This essay explores the sometimes uncanny quality of unconscious experience and unconscious communication that often characterizes life in psychoanalytic relationships. As Ferenczi noted some 70 years ago, the psychoanalytic relationship may >significantly promote the development of subtler manifestations of receptivity.< Special qualities of unconscious receptivity and deep points of contact in the psychoanalytic relationship are explored, with reference to the history of psychoanalytic ideas (e.g., Freud, Ferenczi, Singer, Loewald, Symington) and to findings from other fields such as contemporary quantum science. Clinical vignettes are provided to illustrate such phenomena.
This essay elaborates on some of the ideas set forth in >It Takes One to Know One< in response to Peter Shabad's and Paul Williams's commentaries on that paper. In particular, the distinctions between process and mental structure and between unconscious process and relationship are explored and developed. An attempt is made to clarify some of the similarities and differences between British object relations perspectives and some U.S. relational ideas as they apply to these distinctions and their relevance to clinical technique.
The current emphasis on identifying empirically supported treatments (ESTs) can distort psychotherapy research by emphasizing the investigation of treatment in an atypical context, with atypical patients, in a contrived treatment contract. An alternative to comparing the efficacy of different types of therapeutic techniques for treating focal symptoms is to seek to identify the factors that facilitate therapeutic change in various types of therapeutic intervention. The emphasis on identifying ESTs also has the potential for distorting clinical training and limiting clinicians' ability to develop the skills necessary for becoming effective therapists.
I offer the view that the symptom picture found in most patients with eating disorders, as well as in the symptomatology of many other so-called difficult patients, is the end result of prolonged necessity in infancy to control traumatic dysregulation of affect. I propose that the central issue for an eating-disordered patient is that she is at the mercy of her own physiologic and affective states because she lacks an experience of human relatedness and its potential for reparation that mediates self-regulation. She is enslaved by her felt inability to contain desire as a regulatable affect and is thus unable to hold desire long enough to make choices without the loss of the thing not chosen leading to a dread of self-annihilation. Trauma compromises trust in the reparability of relationship, and for symptoms to be surrendered, trust in reparability must be simultaneously restored. Because felt desire is the mortal enemy of an eating-disordered patient, this fact becomes a central dynamic in the analytic field, leading analyst and patient into a struggle over who shall hold the desire and whether the issue of control over food is allowed to become a subject for negotiation. I discuss the inevitability of the analyst's own dissociative reactions in response to the patient's internal war over desire and control, and the different types of interpersonal enactments into which an analyst is drawn. In this tension, as illustrated through clinical vignettes, analyst and patient slip in and out of a constantly shifting array of self-states and thereby have an opportunity to coconstruct a transitional reality within which the patient's impaired faith in the reliability of human relatedness can be restored, and eating can become linked to appetite rather than to self-protection.