Self Creation, Frank Summers (2003)
Chapter 1: Potential Space
Given all this, “understanding the patient’s present” requires us to “grasp the patient’s experience of the future and how the present moment fits into it. The emptiness, passivity, and complacency we see in some many patients reflect their loss of future, an inability to live in the future-perfect tense, and this empty future issues in the bleakness of their present lives.”
When repeated interpretations are not leading to change, it could be that the patient is not able to “contemplate or implement a different future.” Consequently, the therapeutic relationship “must be transformed from an interpretive field to potential space so that the patient can use the relationship to create new ways of being and relating.”
It’s not enough to simply suggest that the future could be different. “The patient does not believe optimistic prognostications and often regards the clinician who makes them as Polyannaish at best or, at worst, as so self-absorbed as to be unable to understand the patient’s experience.”
In order for “the therapist’s belief in a different future to resonate with the patient, there must be an unarticulated, latent sense of futurity in the patient. Because only possibilities that preexist in the patient will be meaningful, what the therapist finds must already be present in the patient, in however nascent a form.”
Summers provides a case study of a patient named Helen who had no did not have hope in the future. Summers started to point out her lack of future. She understood what he meant, knowing that others had goals, but felt that that was for other people. “Had she ever considered that her life without goals meant that her life lacked meaning, and that without meaning depression [the symptom for which she sought treatment] might result? No, she had not thought of that.”
While Helen felt stuck, Summers “did not see her survival mentality as a static state, but as an adaptive construction required to endure a traumatic childhood.” He “sensed potential in her that she did not perceive.” When interpretations stopped making much difference, he shifted his strategy “from interpretation of past and present to a focus on finding disavowed indications of potential future.” He asked, “If you were not focused on survival, what then?” She responded by saying, “Of course, if I had the opportunity, I would love to pursue literature.” She had previously talked about reading but had never before expressed this desire, not even to herself. In so doing, she had “discovered a potential ambition that had always been there, but she had never before allowed herself to formulate it into a possibility.”
Summers proceeded to point out other interests she had shared. “It had never before occurred to her that enjoyment of these endeavors could be developed so that they could play a significant role in her life.” They further discussed these interests, and Helen became aware of the concept of the future-perfect tense. All this illustrates the importance of the therapist’s ability to see the patient’s unrealized potential. Summers saw in Helen “the possibility for a future in literature before she did.”
Helen was only able to accept the potential that Summers saw because he had first shown that he had seen her pain. He had first shown his ability to understand “why she could see no future.” This is true of other patients who lack a sense of futurity, as they need the therapist to first “grasp their hopelessness before a belief in something more can be engaged.”
Summers compares his approach with Viktor Frankl’s logotherapy. However, while Frankl’s approach “aims to provide the patient with a sense of meaning,” Summers believes that it is also necessary to understand the patient’s past and his transference. “By dismissing these dimensions, Frankl loses the depth of experience that has always been the hallmark of psychoanalytic therapy. Without such exploration, any view of the future is likely to be superficial and unlikely to have staying power.”
Chapter 3: The Therapist’s Vision of the Patient
If we aim “to nurture undeveloped potential,” we “must ponder a vision of who the patient can become.”
Hans Loewald pioneered the idea of the therapist’s vision for the patient (“On the Therapeutic Action of Psychoanalysis,” 1960). He likened the therapist-patient relationship was like the parent-child relationship: “The parent is in an empathic relationship of understanding the child’s particular stage in development, yet ahead of his vision of the child’s future and mediating this vision to the child in his dealing with him.”
Winnicott similarly (“The Theory of the Parent-Infant Relationship,” 1960) wrote about “the spontaneous gesture that moves the child to new experience, toward acquisition of new knowledge, mastery and exploration of the world.” Winnicott believed that the mother’s empathy “includes appreciation for both who the child is and who the child may become.” In her empathy the mother “both engages the child’s spontaneity and adds a vision that the mother constructs from it, an addition to which the child must respond.”
The notion of the therapist’s vision adds a dimension to the therapeutic alliance, as the therapist must also be “allied with the patient’s latent possibilities.” The therapist must work to understand how the patient’s defenses are working against “the realization of possibilities contained in the analyst’s vision of the patient.”
The therapist should not worry that sharing his vision of the patient will mold “the patient to a preformed image.” Rather the therapist must simply make sure that his “vision is formed from the patient’s material.” As Winnicott suggested, the therapist engage in “the dialectical interplay between the therapist’s vision and the patient’s spontaneous gesture. The result of this process is the emergence of the true self.”
Chapter 4: Therapeutic Action as the Creation of Meaning
Creation
To understand self creation, we should first understand the basic elements of creation. Csikszentmihalyi (“Creativity,” 1996) found that in both artistic and scientific creativity it is typical for the individual to repeatedly work on the problem “in a seemingly fruitless manner until a sudden change occurs.” Summers emphasized that this process involves “the persistent confrontation of a problem without result until a sudden change seems to suggest a fresh approach.”
Applying these findings to psychoanalysis, we can see how “the hard and seemingly unproductive battle to overcome stubborn traits and dynamics” can be necessary. “The attempt to translate understanding into new psychological patterns often incubates unconsciously until a sudden association suggests a new approach. If the breakthrough association is to become part of the self, it must be elaborated in subsequent analytic work”
Socrates
Summers likens analytic work to Socratic dialogue. An analytic session, like a Socratic dialogue, aims to expand knowledge. The patient enters the session assuming certain beliefs to be axiomatic and in the process of analysis learns that some of them might in fact not be true.
Transference and Potential Space
Transference conserves the old, as it preserves the same old affect with a new object. Put different, the patient who engages in transferences “is precluding the experience of novelty by refusing to see the current situation as new. As an effort to diminish the originality of experience by giving it preexisting form, transference is not creative but conservative.”
In order to create new meanings, potential space must be created, and this is only possible by first overcoming transference meaning.
Theory of Technique
Theorists have historically believed that there are three major psychoanalytic techniques: interpretation in the transference, interpretation outside the transference, and understanding of the patient’s past (Menninger and Holzman, “Theory of Psychoanalytic Technique,” 1958). Summers writes that a fourth technique is needed: the creation of potential and with it “the creation of new ways of being and relating” (Winnicott, “Playing and Reality,” 1971).
If we conceptualize all aspects of the patient’s relationship to the analyst as transference, “the crucial difference between transference and potential space is blurred.” As the patient begins to relinquish old relational patterns, he enters into a void “in which the patient has no anchoring points for navigating the interpersonal world.” The patient begins to feel “the threat of nonexistence,” and the analyst too feels anxious that “the patient’s sense of self is slipping away.” This “perceived void provides the openness needed for the establishment of potential space.” “Often the patient’s incipient self-expressions remain undeveloped because the analyst does not see their potentially decisive importance. To interpret such nascent states as transference is to miss their potential to become new ways of being.”
The dyad might feel like things are stagnant. “When the patient attempts to keep the old pattern, the analyst tries to open the analytic field to new possibilities.” Summers tells of a patient named Leo who would not express anger, fearing that doing so would result in violence. Summers interpreted Leo’s anger, but he also created the opportunity for Leo to express anger in their sessions. Leo had assumed that Summers would respond to his angry outbursts by ending treatment, but of course Summers didn’t do that. Leo in time came to understand his anger differently and learned how it could even be constructive.
Understanding as Creating
“When potential space is opened by the relaxation of defenses, whatever arises at this point may be regarded as a free association in the broadest sense.” However, these free associations point, not to the past, but to the future, to what the patient might become. “It falls to the analyst to convey that the patient’s spontaneous gestures, expressions of new experience unencumbered by previously existing form, are the best guide to what comes next. The analytic task is to detect the project implicit in the spontaneous gestures evoked in transitional space, even though their eventual shape cannot be foreseen.”
Associations in potential space “are analogous to an infant’s spontaneous gestures.” “An incipient interest, desire, or ambition will emerge in however nascent a form, and once elaborated into its full meaning, has the capability of issuing in new, more authentic ways of engaging the world. However, as the patient is typically only aware of a vaguely defined, unformed experience, the potential of this emerging material is rarely seen by the patient until recognized by the analyst.” Thus, the analyst’s vision of the patient is essential.
“Just as the infant does not know her experience until the parent’s gaze makes it real, so the patient does not believe in the reality of her unformed states until the analyst recognizes them” (Jessica Benjamin, “Like Subjects, Love Objects,” 1995). “The patient is drawn to the direction of the spontaneous gesture, but, lacking articulation and without recognition from the other, the experience does not feel real.” However, if the analyst can grasp the patient’s associations as “potential aspects of self, these budding states have the possibility of becoming articulated into ways of being and relating.”
Example
Anna had lived a life of compliance to others. One day Summers asked about those she envied, and discussed those who “inserted their views in every situation and ‘pushed back’ if others had conflicting desires.” Anna continued talking and then “exploded with a rage previously unknown to her. Initially, she unleashed a vitriolic attack at her mother for promoting her fear of abandonment, but this eruption was soon followed by an outpouring of rage at a list of people who she felt had taken advantage of her compliance.” These outbursts “constituted a free association indicating a previously buried desire to articulate her desires and interests and anger at their suppression.”
Summers understood that “[t]he meaning of Anna’s rage” could not be “found in its developmental origins because in a very real sense her explosion had no meaning in the past. For Anna, aggression of any type had existed only in potential form until the moment of its eruption.”
He decided not to view her “newly found aggression” as transference “but as use of potential space, a spontaneous gesture with the potential for self creation. The primary basis for this judgment was the fact that the inhibition of her aggressivity had been well understood, and Anna’s frustration resulted from the futility of her understanding.”
Chapter 5: The Art of Possibilities
When patients feel on the verge of relinquishing one trait, they “tend to become anxious about falling into the opposite pattern.” When Anna, for example, contemplated becoming less compliant, “she immediately feared becoming selfish and disrespectful of others.” Benjamin argued that many human traits are linked as pairs of antinomies, e.g., aggression and passivity, grandiosity and inadequacy, love and hatred (“The Shadow of the Other,” 1997).
This makes sense once we understand that we don’t internalize an object but an object relationship consisting of the self, the object, and the affect joining them (Kernberg, “Object Relations Theory in Clinical Practice,” 1988). The patient can enact either the self-state or the object-state, “casting the other in the opposite side of the object relationship.” This means that “any expressed pattern is one side of an object relationship. For example, a patient who has a pattern of being a victim has internalized an object relationship of ‘perpetrator-victim’ that can be reversed so that the patient becomes the perpetrator.”
“Anna feared becoming selfish because a self-involved, insensitive trait was the other side of her submissive-narcissistic internalized object relationship.” These two sides exist in what Benjamin called “complementarity.” Moving “from one to the other is not to change the level of relating but simply to flip the same object relationship to its other side.”
Given that a reversal — e.g., going from compliant to aggressive — “stays within the same object-relational configuration, the enactment of the opposite pole of an antinomy is not more authentic than the original pattern.” If Anna were to become self-centered, she would “have to bury her sensitivity to and caring for others. Far from being a genuine expression of who she is,” by being selfish, she would have betrayed some deeply held values.
The Creative Challenge
A symptom “is the effort of a buried aspect of the self to gain expression, albeit in an indirect manner.” Anna, for instance, experienced symptoms because by being over-compliant she was burying an aspect of her real self.
The answer is not to find a middle ground, as antinomies are “complementary poles of the same object relationship” and “have no midpoint.” Each “pole of the object relationship contains an important aspect of the patient’s self, and there must be room in the analytic relationship for the expression of each if the patient is to transcend the pathological pattern. For Anna, this meant being both generous and self-respecting. To live in both of these ways constituted a new possibility for bother her charitable nature and self-regard: her freely chosen generosity enhanced, rather than eroded, her self-respect, and the latter had no trace of selfishness.” Expression of these two “deeply held values was not a ‘middle ground’ of compromise between the two, but the creation of a new ability, the capacity to live in accordance with self-respect and generosity.” ‘
This notion of personality change “implies that the patient’s desire can assume different forms and be satisfied in various manners.” Contrary to this possibility, the analytic tradition has traditionally held that desire cannot be changed. Freud (wrongly) believed that desire could not be changed but could be expressed in four different ways (repression, sublimation, reversal into its opposite, or turning around on the self). He believed that only sublimation was healthy, but this simply meant that the love one felt for his mother as a boy is not being transferred onto a new object, although the love itself is the same.
Conclusion
Summers returns to the concept of working through, which means that “an insight must be repeatedly gone over until it becomes integrated in a way that leads to the alteration of old patterns.” Summers says that we must understand the patient’s core desire, and once we do this, we must give them the opportunity to explore different, more adaptives ways in which that desire can be met. We must, in other words, provide the patient with opportunities to create new possibilities.
Anna, for instance, first needed to understand that it was so tough for her to be aggressive, because when younger she had come to believe that any aggression would result in abandonment. Additionally, however, Anna needed the opportunity to explore new ways of being aggressive, ways that would not contradict her value of altruism, and when she created this new possibility, she saw that she could be aggressive without fearing abandonment.
Chapter 6: The Analyst’s Process
To allow the creation of potential space, the therapist must restrain his “natural tendency to ‘match’ affective expressions.” Doing this creates an unnatural feeling that can result in mounting tension. “This can cause anxiety for the patient, who now has “no guidelines for his behavior and turns to the therapist to relieve his free-floating feeling by filling the space.” The therapist must resist this urge to comply with the patient’s request. This might make the therapist “feel cold-hearted and even sadistic as the patient suffers from a sense of nonbeing.” “However, to meet the patient’s request is to fill the space, thereby reducing its potential for creation.”
It is risky to envision what the patient might become. “What if the patient’s potential as viewed by the therapist does not appear to be materializing? What if the expected future does not come?” We also run the risk of imposing our own preconceptions on the patient, as “[d]eeply etched in the heart of all analysts is the principle that we should not influence our patients’ development with our own values and biases.” The best antidote to this anxiety is to make sure to root our vision “in the patient’s free associations and interactions as they emerge.” And of course we must be willing to change our vision as we learn more about the patient.
Chapter 7: Clinical Application — Somatic Symptoms
Development and Object Relations Theory
Referencing the work of Silvan Tomkins, Summers writes that it is now known that basic affects are inborn. Such affects as “interest, enjoyment, surprise, distress, anger, fear, and disgust do not have to be learned. An infant will react to environmental circumstances in any of these ways without having witnessed them.” Affects, then, are not somatic symptoms; rather, affects communicate through the body “what is cared about, what matters.” If the mother is properly responsive to the child’s affects “by correctly identifying them and providing an ‘optimal zone of affective engagement,” the child uses his affects to form a relationship between himself and the world” (Demos 1988 and 1992).
Development research has shown that “affective life is, from the beginning, organized around relating to others” (Stern, “The Interpersonal World of the Infant,” 1985). Bowlby believed that this “serves the adaptive purpose of keeping the young child close to the protector” (“Attachment and Loss: Vol. 1,” 1969). Whatever the evolutionary purpose, “the child needs and seems prewired to form an attachment to the caretaker and feels threatened without it” (Bowlby, “A Secure Base,” 1988). The child is not preprogrammed for “a pleasure-seeking life oblivious to reality, but for interaction with a real person through a relationship mediated by affective states.”
In addition to forming relationships, children are “interested in the world of nonhuman objects.” “Indeed, we now know that neonates possess considerable mental capability for exploring the world from the first days of life. They can detect contingencies and patterns; they plan and are capable of voluntary motor controls” (Demos, 1992). The “autonomous nature of children’s curiosity about and elaboration of the world supports the notion that they are inherently motivated to exercise their capacities to form a self” (Summers, 1999, pp. 45-53). Consequently, “if self potential is to be realized, it must be possible for affects to be used in accordance with the needs of the self. For example, aggression must be available to fulfill ambitions, and affection must be accessible for intimate relationships. The child must be free to pursue his interests.” Jessica Benjamin argued that “such affective freedom is possible only if the caretakers’ accepting and approving gaze recognizes and nurtures the child’s spontaneous affective expressions” (“Like Subjects, Love Objects,” 1995).
The Psychoanalytic Concept of Ownership
Developmental research and object relations theory provide the foundations for a sense of personal ownership. “As we have seen, if caretakers are responsive to the child’s psychic states, affects become elaborated into new ways of being and relating.” When the child expresses an affect, and the parent responds to that affect — acknowledging it, perhaps echoing it — that affect then “becomes a characteristic way of relating to the environment and thereby a part of the self organization.”
The Psychopathology of Affective Life
The “child’s affective states require a resonance with the caretaker such that the child feels her affects are not only welcomed and appreciated, but also ‘real.’” “It is only through the responsiveness of the other that the child has a sense of her own reality.” If the caretaker ignores the child’s affects, “she feels that they are somehow invalid or defective.” And if the caretaker provides a negative responds to the child’s affect, “the affect will be experienced by the child as threatening the bond. Believing that an affect will cost the love of the parent,” the child will learn to “bury” the affect “in order to maintain the caretaker connection.”
As Freud told us, “if an affect is denied entrance into consciousness, it seeks expression in another form.” Clinical experience has confirmed Freud’s claim. As Summers has shown, children are motivated “to exercise and develop inborn capacities,” and “affects are a crucial component of this movement.” Since an affect “that is disavowed cannot mediate the self’s relationship to the world,” self-development is stunted, an “important potential component of the self” is lost.
When an affective state is arrested, our emotions look for another outlet. If a child’s affects are neglected or opposed, he will get angry. If the child’s anger is neglected or opposed, he act out his anger through his behavior (e.g., by breaking rules, defying his parents, etc.). Or he might become overexcited. Or he might respond in a host of other ways, including through somatization.
Psychopathology of the Body
Affects are bodily experiences. “In addition to the measurable level of neurological excitation that inheres in affects, the latter are experienced in the body. When the mother enters the room, for example, the infant’s is a bodily reaction: he gurgles and wiggles his own body.” Even as the child grows, “affects always retain a bodily component.”
Given this affect-body connection, it follows that when a child “owns his affective states, he owns his bodily experience.” Conversely, when a child suppresses an affect, he disowns an “aspect of bodily experience.”
Given this affect-body connection, it also follows that when a child suppresses or aries an affect, he will experience a bodily tension. “To suppress anger, for example, means to contain aggressive expressions by countermeasures of both psyche and the musculature. As affective experiences are now divorced from human interaction, the body learns to contain the tension of somatic urges that cannot be brought to fruition.”
Freud believed that we experience bodily tension when a drive is prevented from discharging. Summers believes, in contrast, believes that we experience bodily tension when our early environment prohibits us from expressing our affects and by extension prohibits us from exercising our “capacities” and becoming “fully human.” “For example, if aggression is disavowed, the self cannot pursue goals, realize ambitions, achieve mastery over conflict, or engage in competition.”
Somatic symptoms represent “the bodily imprisonment of arrested affective potential.” When anger is prohibited from developing, for instance, the anger does not cease to exist “and will find some indirect means of expression.” The child who cannot express anger “may complain of stomach aches or pain in various parts of the body.” It’s not clear “why in some people disavowed affects” manifest in different symptoms in some patients than others.
Even when the symptoms are not clearly somatic, “there is often a bodily component. Anxiety symptoms, for example, are experienced in the body: sweaty palms, racing heart, and hyperventilation are all bodily expressions.”
Summers next turns to the Anna O, who had a host of somatic symptoms. Josef Breuer had been impressed by Anna’s many talents and believed she should find a way to help others. When Breuer asked Anna to recall the time each symptom first originated, she experienced “considerable symptom relief.” However, after working with Breuer, she was hospitalized three times. She did not experience full relief until she moved to Frankfurt and became active in charitable work. “It is clear from this case that the analytic task in the treatment of the disowned body is to discover buried affective potential and facilitate its articulation into ways of being and relating so that the patient can assume ownership of his bodily states.”
Clinical Technique
Summers provides a case study of Jenny, who was “initially hospitalized medically, but no physical source of the symptoms was discovered.” Summers came to understand Jenny’s history and offered interpretations to help her understand her hidden desires. He then shifted his clinical stance “from understanding to creating, that is, from transference space to potential space. I asked Jenny what she would do if she were free of guilt and identification with her mother.”
This served as an important jumping-off place and Jenny became to make changs in her personal life. “Her changes extended beyond new interests to a general awareness and expression of previously disavowed affects. For example, she was able to articulate her anger about the severe limitations of her previous life.”
Jenny’s somatic pains began to disappear. “We never discussed the specific meaning of any individual symptom. Jenny felt, and I concurred, that the symptoms were the expression in her body of the tension resulting from the disavowal and suppression of a great deal of her affective life.” Jenny’s “inability to experience spontaneity, joy, excitement and pursue her interests had led to tension that was communicated somatically.”
Chapter 9: Clinical Application — Attachment to Bad Objections
Individuals attached to bad objects have harsh internal voices. “These demonic voices are thought of in object relations terms as internalized bad objects. Seemingly unable to register positive experience, the patient seems to possess an internal screen filtering out anything that might feel good but attracting the influence of a negative event.”
Eliminating bad objects is incredibly difficult. “Even after we understand the origin of these bad objects and identify their replication in the transference, they tend to stay adhesively attached to the structure of the patient’s psyche.”
Fairbairn
Fairbairn believed that attachment to bad objects was “the central therapeutic difficulty.” Our primary motive, he believed, is to seek “satisfactory object relationships.” If these relationships are not satisfactory, we conclude that our love is unacceptable to the object. We still desire the object but feel that he or she is rejecting. We respond by internalizing the object, our hope mean that by internalizing the object we will be able to “master the pain and frustration of the unsatisfying object relationship.” Moreover, we split the object into two, an exciting object and a rejecting object. The exciting object seeks a satisfactory relationship, but the rejecting object represses the longing for the exciting object “to avoid frustration and the shame of feeling that his love is unacceptable.”
When we internalize an object, that object organizes our experience, and for this reason, Fairbairn concluded that internalized objects become components of the self structure. Fairbairn wrote that every internalized object has a corresponding ego structure, the exciting object connected to the libidinal ego and the rejecting object to the anti-libidinal ego. “When an object is internalized, it becomes a structure, a part of the psychic organization.” Therefore, we can say that the bad object is “a component of the self.”
To illustrate how a bad object organizes our experiences, Summers talks about a man named Danny, who had internalized his father and continually flagellated himself for his failures while diminishing his successes. Thus, Danny’s bad object “provided a structure to his experience,” and he thus felt it was a part of the self.
Bad Objects and the Self
If an internalized object is merely an object, then “it is difficult to see why patients cling to them.” But if internalized objects are part of the self structure, then it follows that when we relinquish an internalized object, we are also relinquishing “a way of constructing and organizing experience.” Our “very sense of self is disrupted, and experiences that once fit into known categories become disorienting.”
Thus, Danny’s “self-flagellation, although excruciatingly painful, maintained a connection with his father; indeed hearing the voice was the only way he could hold on to that relationship. His fear of abandonment by his father was so intense that he preferred the pain of self-attack to the risk of losing an illusory connection to the older man.”
In therapy Danny came to realize that he had never had a good relationship with his father but that he had needed to hold onto this belief “to sustain him through a childhood lived without a paternal bond.” However, coming to realize that “he had been holding on to a forlorn wish” did not “extinguish the hold of the bad object.” He consciously wanted to relinquish this bad object, but “whenever he contemplated any type of self assessment, he launched into self-accusation.” Danny, it must be emphasized, was “not attached to a real relationship but to an illustory connection.”
When Danny thought about no longer being so self-critical, he would at first feel happy but then felt anxious that this would cause him to “go too far,” meaning he feared that if he wasn’t so self-critical he would “indulge himself in self-aggrandizement that he would not be able to control.” “Yet the only alternative to manic, self-indulgent grandiosity that Danny could contemplate was self-punishment: his internalized bad object was an organized way of controlling his tendency toward self-inflation, thus providing him with a structure that relaxed his anxiety of losing control.”
Danny’s bad object “served to organize his responses to success and failure; it provided him with a self-definition, albeit a painful one. Thus, his stubborn bond to the bad object was not only a way of keeping a connection to his father but also a means for maintaining a self-organization that helped him negotiate the interpersonal world.”
If we do not “have a concept of an emergent self-structure that can be created from the ambiguity, the danger exists of the patient returning to the influence of the bad object in order to regain the only sense of self he knows.”
Therapeutic Action
To help the patient let go of the bad object, we must first hold the patient’s anxiety about relinquishing it. We must convey hope that “other possibilities exist.” By “establishing and sustaining the void, despite the intensity of the anxiety,” we “open potential space.”
Summers helped one patient, Danny, he insisted him to use free associations. When Danny asked what he should do, Summers asked, “What comes up?” Danny: “I’m an idiot to be suffering like this for nothing.” Summers: “What comes up?” Danny associated to his love of solving problems.
Danny had never fully expressed these feelings, and when he did so, “he felt chaotic and destabilized.” Danny’s associations to problem suggested that he found pleasure in work, but he feared that giving full expression to these feelings would result in “a sense of self-aggrandizement he detested.” Danny next produced the following concatenation of associations: his love for playing with his toys as a child — his interest in fixing cars as an adolescent — his desire for a more exciting sex life with his wife.
Summers encouraged Danny to elaborate on his “pleasurable memories, thoughts, and feelings appearing in the associational train.” Summers strategy was to welcome Danny’s “newly surfacing affective states rather than interpreting them,” a strategy “based on the principle that we were in a potential space in which these unfolding affects represented previously arrested ways of being.”
If Danny had repressed desires, “they would have appeared in consciousness as complete entities,” Summers would have interpreted them. However, because Danny’s desires “appeared in a chaotic, undefined formlessness, Summers knew they were dealing with “incipient psychological states rather than fully defined experiences,” states that “had been occluded before coming to fruition.”
“Danny felt that the experience and expression of positive affects in the analytic space marked a decisive turning point in his life. For the first time, he had permitted himself the full expression of self-affirming affective experiences, especially interest, enjoyment, and excitement, without invoking a negative introjection.”
Danny would experience these positive affects but then predictably also experience self-criticism. Summers responded by highlighting “the evolving affect previously dormant under the dominance of the bad object. Danny then typically abandoned the impulse to attack the excitement or enjoyment and allowed the positive affect to flourish.” In time he began to use his affects as a guide for action.
Summers emphasizes that interpreting bad objects does not by itself diminish their power. Understanding alone does not reduce the power of a bad object “because the prospect of losing the bad object evokes the threat of losing the very structure relied on to engage the world.” However, it is crucial to understand “the origins and function of the bad object,” as doing so puts it “in abeyance its influence so that an alternative can be formed.” For example, once Summers and Danny “grasped the meaning of the bad objects as his father’s voice crushing positive affects,” Danny was motivated “to suspend its organizing function” and “take advantage of the newly opened space to build positive affects into new ways of being and relating that ultimately replaced the role of the bad object in his psyche.”
Grandiosity and the Bad Object
Kohut believed that low self-esteem was “a defense against arrested grandiosity.” The “tenacity of the bad object” can often be a defense against grandiosity. Kohut believed that “when childhood grandiosity remains vulnerable, it may be split off, leaving the self weakened and lacking in healthy self-regard.” Danny fear that giving up the bad object would result in grandiosity, but this was only a fear. Danny “did not have a split-off organized grandiose self waiting for the chance to engage the world.” When he tried to give us the bad object, a split-off grandiose self did not emerge but instead he “became disorganized at the thought of being able to think, act, and feel as he pleased.” In sum, the role of Danny’s bad object “was not so much to protect against the emergence of a grandiose self as to provide a sense of self.”
Conclusion
Fairbairn explained that bad objects are so difficult to expunge because they’re internal structures. Summers has based his clinical strategy on this insight. Further, as he has shown, “the new self must be created before the old organization can be given up completely. To overcome the malignant effects of bad object dominance, the therapist must take an active role in assisting the patient’s creation of a new self structure.” Summers has expended Fairbairn’s thinking “to the adoption of a facilitative role for the therapist,” and in so doing he aligns Fairbairn “with Bollas’ (1987) concept that psychoanalytic therapy is not about discrete affects but about the building of a new self organization.” As soon as the patient understands what function the bad object serves, “the therapist shifts roles from interpreter of the patient’s experience to facilitator of the new experience.”
Chapter 10: Clinical Application — Narcissistic Injury
Summer talks about patients with low self-esteem. These individuals feel defective, and he describes this feeling as a narcissistic injury.
In sum, as Blatt and Blass (1992) put it, “there are two fundamental dimensions of human experience: the needs for relatedness and for self-definition.” The former need is met through affective attunement. The latter need is met when we’re given “space in which to explore and master the environment.” Both dimensions “are necessary for the child to achieve an adequate sense of self-worth.”
If we’re deprived of the opportunities needed to develop the feelings that we’re supported by others, that we can trust our affects, and that we’re effective, we will become increasingly isolated and construct different defenses to protect ourselves from feeling defective.
Therapeutic Action
Given that narcissistic vulnerability is caused by beliefs that (1) others don’t support us, (2) our affects can’t be trusted, and (3) our feeling of ineffectiveness, the following things must happen in treatment.
It is essential that the therapist attunes to the patient. Attunement allows the patient to feel supported. Moreover, attunement confirms the patient’s affective states, thus facilitating her “ability to believe in her own affective responses.” Additionally, the therapist must create space for the patient to exercise her agency by influencing the therapeutic relationship.
“This acquisition of new interpersonal patterns follows the model of procedural learning in which behavior is learned by doing. As the patient operates more authentically and effectively in the relationship with the analyst, she is acquiring competence in a manner more akin to the development of bicycle skills than declarative-semantic learning.”
Summers again provides Anna as an example, this time an example of how to treat someone with narcissistic injuries. Anna had always subjected herself to others. Summers encouraged her to begin expressing herself, and in the process she realized that she had repressed some deeply held feelings and values and in time realized why she had repressed them. Anna began to express many of these feelings and values in therapy, and she slowly started to make changes in her daily life, e.g., standing up for her own needs in relationships.
Many in society believe that they cannot trust themselves to make good decisions because they have low self-esteem. Summers thinks it’s the opposite: people like Anna have low self-esteem because they have difficulty trusting their “affects as reliable beacons of conduct.” According to Summers, “failures in early relationships lead the child to doubt the importance and value of her affective states, resulting in a feeling of defectiveness.”
And so Anna experienced change when she began to “to risk bringing her affects into the analytic relationship.” In so doing, she “began to develop and value the capacity to utilize formerly buried, nascent states.” As she did this and experienced changes in her life, she came to prefer this new way of being. “It was the new-found ability to live her life on the basis of her affect, values, and beliefs that provided the foundation for her self-esteem, not the other way around.”
Why does insight not always lead to behavioral change?
Freud answered this question by positing the idea of “working through,” the idea that repeating insights eventually leads to change (“Remembering, Repeating, and Working Through,” 1914). Freud and later analysts added that the insight must often be experienced “at a deeply affective level.”
Since Freud, different analytic schools have provided different answers to the question. Ego psychologists: change is made possible by interpretations focusing on libidinal wishes and defense mechanisms. Kleinians: change comes by interpreting “early, primitive, especially aggressively dominated fantasies.” Kohut: change comes through the creation of a new object relationship. Winnicott: change comes through the analyst’s holding function when the patient has regressed to dependence. Relational analysts: change comes when attention is brought to the analytic relationship. Certain interpersonal therapists: change comes through interpretation and assigning the patient “action techniques.”
All these strategies are “directed to the analyst’s offerings, with the result that the patient is viewed as a recipient of analytic interpretation.” Although relational analysis states that the patient takes an active part in treatment, it nevertheless treats the patient as a recipient, as the concept of co-construction consists of “the analyst’s participation in the patient’s transference patterns.” And although the above interpersonal analysis encourages patients to attempt new behaviors, the patient does so “at the therapist’s exhortation.”
Creation and Growth
The goals of analysis have broadened to include, not just the resolution of intrapsychic conflict, but also self-development. If self-development is the goal of analysis, “the therapeutic action of psychoanalysis must include room for the patient to create new ways of being and relating.” Evidence that activity and creation are central to growth can be found in advances in both developmental research and learning theory.
Developmental Research. Researchers have found that “the child requires not only affective attunement, but also the space to experience his own affective states and participation in relieving distressing situations.” Beebe and Lachmann found that most secure babies were not those whose mothers were the most attuned to their affective states but “those infants that fall in the midrange of affective and vocal matching with their mothers. They concluded that infants need both mutual regulation and the opportunity for self-regulation, an opportunity impeded by overattunement” (“Co-constructing inner and relational processes,” 1998). Similarly, both Bowlby and Ainsworth “found that securely attached infants had mothers who were emotionally available and made a push toward autonomy.”
Demos “found that a child’s sense of agency is best promoted not by the parent who relieves stress by providing immediate comfort, but by the parent who allows the child to experience pain and helps to resolve it in a way that makes the infant feel like a coparticipant in the relief of tension.” Demos concluded that there seems to be “an optimal zone of affective experience that allows the infant
Learning Theory. Learning theorists have come to recognize “the importance of procedural as well as declarative-semantic learning.” Procedural learning is learning by doing and cannot usually be put into words. We now know that “much learning occurs through action and nonverbal interaction.” For example, “bicycle riding is learned by doing and the ‘memory’ consists of knowing how to do it, rather than statements that can be recalled.” The relevance of this discovery to analysis is that procedural learning is acquired by doing. “This fact amends the role of the teacher from the largely didactic one required for declarative-semantic learning to the provision of opportunity and guidance for the student’s activity.”
Children acquire interpersonal skills through procedural learning. They learn “how to relate to the parent in the process of parent-child interactions well before the child is able to put such learning into words. The parent provides the opportunity for the child to interact, and, while engaging the interaction, the child learns the rules of social relating.” This illustrates “the importance of action, of learning by doing, in emotional growth.”
Further, adult developmental research that adults continue to have “growth expansion motives,” that is, “the need to expand creatively their interests and capacities in both the social and vocational arenas.” Research “indicate that the desire and need to make a creative mark, to develop one’s own interests and make a unique contribution, increases at least into middle age, and, in healthy persons, remains until the end of life.” Research also suggests that “personality change can occur at any stage of the life cycle.”
Given all this, it seems to follow that “any concept of therapeutic action in which the patient does not actively contribute on the basis of authentic personal experience is in danger of becoming a relationship of compliance (however well disgusted), rather than a creation of new self-structure.” Interpretations are still essential, as they can make the patient aware of why he clings to old patterns, and they can make him aware of new ways he can be.
Potential Space
The creation of the self “can be achieved through a dual process of interpretation and the use of the psychotherapeutic relationship for the creation of new ways of being and relating.” That is, in addition to interpretation, “the analytic process must provide the opportunity for the creation of new patterns to replace those targeted by analytic investigation.” Thus, the analytic space “includes not only room for interpretation, but also a space for the patient’s creation.”
Winnicott’s concept of the analytic setting “was meant to provide room in the relationship for the patient to create a new object relationship,” what he called “the analytic object.” This therapeutic stance “requires attention to and nurturance of the patient’s need for a spontaneous gesture.”
Winnicott regarded transitional phenomena as an intermediate level between “objective reality” and “absolute fantasy.” Transitional phenomena originates in infancy when “the child first recognizes the self-other distinction but is unable to accept the mother’s externality.” The child “exists in a paradoxical world in which she can treat an object as though it were a part of the self, even though she knows it is not.” Transitional space is “the area of illusion between the omnipotent fantasy life of early infancy and the later acceptance of objective reality.” The infant will eventually relinquish the transitional object, but “the transitional realm of experience remains a capacity throughout life,” and things like religion and aesthetics “require some degree of illusion.”
He came to believe that the therapeutic space was like the transitional space, taking place in the “overlap of two subjectivities.” Before this, the analytic space was understood as a place “for the patient’s material, the analyst’s interpretations, and the patient’s response to those insights.” Winnicott added transitional space, or potential space. He saw this space as a place in which the patient could be creative “within the therapeutic dyad.” The distinctive feature of potential space is “formlessness,” “the maximal openness the therapist can tolerate so that the relationship can be created according to the patient’s needs within the givens of the therapist and the setting.”
Since the potential space is meant to “provide optimum opportunity for the creation of new aspects of the self,” structure must be minimized. However, “the boundary is as important as the ambiguity” because potential space, like transitional space, “exists within a relationship constrained by the limits of the other.” And this boundary “distinguishes potential space from fantasy, just as its openness differentiates potential space from reality.”
Potential space “has no determined meaning,” and “any meaning it is to have exists only as potential and, therefore, lies in the future. Potential space has a not-yet-formed quality; its meaning is to be created. Because the potential of space can be seen only in projection toward future meanings, the future is an essential component of potential space.”
Summary
Summers defines therapeutic action “as a dual process consisting of an interpretive phase that operates as a propaedeutic for the building of a new self. In this dual model of therapeutic action, the old self is transcended only as new ways of being and relating are created in the second phase.”
As soon as “a psychological configuration is understood, the therapist suspends interpretation as well as any other techniques or interventions for the purpose of facilitating the creation of new meaning by the patient. In other words, the space is given over to the free play of the patient’s imagination. Whatever associations, memories, or sensations now appear are viewed not as a source of understanding the patient’s current patterns, but as incipient indications of the shape a new self might assume.”
It is often essential for the therapist to “not only open the space for the creation of new possibilities” but to also “have a vision, some sense of the potential that can be realized by the patient in the therapeutic space.”
Chapter 2: The Future
Importance of the Future
Freud answered this question by positing the idea of “working through,” the idea that repeating insights eventually leads to change (“Remembering, Repeating, and Working Through,” 1914). Freud and later analysts added that the insight must often be experienced “at a deeply affective level.”
Since Freud, different analytic schools have provided different answers to the question. Ego psychologists: change is made possible by interpretations focusing on libidinal wishes and defense mechanisms. Kleinians: change comes by interpreting “early, primitive, especially aggressively dominated fantasies.” Kohut: change comes through the creation of a new object relationship. Winnicott: change comes through the analyst’s holding function when the patient has regressed to dependence. Relational analysts: change comes when attention is brought to the analytic relationship. Certain interpersonal therapists: change comes through interpretation and assigning the patient “action techniques.”
All these strategies are “directed to the analyst’s offerings, with the result that the patient is viewed as a recipient of analytic interpretation.” Although relational analysis states that the patient takes an active part in treatment, it nevertheless treats the patient as a recipient, as the concept of co-construction consists of “the analyst’s participation in the patient’s transference patterns.” And although the above interpersonal analysis encourages patients to attempt new behaviors, the patient does so “at the therapist’s exhortation.”
Creation and Growth
The goals of analysis have broadened to include, not just the resolution of intrapsychic conflict, but also self-development. If self-development is the goal of analysis, “the therapeutic action of psychoanalysis must include room for the patient to create new ways of being and relating.” Evidence that activity and creation are central to growth can be found in advances in both developmental research and learning theory.
Developmental Research. Researchers have found that “the child requires not only affective attunement, but also the space to experience his own affective states and participation in relieving distressing situations.” Beebe and Lachmann found that most secure babies were not those whose mothers were the most attuned to their affective states but “those infants that fall in the midrange of affective and vocal matching with their mothers. They concluded that infants need both mutual regulation and the opportunity for self-regulation, an opportunity impeded by overattunement” (“Co-constructing inner and relational processes,” 1998). Similarly, both Bowlby and Ainsworth “found that securely attached infants had mothers who were emotionally available and made a push toward autonomy.”
Demos “found that a child’s sense of agency is best promoted not by the parent who relieves stress by providing immediate comfort, but by the parent who allows the child to experience pain and helps to resolve it in a way that makes the infant feel like a coparticipant in the relief of tension.” Demos concluded that there seems to be “an optimal zone of affective experience that allows the infant
Learning Theory. Learning theorists have come to recognize “the importance of procedural as well as declarative-semantic learning.” Procedural learning is learning by doing and cannot usually be put into words. We now know that “much learning occurs through action and nonverbal interaction.” For example, “bicycle riding is learned by doing and the ‘memory’ consists of knowing how to do it, rather than statements that can be recalled.” The relevance of this discovery to analysis is that procedural learning is acquired by doing. “This fact amends the role of the teacher from the largely didactic one required for declarative-semantic learning to the provision of opportunity and guidance for the student’s activity.”
Children acquire interpersonal skills through procedural learning. They learn “how to relate to the parent in the process of parent-child interactions well before the child is able to put such learning into words. The parent provides the opportunity for the child to interact, and, while engaging the interaction, the child learns the rules of social relating.” This illustrates “the importance of action, of learning by doing, in emotional growth.”
Further, adult developmental research that adults continue to have “growth expansion motives,” that is, “the need to expand creatively their interests and capacities in both the social and vocational arenas.” Research “indicate that the desire and need to make a creative mark, to develop one’s own interests and make a unique contribution, increases at least into middle age, and, in healthy persons, remains until the end of life.” Research also suggests that “personality change can occur at any stage of the life cycle.”
Given all this, it seems to follow that “any concept of therapeutic action in which the patient does not actively contribute on the basis of authentic personal experience is in danger of becoming a relationship of compliance (however well disgusted), rather than a creation of new self-structure.” Interpretations are still essential, as they can make the patient aware of why he clings to old patterns, and they can make him aware of new ways he can be.
Potential Space
The creation of the self “can be achieved through a dual process of interpretation and the use of the psychotherapeutic relationship for the creation of new ways of being and relating.” That is, in addition to interpretation, “the analytic process must provide the opportunity for the creation of new patterns to replace those targeted by analytic investigation.” Thus, the analytic space “includes not only room for interpretation, but also a space for the patient’s creation.”
Winnicott’s concept of the analytic setting “was meant to provide room in the relationship for the patient to create a new object relationship,” what he called “the analytic object.” This therapeutic stance “requires attention to and nurturance of the patient’s need for a spontaneous gesture.”
Winnicott regarded transitional phenomena as an intermediate level between “objective reality” and “absolute fantasy.” Transitional phenomena originates in infancy when “the child first recognizes the self-other distinction but is unable to accept the mother’s externality.” The child “exists in a paradoxical world in which she can treat an object as though it were a part of the self, even though she knows it is not.” Transitional space is “the area of illusion between the omnipotent fantasy life of early infancy and the later acceptance of objective reality.” The infant will eventually relinquish the transitional object, but “the transitional realm of experience remains a capacity throughout life,” and things like religion and aesthetics “require some degree of illusion.”
He came to believe that the therapeutic space was like the transitional space, taking place in the “overlap of two subjectivities.” Before this, the analytic space was understood as a place “for the patient’s material, the analyst’s interpretations, and the patient’s response to those insights.” Winnicott added transitional space, or potential space. He saw this space as a place in which the patient could be creative “within the therapeutic dyad.” The distinctive feature of potential space is “formlessness,” “the maximal openness the therapist can tolerate so that the relationship can be created according to the patient’s needs within the givens of the therapist and the setting.”
Since the potential space is meant to “provide optimum opportunity for the creation of new aspects of the self,” structure must be minimized. However, “the boundary is as important as the ambiguity” because potential space, like transitional space, “exists within a relationship constrained by the limits of the other.” And this boundary “distinguishes potential space from fantasy, just as its openness differentiates potential space from reality.”
Potential space “has no determined meaning,” and “any meaning it is to have exists only as potential and, therefore, lies in the future. Potential space has a not-yet-formed quality; its meaning is to be created. Because the potential of space can be seen only in projection toward future meanings, the future is an essential component of potential space.”
Summary
Summers defines therapeutic action “as a dual process consisting of an interpretive phase that operates as a propaedeutic for the building of a new self. In this dual model of therapeutic action, the old self is transcended only as new ways of being and relating are created in the second phase.”
As soon as “a psychological configuration is understood, the therapist suspends interpretation as well as any other techniques or interventions for the purpose of facilitating the creation of new meaning by the patient. In other words, the space is given over to the free play of the patient’s imagination. Whatever associations, memories, or sensations now appear are viewed not as a source of understanding the patient’s current patterns, but as incipient indications of the shape a new self might assume.”
It is often essential for the therapist to “not only open the space for the creation of new possibilities” but to also “have a vision, some sense of the potential that can be realized by the patient in the therapeutic space.”
Chapter 2: The Future
Importance of the Future
It’s important to spend time discussing the patient’s past, but focusing too much on the past limits our understanding of the patient as well as our ability to help him transcend his present difficulties. Most patients “cannot conceive of new possibilities” and lack “a belief in a different future.” Most patients do not have a sense of the future because their life “is an endless present.” And without “a sense of futurity,” there can be “little hope of overcoming the limitations of the childhood self.”
Phenomenological philosophers like Husserl, Bergson, and Heidegger help us to better understand time, and when we do so, we realize that the future is “inherent in all experience of present and past.” We can’t help but experience time as projected, “thrown toward the future, and, as we move toward the future.” Every “present moment is embedded within some future project, a conception of life’s trajectory, and gains its meaning only in that context.” When two people are talking on the street, for example, “the meaning of that encounter is determined by the intention of both parties. The meaning of their conversation is decisively different if one person is trying to sell the other a product, hand him a coupon or beg for money, or if the two friends are meeting after a long absence.”
Similarly, developmental researchers have found that “the future is embedded in the psyche from the inception of life.” Observations have found that “from her earliest days the infant comes to expect responses from the caretaker and reacts negatively to failed anticipation.” Additionally, the infant engages in many behaviors, “such as sucking on its own, for no purpose other than to do it herself; such behavior has no apparent ‘because motive’ but, rather, is done ‘in order to’ acquire the ability to perform the activity.” Thus, it appears that goal-directed action is “built into the human psyche virtually from birth.”
Finally, many object relations theorists focus on the idea of developmental arrest. And the concept of developmental arrest implies that the future was previously blocked and that there is still undeveloped potential that can be unleashed in the future.
Clinical Application
Phenomenological philosophers like Husserl, Bergson, and Heidegger help us to better understand time, and when we do so, we realize that the future is “inherent in all experience of present and past.” We can’t help but experience time as projected, “thrown toward the future, and, as we move toward the future.” Every “present moment is embedded within some future project, a conception of life’s trajectory, and gains its meaning only in that context.” When two people are talking on the street, for example, “the meaning of that encounter is determined by the intention of both parties. The meaning of their conversation is decisively different if one person is trying to sell the other a product, hand him a coupon or beg for money, or if the two friends are meeting after a long absence.”
Similarly, developmental researchers have found that “the future is embedded in the psyche from the inception of life.” Observations have found that “from her earliest days the infant comes to expect responses from the caretaker and reacts negatively to failed anticipation.” Additionally, the infant engages in many behaviors, “such as sucking on its own, for no purpose other than to do it herself; such behavior has no apparent ‘because motive’ but, rather, is done ‘in order to’ acquire the ability to perform the activity.” Thus, it appears that goal-directed action is “built into the human psyche virtually from birth.”
Finally, many object relations theorists focus on the idea of developmental arrest. And the concept of developmental arrest implies that the future was previously blocked and that there is still undeveloped potential that can be unleashed in the future.
Clinical Application
Given all this, “understanding the patient’s present” requires us to “grasp the patient’s experience of the future and how the present moment fits into it. The emptiness, passivity, and complacency we see in some many patients reflect their loss of future, an inability to live in the future-perfect tense, and this empty future issues in the bleakness of their present lives.”
When repeated interpretations are not leading to change, it could be that the patient is not able to “contemplate or implement a different future.” Consequently, the therapeutic relationship “must be transformed from an interpretive field to potential space so that the patient can use the relationship to create new ways of being and relating.”
It’s not enough to simply suggest that the future could be different. “The patient does not believe optimistic prognostications and often regards the clinician who makes them as Polyannaish at best or, at worst, as so self-absorbed as to be unable to understand the patient’s experience.”
Summers provides a case study of a patient named Helen who had no did not have hope in the future. Summers started to point out her lack of future. She understood what he meant, knowing that others had goals, but felt that that was for other people. “Had she ever considered that her life without goals meant that her life lacked meaning, and that without meaning depression [the symptom for which she sought treatment] might result? No, she had not thought of that.”
While Helen felt stuck, Summers “did not see her survival mentality as a static state, but as an adaptive construction required to endure a traumatic childhood.” He “sensed potential in her that she did not perceive.” When interpretations stopped making much difference, he shifted his strategy “from interpretation of past and present to a focus on finding disavowed indications of potential future.” He asked, “If you were not focused on survival, what then?” She responded by saying, “Of course, if I had the opportunity, I would love to pursue literature.” She had previously talked about reading but had never before expressed this desire, not even to herself. In so doing, she had “discovered a potential ambition that had always been there, but she had never before allowed herself to formulate it into a possibility.”
Summers proceeded to point out other interests she had shared. “It had never before occurred to her that enjoyment of these endeavors could be developed so that they could play a significant role in her life.” They further discussed these interests, and Helen became aware of the concept of the future-perfect tense. All this illustrates the importance of the therapist’s ability to see the patient’s unrealized potential. Summers saw in Helen “the possibility for a future in literature before she did.”
Helen was only able to accept the potential that Summers saw because he had first shown that he had seen her pain. He had first shown his ability to understand “why she could see no future.” This is true of other patients who lack a sense of futurity, as they need the therapist to first “grasp their hopelessness before a belief in something more can be engaged.”
Summers compares his approach with Viktor Frankl’s logotherapy. However, while Frankl’s approach “aims to provide the patient with a sense of meaning,” Summers believes that it is also necessary to understand the patient’s past and his transference. “By dismissing these dimensions, Frankl loses the depth of experience that has always been the hallmark of psychoanalytic therapy. Without such exploration, any view of the future is likely to be superficial and unlikely to have staying power.”
Chapter 3: The Therapist’s Vision of the Patient
If we aim “to nurture undeveloped potential,” we “must ponder a vision of who the patient can become.”
Hans Loewald pioneered the idea of the therapist’s vision for the patient (“On the Therapeutic Action of Psychoanalysis,” 1960). He likened the therapist-patient relationship was like the parent-child relationship: “The parent is in an empathic relationship of understanding the child’s particular stage in development, yet ahead of his vision of the child’s future and mediating this vision to the child in his dealing with him.”
Winnicott similarly (“The Theory of the Parent-Infant Relationship,” 1960) wrote about “the spontaneous gesture that moves the child to new experience, toward acquisition of new knowledge, mastery and exploration of the world.” Winnicott believed that the mother’s empathy “includes appreciation for both who the child is and who the child may become.” In her empathy the mother “both engages the child’s spontaneity and adds a vision that the mother constructs from it, an addition to which the child must respond.”
The notion of the therapist’s vision adds a dimension to the therapeutic alliance, as the therapist must also be “allied with the patient’s latent possibilities.” The therapist must work to understand how the patient’s defenses are working against “the realization of possibilities contained in the analyst’s vision of the patient.”
The therapist should not worry that sharing his vision of the patient will mold “the patient to a preformed image.” Rather the therapist must simply make sure that his “vision is formed from the patient’s material.” As Winnicott suggested, the therapist engage in “the dialectical interplay between the therapist’s vision and the patient’s spontaneous gesture. The result of this process is the emergence of the true self.”
Chapter 4: Therapeutic Action as the Creation of Meaning
Creation
To understand self creation, we should first understand the basic elements of creation. Csikszentmihalyi (“Creativity,” 1996) found that in both artistic and scientific creativity it is typical for the individual to repeatedly work on the problem “in a seemingly fruitless manner until a sudden change occurs.” Summers emphasized that this process involves “the persistent confrontation of a problem without result until a sudden change seems to suggest a fresh approach.”
Applying these findings to psychoanalysis, we can see how “the hard and seemingly unproductive battle to overcome stubborn traits and dynamics” can be necessary. “The attempt to translate understanding into new psychological patterns often incubates unconsciously until a sudden association suggests a new approach. If the breakthrough association is to become part of the self, it must be elaborated in subsequent analytic work”
Socrates
Summers likens analytic work to Socratic dialogue. An analytic session, like a Socratic dialogue, aims to expand knowledge. The patient enters the session assuming certain beliefs to be axiomatic and in the process of analysis learns that some of them might in fact not be true.
Transference and Potential Space
Transference conserves the old, as it preserves the same old affect with a new object. Put different, the patient who engages in transferences “is precluding the experience of novelty by refusing to see the current situation as new. As an effort to diminish the originality of experience by giving it preexisting form, transference is not creative but conservative.”
In order to create new meanings, potential space must be created, and this is only possible by first overcoming transference meaning.
Theory of Technique
Theorists have historically believed that there are three major psychoanalytic techniques: interpretation in the transference, interpretation outside the transference, and understanding of the patient’s past (Menninger and Holzman, “Theory of Psychoanalytic Technique,” 1958). Summers writes that a fourth technique is needed: the creation of potential and with it “the creation of new ways of being and relating” (Winnicott, “Playing and Reality,” 1971).
If we conceptualize all aspects of the patient’s relationship to the analyst as transference, “the crucial difference between transference and potential space is blurred.” As the patient begins to relinquish old relational patterns, he enters into a void “in which the patient has no anchoring points for navigating the interpersonal world.” The patient begins to feel “the threat of nonexistence,” and the analyst too feels anxious that “the patient’s sense of self is slipping away.” This “perceived void provides the openness needed for the establishment of potential space.” “Often the patient’s incipient self-expressions remain undeveloped because the analyst does not see their potentially decisive importance. To interpret such nascent states as transference is to miss their potential to become new ways of being.”
The dyad might feel like things are stagnant. “When the patient attempts to keep the old pattern, the analyst tries to open the analytic field to new possibilities.” Summers tells of a patient named Leo who would not express anger, fearing that doing so would result in violence. Summers interpreted Leo’s anger, but he also created the opportunity for Leo to express anger in their sessions. Leo had assumed that Summers would respond to his angry outbursts by ending treatment, but of course Summers didn’t do that. Leo in time came to understand his anger differently and learned how it could even be constructive.
Understanding as Creating
“When potential space is opened by the relaxation of defenses, whatever arises at this point may be regarded as a free association in the broadest sense.” However, these free associations point, not to the past, but to the future, to what the patient might become. “It falls to the analyst to convey that the patient’s spontaneous gestures, expressions of new experience unencumbered by previously existing form, are the best guide to what comes next. The analytic task is to detect the project implicit in the spontaneous gestures evoked in transitional space, even though their eventual shape cannot be foreseen.”
Associations in potential space “are analogous to an infant’s spontaneous gestures.” “An incipient interest, desire, or ambition will emerge in however nascent a form, and once elaborated into its full meaning, has the capability of issuing in new, more authentic ways of engaging the world. However, as the patient is typically only aware of a vaguely defined, unformed experience, the potential of this emerging material is rarely seen by the patient until recognized by the analyst.” Thus, the analyst’s vision of the patient is essential.
“Just as the infant does not know her experience until the parent’s gaze makes it real, so the patient does not believe in the reality of her unformed states until the analyst recognizes them” (Jessica Benjamin, “Like Subjects, Love Objects,” 1995). “The patient is drawn to the direction of the spontaneous gesture, but, lacking articulation and without recognition from the other, the experience does not feel real.” However, if the analyst can grasp the patient’s associations as “potential aspects of self, these budding states have the possibility of becoming articulated into ways of being and relating.”
Example
Anna had lived a life of compliance to others. One day Summers asked about those she envied, and discussed those who “inserted their views in every situation and ‘pushed back’ if others had conflicting desires.” Anna continued talking and then “exploded with a rage previously unknown to her. Initially, she unleashed a vitriolic attack at her mother for promoting her fear of abandonment, but this eruption was soon followed by an outpouring of rage at a list of people who she felt had taken advantage of her compliance.” These outbursts “constituted a free association indicating a previously buried desire to articulate her desires and interests and anger at their suppression.”
Summers understood that “[t]he meaning of Anna’s rage” could not be “found in its developmental origins because in a very real sense her explosion had no meaning in the past. For Anna, aggression of any type had existed only in potential form until the moment of its eruption.”
He decided not to view her “newly found aggression” as transference “but as use of potential space, a spontaneous gesture with the potential for self creation. The primary basis for this judgment was the fact that the inhibition of her aggressivity had been well understood, and Anna’s frustration resulted from the futility of her understanding.”
Chapter 5: The Art of Possibilities
When patients feel on the verge of relinquishing one trait, they “tend to become anxious about falling into the opposite pattern.” When Anna, for example, contemplated becoming less compliant, “she immediately feared becoming selfish and disrespectful of others.” Benjamin argued that many human traits are linked as pairs of antinomies, e.g., aggression and passivity, grandiosity and inadequacy, love and hatred (“The Shadow of the Other,” 1997).
This makes sense once we understand that we don’t internalize an object but an object relationship consisting of the self, the object, and the affect joining them (Kernberg, “Object Relations Theory in Clinical Practice,” 1988). The patient can enact either the self-state or the object-state, “casting the other in the opposite side of the object relationship.” This means that “any expressed pattern is one side of an object relationship. For example, a patient who has a pattern of being a victim has internalized an object relationship of ‘perpetrator-victim’ that can be reversed so that the patient becomes the perpetrator.”
“Anna feared becoming selfish because a self-involved, insensitive trait was the other side of her submissive-narcissistic internalized object relationship.” These two sides exist in what Benjamin called “complementarity.” Moving “from one to the other is not to change the level of relating but simply to flip the same object relationship to its other side.”
Given that a reversal — e.g., going from compliant to aggressive — “stays within the same object-relational configuration, the enactment of the opposite pole of an antinomy is not more authentic than the original pattern.” If Anna were to become self-centered, she would “have to bury her sensitivity to and caring for others. Far from being a genuine expression of who she is,” by being selfish, she would have betrayed some deeply held values.
The Creative Challenge
A symptom “is the effort of a buried aspect of the self to gain expression, albeit in an indirect manner.” Anna, for instance, experienced symptoms because by being over-compliant she was burying an aspect of her real self.
The answer is not to find a middle ground, as antinomies are “complementary poles of the same object relationship” and “have no midpoint.” Each “pole of the object relationship contains an important aspect of the patient’s self, and there must be room in the analytic relationship for the expression of each if the patient is to transcend the pathological pattern. For Anna, this meant being both generous and self-respecting. To live in both of these ways constituted a new possibility for bother her charitable nature and self-regard: her freely chosen generosity enhanced, rather than eroded, her self-respect, and the latter had no trace of selfishness.” Expression of these two “deeply held values was not a ‘middle ground’ of compromise between the two, but the creation of a new ability, the capacity to live in accordance with self-respect and generosity.” ‘
This notion of personality change “implies that the patient’s desire can assume different forms and be satisfied in various manners.” Contrary to this possibility, the analytic tradition has traditionally held that desire cannot be changed. Freud (wrongly) believed that desire could not be changed but could be expressed in four different ways (repression, sublimation, reversal into its opposite, or turning around on the self). He believed that only sublimation was healthy, but this simply meant that the love one felt for his mother as a boy is not being transferred onto a new object, although the love itself is the same.
Conclusion
Summers returns to the concept of working through, which means that “an insight must be repeatedly gone over until it becomes integrated in a way that leads to the alteration of old patterns.” Summers says that we must understand the patient’s core desire, and once we do this, we must give them the opportunity to explore different, more adaptives ways in which that desire can be met. We must, in other words, provide the patient with opportunities to create new possibilities.
Anna, for instance, first needed to understand that it was so tough for her to be aggressive, because when younger she had come to believe that any aggression would result in abandonment. Additionally, however, Anna needed the opportunity to explore new ways of being aggressive, ways that would not contradict her value of altruism, and when she created this new possibility, she saw that she could be aggressive without fearing abandonment.
Chapter 6: The Analyst’s Process
To allow the creation of potential space, the therapist must restrain his “natural tendency to ‘match’ affective expressions.” Doing this creates an unnatural feeling that can result in mounting tension. “This can cause anxiety for the patient, who now has “no guidelines for his behavior and turns to the therapist to relieve his free-floating feeling by filling the space.” The therapist must resist this urge to comply with the patient’s request. This might make the therapist “feel cold-hearted and even sadistic as the patient suffers from a sense of nonbeing.” “However, to meet the patient’s request is to fill the space, thereby reducing its potential for creation.”
It is risky to envision what the patient might become. “What if the patient’s potential as viewed by the therapist does not appear to be materializing? What if the expected future does not come?” We also run the risk of imposing our own preconceptions on the patient, as “[d]eeply etched in the heart of all analysts is the principle that we should not influence our patients’ development with our own values and biases.” The best antidote to this anxiety is to make sure to root our vision “in the patient’s free associations and interactions as they emerge.” And of course we must be willing to change our vision as we learn more about the patient.
The therapist must at times have faith that the client has potential and that within that potential there is “power to provide a rewarding future. Such faith does not come easily because the patient’s pathology stands between unrealized possibilities at the patient’s core and the analyst’s effort to achieve a depth understanding.”
Chapter 7: Clinical Application — Somatic Symptoms
Development and Object Relations Theory
Referencing the work of Silvan Tomkins, Summers writes that it is now known that basic affects are inborn. Such affects as “interest, enjoyment, surprise, distress, anger, fear, and disgust do not have to be learned. An infant will react to environmental circumstances in any of these ways without having witnessed them.” Affects, then, are not somatic symptoms; rather, affects communicate through the body “what is cared about, what matters.” If the mother is properly responsive to the child’s affects “by correctly identifying them and providing an ‘optimal zone of affective engagement,” the child uses his affects to form a relationship between himself and the world” (Demos 1988 and 1992).
Development research has shown that “affective life is, from the beginning, organized around relating to others” (Stern, “The Interpersonal World of the Infant,” 1985). Bowlby believed that this “serves the adaptive purpose of keeping the young child close to the protector” (“Attachment and Loss: Vol. 1,” 1969). Whatever the evolutionary purpose, “the child needs and seems prewired to form an attachment to the caretaker and feels threatened without it” (Bowlby, “A Secure Base,” 1988). The child is not preprogrammed for “a pleasure-seeking life oblivious to reality, but for interaction with a real person through a relationship mediated by affective states.”
In addition to forming relationships, children are “interested in the world of nonhuman objects.” “Indeed, we now know that neonates possess considerable mental capability for exploring the world from the first days of life. They can detect contingencies and patterns; they plan and are capable of voluntary motor controls” (Demos, 1992). The “autonomous nature of children’s curiosity about and elaboration of the world supports the notion that they are inherently motivated to exercise their capacities to form a self” (Summers, 1999, pp. 45-53). Consequently, “if self potential is to be realized, it must be possible for affects to be used in accordance with the needs of the self. For example, aggression must be available to fulfill ambitions, and affection must be accessible for intimate relationships. The child must be free to pursue his interests.” Jessica Benjamin argued that “such affective freedom is possible only if the caretakers’ accepting and approving gaze recognizes and nurtures the child’s spontaneous affective expressions” (“Like Subjects, Love Objects,” 1995).
The Psychoanalytic Concept of Ownership
Developmental research and object relations theory provide the foundations for a sense of personal ownership. “As we have seen, if caretakers are responsive to the child’s psychic states, affects become elaborated into new ways of being and relating.” When the child expresses an affect, and the parent responds to that affect — acknowledging it, perhaps echoing it — that affect then “becomes a characteristic way of relating to the environment and thereby a part of the self organization.”
The Psychopathology of Affective Life
The “child’s affective states require a resonance with the caretaker such that the child feels her affects are not only welcomed and appreciated, but also ‘real.’” “It is only through the responsiveness of the other that the child has a sense of her own reality.” If the caretaker ignores the child’s affects, “she feels that they are somehow invalid or defective.” And if the caretaker provides a negative responds to the child’s affect, “the affect will be experienced by the child as threatening the bond. Believing that an affect will cost the love of the parent,” the child will learn to “bury” the affect “in order to maintain the caretaker connection.”
As Freud told us, “if an affect is denied entrance into consciousness, it seeks expression in another form.” Clinical experience has confirmed Freud’s claim. As Summers has shown, children are motivated “to exercise and develop inborn capacities,” and “affects are a crucial component of this movement.” Since an affect “that is disavowed cannot mediate the self’s relationship to the world,” self-development is stunted, an “important potential component of the self” is lost.
When an affective state is arrested, our emotions look for another outlet. If a child’s affects are neglected or opposed, he will get angry. If the child’s anger is neglected or opposed, he act out his anger through his behavior (e.g., by breaking rules, defying his parents, etc.). Or he might become overexcited. Or he might respond in a host of other ways, including through somatization.
Psychopathology of the Body
Affects are bodily experiences. “In addition to the measurable level of neurological excitation that inheres in affects, the latter are experienced in the body. When the mother enters the room, for example, the infant’s is a bodily reaction: he gurgles and wiggles his own body.” Even as the child grows, “affects always retain a bodily component.”
Given this affect-body connection, it follows that when a child “owns his affective states, he owns his bodily experience.” Conversely, when a child suppresses an affect, he disowns an “aspect of bodily experience.”
Given this affect-body connection, it also follows that when a child suppresses or aries an affect, he will experience a bodily tension. “To suppress anger, for example, means to contain aggressive expressions by countermeasures of both psyche and the musculature. As affective experiences are now divorced from human interaction, the body learns to contain the tension of somatic urges that cannot be brought to fruition.”
Freud believed that we experience bodily tension when a drive is prevented from discharging. Summers believes, in contrast, believes that we experience bodily tension when our early environment prohibits us from expressing our affects and by extension prohibits us from exercising our “capacities” and becoming “fully human.” “For example, if aggression is disavowed, the self cannot pursue goals, realize ambitions, achieve mastery over conflict, or engage in competition.”
Somatic symptoms represent “the bodily imprisonment of arrested affective potential.” When anger is prohibited from developing, for instance, the anger does not cease to exist “and will find some indirect means of expression.” The child who cannot express anger “may complain of stomach aches or pain in various parts of the body.” It’s not clear “why in some people disavowed affects” manifest in different symptoms in some patients than others.
Even when the symptoms are not clearly somatic, “there is often a bodily component. Anxiety symptoms, for example, are experienced in the body: sweaty palms, racing heart, and hyperventilation are all bodily expressions.”
Summers next turns to the Anna O, who had a host of somatic symptoms. Josef Breuer had been impressed by Anna’s many talents and believed she should find a way to help others. When Breuer asked Anna to recall the time each symptom first originated, she experienced “considerable symptom relief.” However, after working with Breuer, she was hospitalized three times. She did not experience full relief until she moved to Frankfurt and became active in charitable work. “It is clear from this case that the analytic task in the treatment of the disowned body is to discover buried affective potential and facilitate its articulation into ways of being and relating so that the patient can assume ownership of his bodily states.”
Clinical Technique
Summers provides a case study of Jenny, who was “initially hospitalized medically, but no physical source of the symptoms was discovered.” Summers came to understand Jenny’s history and offered interpretations to help her understand her hidden desires. He then shifted his clinical stance “from understanding to creating, that is, from transference space to potential space. I asked Jenny what she would do if she were free of guilt and identification with her mother.”
This served as an important jumping-off place and Jenny became to make changs in her personal life. “Her changes extended beyond new interests to a general awareness and expression of previously disavowed affects. For example, she was able to articulate her anger about the severe limitations of her previous life.”
Jenny’s somatic pains began to disappear. “We never discussed the specific meaning of any individual symptom. Jenny felt, and I concurred, that the symptoms were the expression in her body of the tension resulting from the disavowal and suppression of a great deal of her affective life.” Jenny’s “inability to experience spontaneity, joy, excitement and pursue her interests had led to tension that was communicated somatically.”
Chapter 8: Clinical Application — Depression
“When a child is required to restrict her authentic affects to maintain early attachments, she does not believe her experience is valuable, interesting to others, or able to sustain relationships.” Such a child develops a defensive strategy to maintain these attachments (examples of which include “compliance, aloofness, intellectual precision, and self-aggrandizement”), and she learns to “navigate the social world at the cost of genuine affective connection.” Being disconnected “from lived experience means the patient can derive little satisfaction from it,” but attempts to relinquish the defensive strategy triggers fears of abandonment.
The root of depression is “not the loss of the object per se, but the incompletely developed self that led to the clinging tie to the object which, in turn, makes the self vulnerable to collapse when the object is lost.”
“When a child is required to restrict her authentic affects to maintain early attachments, she does not believe her experience is valuable, interesting to others, or able to sustain relationships.” Such a child develops a defensive strategy to maintain these attachments (examples of which include “compliance, aloofness, intellectual precision, and self-aggrandizement”), and she learns to “navigate the social world at the cost of genuine affective connection.” Being disconnected “from lived experience means the patient can derive little satisfaction from it,” but attempts to relinquish the defensive strategy triggers fears of abandonment.
The root of depression is “not the loss of the object per se, but the incompletely developed self that led to the clinging tie to the object which, in turn, makes the self vulnerable to collapse when the object is lost.”
Chapter 9: Clinical Application — Attachment to Bad Objections
Individuals attached to bad objects have harsh internal voices. “These demonic voices are thought of in object relations terms as internalized bad objects. Seemingly unable to register positive experience, the patient seems to possess an internal screen filtering out anything that might feel good but attracting the influence of a negative event.”
Eliminating bad objects is incredibly difficult. “Even after we understand the origin of these bad objects and identify their replication in the transference, they tend to stay adhesively attached to the structure of the patient’s psyche.”
Fairbairn
Fairbairn believed that attachment to bad objects was “the central therapeutic difficulty.” Our primary motive, he believed, is to seek “satisfactory object relationships.” If these relationships are not satisfactory, we conclude that our love is unacceptable to the object. We still desire the object but feel that he or she is rejecting. We respond by internalizing the object, our hope mean that by internalizing the object we will be able to “master the pain and frustration of the unsatisfying object relationship.” Moreover, we split the object into two, an exciting object and a rejecting object. The exciting object seeks a satisfactory relationship, but the rejecting object represses the longing for the exciting object “to avoid frustration and the shame of feeling that his love is unacceptable.”
When we internalize an object, that object organizes our experience, and for this reason, Fairbairn concluded that internalized objects become components of the self structure. Fairbairn wrote that every internalized object has a corresponding ego structure, the exciting object connected to the libidinal ego and the rejecting object to the anti-libidinal ego. “When an object is internalized, it becomes a structure, a part of the psychic organization.” Therefore, we can say that the bad object is “a component of the self.”
To illustrate how a bad object organizes our experiences, Summers talks about a man named Danny, who had internalized his father and continually flagellated himself for his failures while diminishing his successes. Thus, Danny’s bad object “provided a structure to his experience,” and he thus felt it was a part of the self.
Bad Objects and the Self
If an internalized object is merely an object, then “it is difficult to see why patients cling to them.” But if internalized objects are part of the self structure, then it follows that when we relinquish an internalized object, we are also relinquishing “a way of constructing and organizing experience.” Our “very sense of self is disrupted, and experiences that once fit into known categories become disorienting.”
Thus, Danny’s “self-flagellation, although excruciatingly painful, maintained a connection with his father; indeed hearing the voice was the only way he could hold on to that relationship. His fear of abandonment by his father was so intense that he preferred the pain of self-attack to the risk of losing an illusory connection to the older man.”
In therapy Danny came to realize that he had never had a good relationship with his father but that he had needed to hold onto this belief “to sustain him through a childhood lived without a paternal bond.” However, coming to realize that “he had been holding on to a forlorn wish” did not “extinguish the hold of the bad object.” He consciously wanted to relinquish this bad object, but “whenever he contemplated any type of self assessment, he launched into self-accusation.” Danny, it must be emphasized, was “not attached to a real relationship but to an illustory connection.”
When Danny thought about no longer being so self-critical, he would at first feel happy but then felt anxious that this would cause him to “go too far,” meaning he feared that if he wasn’t so self-critical he would “indulge himself in self-aggrandizement that he would not be able to control.” “Yet the only alternative to manic, self-indulgent grandiosity that Danny could contemplate was self-punishment: his internalized bad object was an organized way of controlling his tendency toward self-inflation, thus providing him with a structure that relaxed his anxiety of losing control.”
Danny’s bad object “served to organize his responses to success and failure; it provided him with a self-definition, albeit a painful one. Thus, his stubborn bond to the bad object was not only a way of keeping a connection to his father but also a means for maintaining a self-organization that helped him negotiate the interpersonal world.”
If we do not “have a concept of an emergent self-structure that can be created from the ambiguity, the danger exists of the patient returning to the influence of the bad object in order to regain the only sense of self he knows.”
Therapeutic Action
To help the patient let go of the bad object, we must first hold the patient’s anxiety about relinquishing it. We must convey hope that “other possibilities exist.” By “establishing and sustaining the void, despite the intensity of the anxiety,” we “open potential space.”
Summers helped one patient, Danny, he insisted him to use free associations. When Danny asked what he should do, Summers asked, “What comes up?” Danny: “I’m an idiot to be suffering like this for nothing.” Summers: “What comes up?” Danny associated to his love of solving problems.
Danny had never fully expressed these feelings, and when he did so, “he felt chaotic and destabilized.” Danny’s associations to problem suggested that he found pleasure in work, but he feared that giving full expression to these feelings would result in “a sense of self-aggrandizement he detested.” Danny next produced the following concatenation of associations: his love for playing with his toys as a child — his interest in fixing cars as an adolescent — his desire for a more exciting sex life with his wife.
Summers encouraged Danny to elaborate on his “pleasurable memories, thoughts, and feelings appearing in the associational train.” Summers strategy was to welcome Danny’s “newly surfacing affective states rather than interpreting them,” a strategy “based on the principle that we were in a potential space in which these unfolding affects represented previously arrested ways of being.”
If Danny had repressed desires, “they would have appeared in consciousness as complete entities,” Summers would have interpreted them. However, because Danny’s desires “appeared in a chaotic, undefined formlessness, Summers knew they were dealing with “incipient psychological states rather than fully defined experiences,” states that “had been occluded before coming to fruition.”
“Danny felt that the experience and expression of positive affects in the analytic space marked a decisive turning point in his life. For the first time, he had permitted himself the full expression of self-affirming affective experiences, especially interest, enjoyment, and excitement, without invoking a negative introjection.”
Danny would experience these positive affects but then predictably also experience self-criticism. Summers responded by highlighting “the evolving affect previously dormant under the dominance of the bad object. Danny then typically abandoned the impulse to attack the excitement or enjoyment and allowed the positive affect to flourish.” In time he began to use his affects as a guide for action.
Summers emphasizes that interpreting bad objects does not by itself diminish their power. Understanding alone does not reduce the power of a bad object “because the prospect of losing the bad object evokes the threat of losing the very structure relied on to engage the world.” However, it is crucial to understand “the origins and function of the bad object,” as doing so puts it “in abeyance its influence so that an alternative can be formed.” For example, once Summers and Danny “grasped the meaning of the bad objects as his father’s voice crushing positive affects,” Danny was motivated “to suspend its organizing function” and “take advantage of the newly opened space to build positive affects into new ways of being and relating that ultimately replaced the role of the bad object in his psyche.”
Grandiosity and the Bad Object
Kohut believed that low self-esteem was “a defense against arrested grandiosity.” The “tenacity of the bad object” can often be a defense against grandiosity. Kohut believed that “when childhood grandiosity remains vulnerable, it may be split off, leaving the self weakened and lacking in healthy self-regard.” Danny fear that giving up the bad object would result in grandiosity, but this was only a fear. Danny “did not have a split-off organized grandiose self waiting for the chance to engage the world.” When he tried to give us the bad object, a split-off grandiose self did not emerge but instead he “became disorganized at the thought of being able to think, act, and feel as he pleased.” In sum, the role of Danny’s bad object “was not so much to protect against the emergence of a grandiose self as to provide a sense of self.”
Conclusion
Fairbairn explained that bad objects are so difficult to expunge because they’re internal structures. Summers has based his clinical strategy on this insight. Further, as he has shown, “the new self must be created before the old organization can be given up completely. To overcome the malignant effects of bad object dominance, the therapist must take an active role in assisting the patient’s creation of a new self structure.” Summers has expended Fairbairn’s thinking “to the adoption of a facilitative role for the therapist,” and in so doing he aligns Fairbairn “with Bollas’ (1987) concept that psychoanalytic therapy is not about discrete affects but about the building of a new self organization.” As soon as the patient understands what function the bad object serves, “the therapist shifts roles from interpreter of the patient’s experience to facilitator of the new experience.”
Chapter 10: Clinical Application — Narcissistic Injury
Summer talks about patients with low self-esteem. These individuals feel defective, and he describes this feeling as a narcissistic injury.
The Development of Self-Esteem
Three childhood factors contribute to our self-esteem. (1) the feeling that we’re supported by others, (2) the feeling that we can trust our affects, and (3) the feeling that we’re effective.
(1) The Feeling that We’re Supported by Others. If we receive sufficient affective attunement, we will gain “a significantly greater capacity for relatedness.” If not, we’re more likely to become “isolated and have fewer meaningful interpersonal bonds.”
(2) The Feeling that We Can Trust our Affects. We’re born with the desire to maximize positive affects, and when we develop the ability to sustain positive affects and regulate negative affects, we gain the confidence that we can trust our affects to guide our behavior. Our caregivers can help us learn to trust our affects through affective matching; for example, “if the child is excited, the parent’s excited response promotes the continued use of that affect in subsequent situations” (Beebe and Lachman, Stern 1985). If, however, the caregiver “withdraws or ignores the excitement, the child’s enthusiasm deflates and becomes associated with negative responses and perhaps even shame.”
(3) The Feeling that We’re Effective. We’re born with the desire to exercise agency and develop mastery (Stern 1985). And while attunement from our caregivers helps us to learn to trust our affects, a key ingredient of agency, we also need some space from our caregivers, the opportunity to struggle and grow on our own. This finding has been supported by several researchers:
Three childhood factors contribute to our self-esteem. (1) the feeling that we’re supported by others, (2) the feeling that we can trust our affects, and (3) the feeling that we’re effective.
(1) The Feeling that We’re Supported by Others. If we receive sufficient affective attunement, we will gain “a significantly greater capacity for relatedness.” If not, we’re more likely to become “isolated and have fewer meaningful interpersonal bonds.”
(2) The Feeling that We Can Trust our Affects. We’re born with the desire to maximize positive affects, and when we develop the ability to sustain positive affects and regulate negative affects, we gain the confidence that we can trust our affects to guide our behavior. Our caregivers can help us learn to trust our affects through affective matching; for example, “if the child is excited, the parent’s excited response promotes the continued use of that affect in subsequent situations” (Beebe and Lachman, Stern 1985). If, however, the caregiver “withdraws or ignores the excitement, the child’s enthusiasm deflates and becomes associated with negative responses and perhaps even shame.”
(3) The Feeling that We’re Effective. We’re born with the desire to exercise agency and develop mastery (Stern 1985). And while attunement from our caregivers helps us to learn to trust our affects, a key ingredient of agency, we also need some space from our caregivers, the opportunity to struggle and grow on our own. This finding has been supported by several researchers:
- Demos (1992) found that children who develop agency have parents who don’t take away all their stress but rather allow them to experience some distress and then join with us to collaboratively reduce it.
- Bowlby found that “the most secure babies had mothers who were emotionally available and encouraged autonomy” (A Secure Base, 1988).
- Beebe found that babies with the strongest sense of self were not those with the most closely attuned mothers but “those in the midrange of affective and vocal matching.”
- Sanders (198) wrote that we need “open spaces,” that is, the opportunity “to experience states of interest, enjoyment, and excitement without connection to the other.” Without such open spaces, we do not develop the confidence that we can regulate our emotions on our own, and so we won’t “use them to engage the world.”
In sum, as Blatt and Blass (1992) put it, “there are two fundamental dimensions of human experience: the needs for relatedness and for self-definition.” The former need is met through affective attunement. The latter need is met when we’re given “space in which to explore and master the environment.” Both dimensions “are necessary for the child to achieve an adequate sense of self-worth.”
If we’re deprived of the opportunities needed to develop the feelings that we’re supported by others, that we can trust our affects, and that we’re effective, we will become increasingly isolated and construct different defenses to protect ourselves from feeling defective.
Therapeutic Action
Given that narcissistic vulnerability is caused by beliefs that (1) others don’t support us, (2) our affects can’t be trusted, and (3) our feeling of ineffectiveness, the following things must happen in treatment.
It is essential that the therapist attunes to the patient. Attunement allows the patient to feel supported. Moreover, attunement confirms the patient’s affective states, thus facilitating her “ability to believe in her own affective responses.” Additionally, the therapist must create space for the patient to exercise her agency by influencing the therapeutic relationship.
“This acquisition of new interpersonal patterns follows the model of procedural learning in which behavior is learned by doing. As the patient operates more authentically and effectively in the relationship with the analyst, she is acquiring competence in a manner more akin to the development of bicycle skills than declarative-semantic learning.”
Summers again provides Anna as an example, this time an example of how to treat someone with narcissistic injuries. Anna had always subjected herself to others. Summers encouraged her to begin expressing herself, and in the process she realized that she had repressed some deeply held feelings and values and in time realized why she had repressed them. Anna began to express many of these feelings and values in therapy, and she slowly started to make changes in her daily life, e.g., standing up for her own needs in relationships.
Many in society believe that they cannot trust themselves to make good decisions because they have low self-esteem. Summers thinks it’s the opposite: people like Anna have low self-esteem because they have difficulty trusting their “affects as reliable beacons of conduct.” According to Summers, “failures in early relationships lead the child to doubt the importance and value of her affective states, resulting in a feeling of defectiveness.”
And so Anna experienced change when she began to “to risk bringing her affects into the analytic relationship.” In so doing, she “began to develop and value the capacity to utilize formerly buried, nascent states.” As she did this and experienced changes in her life, she came to prefer this new way of being. “It was the new-found ability to live her life on the basis of her affect, values, and beliefs that provided the foundation for her self-esteem, not the other way around.”
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