Author: Fosha, Diana
Publisher: New York, NY: Basic Books, 2002
Reviewed By: James Grotstein, Fall 2002, pp. 23-25
When I first sat down to read Diana Fosha’s work, I had misgivings. I am in the process of writing my own textbook on psychoanalytic technique and, in the course of doing so, I had occasion to consult a vast array of articles and texts on the subject. What struck me in reading them was that, in the main, they all referred to the theories that supported their technique but did not spell out a protocol for how one should perform that technique. I joked with some of my colleagues that my work would be a “how to” text with algorithms, hypertexts, and “press return.” It was with great relief, consequently, when I got into the substance of Dr. Fosha’s text. She clearly and meticulously defines her protocol for technique in a way that leaves little question. Moreover, one would be hard put to find such an in-depth treatise on affect, which is the principal focus of her technique. She goes to great lengths to define and outline her categories. If anything, her work is over-rich in meticulously selected material and oftentimes becomes overwhelming to read. Yet, paradoxically, I found her book a page-turner and looked forward to taking it up again soon after I had put it down.
My other initial misgivings about reading Dr. Fosha’s work were due to my prejudice, as I came later to evaluate it, that she represented yet a new, albeit vibrant, heresy in psychotherapy, one that was knocking on the door of respectability for validation. I believed that we came from different parts of the forest. I am a psychoanalyst. She is a short-term psychotherapist. What does she have to say that would interest an old codger like me who has been practicing psychoanalysis for over forty years and under many flags: orthodox and classical psychoanalysis, object relations Winnicott and particularly Fairbairn, and now Klein, and Bion with a detour now and then through self psychology and intersubjectivity. I was surprised to learn what she did have to offer me. First of all, I was pleased that, even though Dr. Fosha seems to have sprung from the schools of brief psychotherapy (and she details their history beautifully), she is essentially psychoanalytically-oriented and appears, at least to me, to be a revolutionary from within its borders. I was immensely impressed by the vigor, tone, and direction of her thrust. She wants therapists to work harder and to be more actively engaged with themselves as well as with their patients. I found her decrying many time-honored psychoanalytic practices that I myself had earmarked to attack in my own work.
I have only two criticisms of her work, and they are minor. First, and I diligently searched for the answer-I may have missed it-what is the time limitation for her form of brief psychotherapy and how is it arrived at? Is it different for different patients? The second criticism was her psychoanalytic references were to self psychology, intersubjectivity, relationism, and adaptation. There was a single reference to Guntrip, which should have gone to Fairbairn (about the fear that one’s love is bad), and there were references to Winnicott, but none to Klein and Bion. I believe that she would be quite surprised if she were to observe modern London or even Los Angeles Kleinian/Bionians at work with their patients in the here-and-now in terms of the “emotional turbulence” that transpires in both the analyst and analysand in the analytic session and how the former is quick to assess his/her own emotional state to comprehend what might be going on with the analysand. Kleinian/Bionians tend to be vibrant, active, interpret transference from the first session, and readily interpret positive transference and positive aspects of the analysand in order to quarantine the more destructive internal forces from the positive ones. Furthermore, they are quick to interpret harsh superegos.
Utmostly, and this is a major difference between the way I work as a Kleinian/Bionian, we put much more emphasis on unconscious phantasy and on the unconscious altogether, not so much the dynamic unconscious that had been originally conscious, but on the unrepressed unconscious whence springs the primitive defenses such as splitting of the objects and the ego and projective identification. Put another way, we assume that the analysand, as infant and ongoingly, first imaginatively creates his/her world (in the paranoid-schizoid position) before (s)he had the opportunity to discover the history of the real events that actually happened to them (in the depressive position when they become separate from the object).
Space limitations prevent my doing due justice in reviewing this excellent monumental text. It deserves a major paper. Let me just touch on some of the salient points in it.
Dr. Fosha is right when she emphasizes the importance of affects over unconscious drives. If Freud were alive today, I am sure he would agree. Bion (1962) had already corrected that notion when he conceived of the “L” (love), “H” (hate), and “K” (linkages) between self and object. In other words, he brought Freud’s drives into an emotional epistemology. We can only know (“K”) an object by how we feel (“L” and/or “H”) about them. Furthermore, affects are linked with dreaming and unconscious phantasying, all three of which are involved in making life personal and meaningful. What Dr. Fosha brings to the equation, however, is something more: the diligent micro-searching for her patient’s affects and, when she finds them, she elaborates their significance by, in effect, projecting them on a big screen for careful and prolonged scrutiny. I felt that this aspect of her work was admirable and valid.
The premise Dr. Fosha works under is that affects are the central issue of our existence and that psychopathology indicates the degree to which the subject is out of touch with his/her emotions, i.e., not able to feel his/her emotions, the former being the expressed physically and the latter mentally. The task of psychotherapy is to facilitate the patient’s ability to unite these two affective partners. Her discussion of affect and its relationship to attachment was almost encyclopedic, highly useful, and necessary to support her thesis. She believes, as did Bion, that mental transformations (“learning from experience”) can only occur when subjects are able to know-and accept their feelings and therefore their emotions. The very acceptance of them allows something mysterious to happen, something like an expansion of one’s self and one’s sense of consciousness or awareness. We are never the same for having risked submitting to an experience and allowing ourselves to feel what our emotions have done with it.
I think that Dr. Fosha is quite right to call our attention to the obsolescence of the drive theory of classical analysis and how it must give way to an emphasis on affects. It is so obvious that we fear our emotions more than our drives-and that anger, hate, and rage belong more to the category of emotions than to drives. Matte-Blanco has helped us understand our anxiety about emotions. He sates that they are basically experienced in terms of infinite sets, in other words, without boundaries. As a consequence we could “drown,” “explode,” fragment, or become psychotic. We therapists see this, for instance, with borderline, drug-abusing, or depressive patients, who fear being overwhelmed by their emotions. Consequently, behind each “affect coward” lies a history of poor affect regulation in infancy and childhood. Prime caretakers must not only introduce infants to the names of their feelings and emotions; they must also help them to down-or up-regulate them. Moreover., the caretaker must model good self-affect-modulation for their infants. The literature has grown enormously on outcome studies for infants who were fated to depressed mothers.
Accelerated Experiential-Dynamic Psychotherapy, or AEDP seeks to render the patient affect-competent by persuading him with a variety of techniques to shed his/her defenses and experience his/her core self with its attendant core affects. In the process of achieving this goal the therapist, as mentioned earlier, “details” the emotions in the moment and seeks to compel the patient to enlarge upon them. Fosha emphasizes the importance of the therapist’s responsiveness to the patient as latter begins to shed his/her armor and begin to right him/herself with affective directness and candor. One of her most defining statements was that psychopathology was the product of a compromised capacity to process affect. I believe that she is absolutely right. It was Bion (1962,, 1965, 1970) who believed that psychopathology was due to inadequate dream processing of affects because of the history of a defective parental container. It was a pleasure to see such congruence about the subject of affect from different parts of the forest of therapy. Fosha also emphasizes the history of shame and aloneness, defensive affective events that result from early dissociation due to affective neglect and/or poor bonding and attachment. If we watch carefully, we can detect traces of this in therapy sessions of adults.
She is critical, and rightly so, of the traditional silences of classical analysts (this is not true of Kleinian/Bionians), but I think it would help to say a word about its rationale. Freud believed that psychoanalysis could not cure a psychoneurosis, only a transference neurosis. Thus, a technique of silence emerged to allow the unconscious to come to the surface without the analyst interfering. In the beginning the analyst only interprets negative transference when it becomes a resistance. Utmostly, the rationale for the silence was to allow for this transformation from a psychoneurosis to a transference neurosis, but there is another point. The rules for psychoanalytic technique are virtually the same for dramatic acting-staying loyal to the role. It was believed that if the analyst and analysand remained loyal to the frame and their respective roles, then the unconscious past would dramatically come to the surface. In other words, psychoanalysis is disguised psychodrama and eschews intellectualizations as much as Dr. Fosha. Intellectualizations are more common in psychotherapy because the therapist and patient tend to focus more on manifest content and do not have such ready access, as a rule, to the living drama of the transference.
Now we get to the name and protocol of Dr. Fosha’s technique,” Accelerated Experiential-Dynamic Psychotherapy,” an affective model of change. But why “accelerated.” No sooner did I think that than I asked, “Why not accelerated therapy? I gather from Dr. Fosha that one of the rationales for an accelerated approach has to do with her provenance in short-term therapy theory-that the therapist must approach the patient frontally (not necessarily confront) but keep up the tension that inheres in the interpersonal immediacy between therapist and patient. To put it another way, I wonder if the traditional long-term therapies do not allow the patient too much of an opportunity to withdraw or detour into a defensive morass, thereby leaving them in a state of affect-neglect by default. I experience Dr. Fosha as a “prizefighter of intimacy” who rushes in to the emotional fray with her patients and holds them to the moment, trenchantly saying, “You can run, but you can’t hide.” It is a matter of taking the responsibility to remind the patient of his/her option to be present and accounted for in the moment-by-moment exchanges-without let up till the end of the session. It truly sounds like an emotional workout-and it sounds real. Having read her on this notion of acceleration, I am now all the more pondering how we psychoanalysts do treatment. In retrospect it seems more polite, casual, indirect, timeless. Is it less or more or just as effective? I don’t yet know the answer, but the question has to be asked. There is another rationale for acceleration now that I think of it. Emotions are immediate as well as intense. They come and go with unusual rapidity. It seems only reasonable to attempt to intercept with commensurate speed. What I am gleaning from Dr. Fosha’s approach is her attempt to match symmetrically with the relational affect traffic that transpires between her and her patient. In other words, the emotional traffic occurs in the context of an attachment relationship, a powerful occurrence that Bion termed “emotional turbulence.”
Dr. Fosha states, “So much pathology is the result of anxiety and shame and aloneness...Traditional psychoanalysis is very good at tracking the re-creation of childhood experiences in everyday adult life and in the transference. This is an important activity, particularly in understanding the nature of the genesis of defenses. In the affect model of change, however, the focus is on unlocking affect, giving the patient the chance to ride the deep river of affect and create new experiences...” (pp.4-5). I quite agree with her about the etiological importance of anxiety, shame, and aloneness. And I agree with her about the value of the aims of the affective model. It is her characterization of psychoanalysis, once again, that I should like to expand upon. It may be Dr. Fosha lives and practices in New York where the practice of psychoanalysis has traditionally been conservative-to-orthodox, i.e., behind the times, with the notable exception of the relational and object-relational schools. I agree with her objections to the practice of such traditional techniques as defense analysis and reconstruction. Kleinian/Bionians consider transference to be now not then. Furthermore, analysis of defenses all too often makes the patient all the more defended. Melanie Klein, from the very beginning of her career, analyzed anxiety first because of her realization that anxiety was always the cause of the defenses. One sees her doing this consistently in her Narrative of a Child Analysis (1960). Bion’s (1962) addition of his concept of “container/contained” and “transformations” from “O” (raw unmentalized emotional experience) to “K” (knowledge [feelings] about the emotions set the stage for modern Kleinian/Bionians to consider the entire session as immediate transference, i.e., in the here and now. I believe this trend typifies the work of many relational analysts as well.
Fosha also suggests that the therapist should use his/her own reflective-self function to bypass the patient’s relationship-avoidant defenses. The procedure she advises is that the therapist should disclose how the patient exists in her heart and mind and seeks to elicit how the patient feels about this disclosure. Surprisingly (to me), this technique seems to be quite effective. The patients generally seem surprised at the therapist’s disclosure and are reluctantly forced to acknowledge that this situation differs both from what they had expected and from past history. The technique sounds like seduction and coercion. One would have to study the therapeutic material from immediately following sessions to ascertain how it all went down, e.g., did a subtle split in the ego take place to accommodate the therapist’s enthusiasm. Naturally, this idea went against the grain of my own training, but we owe it to ourselves and our patient’s to be tentatively receptive to new ideas that might help. In that spirit I took it seriously and wondered if it were not a counterphobic psychodrama-like technique that effectively eluded the patient’s defenses and pulled him into relating to the therapist.
Fosha reveals a number of schemata to outline and highlight her therapeutic instrument. She posits two modes of being: self at best and self at worst and encases this polarity in three representational schemata: (a) a triangle of conflict (designating the dynamic intrapsychic perspective), (b) a self-other-emotional triangle (designating a relational perspective), and c) a triangle of comparisons (designating comparisons between past and present relationships).
There is more, much more of content, substance, and value in this text. It is a handbook that one would do well to have close by and peek in from time to time -but seriously because this is a serious innovative work by a serious innovator who deserves, not just our respect, but our time. I have already put some of her ideas to work and found that they worked well. I shall have to labor some more on presenting my positive feelings to the patient and also on coaxing him/her to deal with them. I haven’t dismissed the idea out of hand, however. I recommend this work to all psychotherapists and psychoanalysts. It is as compelling as it is challenging.