an arrest of the self that has become intolerable.

Dr. Kavaler-Adler: So you do not see aggression as a drive. You relate what is normally thought of in the psychoanalytic literature as aggressive drive impulses to affect states.

Dr. Summers: Yes. I see aggression in children as a natural response to frustration, which has a natural cessation when the frustration ends, as Parens (1979) has shown. I see aggression as a healthy force, as Winnicott did, as an opening up true self expression. In those traumatized, where the natural developmental idiom of the self has been arrested, aggression as an individuating force is malignantly transformed into explosiveness.

Dr. Kavaler-Adler: But Winnicott did see aggression as a drive, even though he saw it as having developmental functions related to self expression, particularly in those traumatized.

Dr. Summers: Winnicott believed aggression was inborn, but he did not see hostility or explosiveness as inborn. Remember, Winnicott believed the erotic and the aggressive are naturally fused, so that not only is the erotic aggressive, but also aggression is naturally joyful. In his words “the infant must get a kick out of kicking.” He regarded hostile outbursts and explosiveness as reactions to frustration, rather than inborn drives.

Dr. Kavaler-Adler : How do you see aggression as providing developmental functions?

Dr. Summers: In development, aggression helps the infant define boundaries for the self, separate from early objects, move from fantasy to reality. Aggression also helps the child to master the world and develop ambition. In treatment, I see the expression of hostile aggression in those traumatized as a means of setting a boundary with the analyst when the borderline patient is terrified of succumbing to his/her own merger wishes. The borderline patient is terrified of self-annihilation or self dissolution in fusing into the other with whom one wishes to merge. I also see the killing off of the analyst again and again as Winnicott first spoke of, and later spoken of by Jessica Benjamin, as a testing for safety in the environment. If the character disorder patient can release the intense and hostile affect of aggression that has been inhibited through repression an dissociation and feel safe in an atmosphere, where the analyst hears the message behind the aggression, while refraining from retaliation, the external object, represented by the analyst, can be psychically connected to. The analyst becomes real and three-dimensional. The patient has moved from object relating to object usage, or, in other terms, from the part object level to the whole object level, or, as Benjamin would say, to a new level of intersubjectivity.

Dr. Kavaler-Adler: One of my analysands began to call me a master of negative transference, because I would listen to her aggressive attacks with interest and without retaliation. She couldn’t believe I could listen and even investigate the differentiated meanings that could come out of the aggressive attacks without retaliation, because her parents had always retaliated, her mother withdrawing and giving her the silent treatment. I could see how my non retaliation was crucial to allowing her to move from aggression to anger and more and more into feelings of sadness mixed with both loss and yearning. A full developmental mourning and grieving process could unfold as sadness was tolerated and depressive position concern could be felt for the analyst for the first time. Do you see aggression in developmental terms leading to mourning.

Dr. Summers: I see the need for mourning in relinquishing the old internal parental objects. The holding of aggression is one way this can happen, but only one. A merger relationship for patients who have a fragile self is another. For patients with what I call an inadequate self, affective responsiveness can accomplish this aim. Do not see the privileged role for aggression in the relinquishment of old objects, as some people do. I have had clinical experiences much like you describe, but I have also had patients for whom my acceptance of their love had the same result: the relinquishment of the old object.

Dr. Kavaler-Adler: You mention mourning in a few clinical cases in The Transcending of the Self , but you don’t seem to focus on it as of prime developmental significance as I do.

Dr. Summers: My focus has been elsewhere, as in providing psychic merger experiences with borderlines without collapsing the transitional space and succumbing to physical holding or physical merger. To provide psychic merger I allow fears of action in treatment that I see as potentially expressive of the true self as opposed to being mere acting out. I see the importance in all cases of relinquishing the old objects, but my focus tends to be on the loss of self that results and the attendant annihilation anxiety.

Dr. Kavaler-Adler: Are you referring to Michael Balint’s distinctions between benign and malignant regression?

Dr. Summers: Yes. Balint’s distinction is a useful way of defining the difference between retreat and a new beginning. It is the analyst’s task to transform a retreat into a new beginning. As Balint pointed out, this task requires responsiveness to the patient’s needs, not simply interpretation. I allowed one borderline patient to bring her kitten into a session and to have me play with it a little, or to lie down on a couch covered with a afghan. I held this situation until she was ready to emerge from it. Another patient called me frequently in a panic because she lost me and feared I lost her. The only way I could get her to re-connect was to lower my voice to a soft hum, a sound that immediately made her feel I was there and the anxiety disappeared. I did this over and over until she felt my presence within her. Then, and only then, could she embark on a new beginning.

Dr. Kavaler-Adler: I’m sorry we don’t have time for more. This has been very interesting.

Reviewer Note

Susan Kavaler-Adler is the Founding Director of the Object Relations Institute and the author of, The Compulsion to Create (Routledge, 1993) and The Creative Mystique (Routledge, 1996). Her third book, Mourning and Psychic Transformation will be published by Jason Aronson. Dr. Kavaler-Adler has been in private practice for 23 years and conducts writing, creative and mourning groups and workshops.

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